No worldwide consensus exists regarding the best way to manage patients with asymptomatic carotid artery stenosis (CAS). In this thought-provoking article, Professor A. Ross Naylor presents his argument against the use of a 'one size fits all' approach involving the costly widespread use of surgical or percutaneous interventions, a high percentage of which are unnecessary. Instead, he recommends that the medical community should increase efforts to identify those at particularly high risk for stroke, who are the only patients likely to really benefit from these interventions