Purpose of Review:: Large artery atherosclerosis is an important cause of ischemic stroke. Recent randomized clinical trials have helped clarify the treatment options for conditions such as carotid stenosis and intracranial atherosclerosis. This review outlines the primary findings of these trials and provides current recommendations for treatment.

Recent Findings:: Carotid revascularization is preferred in patients with severe symptomatic carotid stenosis. Carotid endarterectomy achieves lower rates of stroke or death than carotid artery stenting. The risk of stroke or death with stenting is higher among older patients and women. Intensive medical therapy achieves low stroke and death rates in asymptomatic stenosis. Medical therapy and treatment of atherosclerotic risk factors are the mainstay of therapy for intracranial atherosclerosis, and medical therapy is recommended for patients with vertebral artery origin atherosclerosis.

Summary:: Contemporary medical therapy is paramount in large artery atherosclerosis. Patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully weighed while choosing a revascularization procedure for carotid stenosis.

Address correspondence to Dr Seemant Chaturvedi, Department of Neurology, Wayne State University, 8C-UHC, 4201 St. Antoine, Detroit, MI 48201, schaturv@med.wayne.edu.

Relationship Disclosure: Dr Chaturvedi has received compensation for expert witness testimony and research support from AstraZeneca, Daiichi Sankyo, and Johnson & Johnson Services, Inc. Dr Chaturvedi serves as a consultant for Abbott Vascular and W. L. Gore & Associates, Inc; on the executive committee of the Asymptomatic Carotid Trial (ACT)–1 and Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)–2 studies; and as a contributing editor to NEJM Journal Watch Neurology. Dr Bhattacharya has received a research grant from the Ethel & James Flinn Foundation to study poststroke depression in stroke patients.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Chaturvedi and Bhattacharya report no disclosures.