1. The authors recommend medical treatment, which includes antiplatelet therapy and statins for most patients. 2. The authors make every effort to discuss the pros and cons and the uncertainties regarding the benefits from surgery with patients who have either progressive stenosis with ipsilateral silent brain infarction, or impaired vasomotor reactivity, as evaluated by TCD and Diamox test. If they are prepared to accept the up-front perioperative risk, refer them to an excellent and highly skilled surgeon.