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Hypercholesterolemia is a risk factor for carotid artery stenosis and stroke. Statins are the main drugs for the management of hypercholesterolemia and they are strongly recommended by international guidelines for the management of vascular patients. The present review will focus on the associations between cholesterol, carotid artery stenosis and stroke and will cover several topics, including the conservative and perioperative/periprocedural management of carotid patients, the effect of statins on contrast-induced nephropathy developing after endovascular carotid interventions, the role of statin loading prior to endovascular procedures, as well as the indirect beneficial effects of statin treatment on renal function. It will also discuss the topics of statin intolerance and alternative cholesterol-lowering options for statin-intolerant vascular patients. Cholesterol levels play a prognostic role in carotid patients with regards to both short- and long-term stroke and mortality rates. Physicians should keep in mind the pivotal role of cholesterol levels in determining cardiovascular outcomes and the pleiotropic beneficial effects associated with statin use and should not miss the opportunity for cardiovascular risk reduction with aggressive statin treatment.Patients with carotid artery stenosis (CAS) are commonly defined as asymptomatic or symptomatic according with their neurological conditions, however, emerging evidences suggest stratifying patients according also with the presence of cerebral ischemic lesions (CIL). In asymptomatic patients, the presence of CIL increases the risk of future neurologic event from 1% to 4% per year, leading to a stronger indication to carotid revascularization. In symptomatic patients, the presence of CIL does not seem to influence the outcome of the carotid revascularization if the volume of the lesion is small (4,000 mm3) CIL are associated in some experiences with a higher risk of carotid revascularization suggesting to delay the carotid revascularization for at least 4 weeks. As a matter of fact, the evaluation of CIL dimensions and characteristics in patients with CAS gives to the physician involved in the treatment a valuable adjunctive tool in the choice of the ideal treatment.Near occlusion of internal carotid artery (ICA) is a rare and easily misdiagnosed condition and the decision for revascularisation still remains controversial. We conducted an updated meta-analysis in order to investigate outcomes after carotid endarterectomy (CEA), carotid artery stenting (CAS) or best medical treatment (BMT) in patients with near-occlusion of the ICA. We also aimed to investigate the role of time as a potential moderator of the near-ICA occlusion-stroke rate association. A multiple electronic health database search on articles published up to November 2019 was performed. The pooled stroke rate after CEA, CAS and BMT were calculated. We also investigated transient ischemic attack (TIA), stroke-related death, myocardial infarction (MI), any cause of death and ICA restenosis crude rates (%). A total of 33 articles were finally deemed eligible. selleck chemical The pooled stroke rate was 1.52% [95% confidence interval (CI) 0.09-4.02%] after CEA, 1.80% (95% CI 0.61-3.40%) after CAS and 8.39% (95% CI 3.39-14.80%)ention seemed to be safe and effective. A downward trend in the stroke rates over time after CAS and BMT was also discovered. These highlight that patients with near-occlusion of ICA should be included and investigated in future studies.Patients with asymptomatic carotid stenosis (ACS) are at very high risk of coronary events, so they should all receive intensive medical therapy. What is often accepted as "best medical therapy" is usually suboptimal. Truly intensive medical therapy includes lifestyle modification, particularly smoking cessation and a Mediterranean diet. All patients with ACS should receive intensive lipid-lowering therapy, should have their blood pressure well controlled, and should receive B vitamins for lowering of plasma total homocysteine (tHcy) if levels are high; a commonly missed cause of elevated tHcy is metabolic B12 deficiency, which should be diagnosed and treated. Most patients with ACS would be better treated with intensive medical therapy than with either carotid endarterectomy (CEA) or stenting (CAS). A process called "treating arteries instead of treating risk factors" markedly reduced the risk of ACS in an observational study; a randomized trial vs. usual care should be carried out. The few patients with ACS who could benefit (~15%, or perhaps more if recent evidence regarding the risk of intraplaque hemorrhage is borne out) can be identified by a number of features. These include microemboli on transcranial Doppler, intraplaque hemorrhage, reduced cerebrovascular reserve, and echolucency of plaques, particularly "juxtaluminal black plaque". No patient should be subjected to CAS or CEA without evidence of high-risk features, because in most cases the 1-year risk of stroke or death with intervention is higher with either CEA (~2%) or CAS (~4%) than with intensive medical therapy (~0.5%). Most patients, particularly the elderly, would be better treated with CEA than CAS. Most strokes can be prevented in patients with ACS, but truly intensive medical therapy is required.Despite steady advances in medical care, cardiovascular disease remains one of the main causes of death and long-term morbidity worldwide. Up to 30% of strokes are associated with the presence of carotid atherosclerotic plaques. While the degree of stenosis has long been recognized as the main guiding factor in risk stratification and therapeutical decisions, recent evidence suggests that features of unstable, or 'vulnerable', plaques offer better prognostication capabilities. This paradigmatic shift has motivated researchers to explore the potentialities of non-invasive diagnostic tools to image not only the lumen, but also the vascular wall and the structural characteristics of the plaque. The present review will offer a panoramic on the imaging modalities currently available to characterize carotid atherosclerotic plaques and, in particular, it will focus on the increasingly important role covered by multidetector computed tomographic angiography.