A recent study published in JAMA suggests that the chance of stroke (cerebral infarction, stroke) is not high in asymptomatic patients with internal carotid artery stenosis, or even complete vessel occlusion. Medicine has long confirmed the increased incidence of stroke in patients with asymptomatic internal carotid artery stenosis, so carotid plaque screening is now very common in clinical practice. However, the incidence of stroke has decreased significantly with the development of modern comprehensive medical therapy. In patients with severe carotid stenosis, there may be a concern that asymptomatic stenosis may progress to complete occlusion of the vessel, leading to fatal stroke, so there may be a concern that medical treatment alone may not be sufficient, and that clinically, stents may be placed in the internal carotid artery, or the lesion may be surgically removed by dissecting the internal carotid artery (internal carotid endarterectomy). How high is the risk in such a patient? To clarify this question, one investigator analyzed a database of single-center carotid ultrasounds. During the 23-year study period (1990 to 2012), a total of 316 asymptomatic patients developed internal carotid artery occlusion. The mean age was 66.4 years, 71% were male, and 78% suffered from hypertension. Most (80.4%) occlusions occurred before 2002-2003, when intensive medical therapy with plaque area measurement was not yet available. The decrease in the rate of internal carotid artery occlusion during the study period was statistically significant. Only one (0.3%) patient had a stroke at the time of internal carotid artery occlusion. Predictors of unilateral stroke, TIA, or stroke-related death included age, male, and total plaque area. At long-term follow-up, the leading causes of death were myocardial infarction and malignancy. This study showed a surprisingly low incidence of stroke in asymptomatic patients with internal carotid artery occlusion. This finding suggests that intensive medical therapy (including intensive statin application, antiplatelet therapy, blood pressure control and lifestyle modification) has a strong protective effect. Whether intensive medical therapy has progressed to the point where carotid revascularization is no longer needed in asymptomatic patients will be confirmed in the ongoing CREST 2 clinical trial.