Studies on the efficacy of surgical endarterectomy for moderate to severe asymptomatic stenosis (60%-99%) of the internal carotid arteries were done before the introduction of statins into the clinic, and thus, with the development of aggressive medical therapy based on statin lipid-lowering drugs, how much more advantageous is the current surgical treatment versus purely medical therapy? Is it possible that a proportion of patients treated surgically can achieve the same or better results with medical therapy? These questions need to be elucidated by new studies. Some of the findings suggest that aggressive medical therapy, including strict blood pressure management (≤130/80 mmHg), statin lipid-lowering agents (LDL cholesterol reduction to <1.7 mmol/L), and antiplatelet therapy with aspirin or clopidogrel, can control the annual incidence of stroke in moderate-to-severe asymptomatic internal carotid artery stenosis to less than 2%, whereas the complications of surgical treatment can It is not easy to control the complications of surgical treatment to less than 3%, so there is a trend in the industry to strictly control the indications for surgery. Surgery may be considered for moderate-to-severe asymptomatic internal carotid artery stenosis when the following conditions are present: intra-plaque hemorrhage on carotid MRI; echogenic black areas ≥3 mm2 in the plaque near the lumen detected by carotid ultrasound, with isolated white areas detected within the hypoechoic zone; severe stenosis; or progressive stenosis despite aggressive medical therapy Patients with asymptomatic internal carotid artery stenosis with one or more of the above conditions may be considered for carotid endarterectomy or stent placement, but the advantages and disadvantages compared with medical therapy may not be clear. However, prospective controlled studies are still needed to confirm the advantages and disadvantages compared with medical treatment.