From the Guidelines
The patient should undergo a carotid ultrasound and a CT scan of the head as soon as possible to investigate the potential vascular and structural causes of memory loss, as these diagnostic tests are essential first steps in determining the etiology of memory loss. The carotid ultrasound can identify stenosis or blockages in the carotid arteries that might be reducing blood flow to the brain, potentially causing vascular cognitive impairment, as recommended by the 2018 Canadian Stroke Best Practice Recommendations 1. The CT scan can detect structural abnormalities such as tumors, strokes, or brain atrophy that might explain the memory symptoms.
According to the 2018 Canadian Stroke Best Practice Recommendations 1, brain imaging (CT or MRI) and noninvasive vascular imaging (including carotid imaging) should be completed as part of the initial assessment for patients presenting with suspected acute or recent transient ischemic attack or non-disabling ischemic stroke. The guidelines also recommend that vascular imaging is used to identify significant symptomatic extracranial carotid artery stenosis for which patients should be referred for possible carotid revascularization [Evidence Level A] 1.
Some key points to consider in the diagnostic workup include:
- The carotid ultrasound is a noninvasive test that can detect stenosis or blockages in the carotid arteries, as recommended by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1.
- The CT scan of the head can detect structural abnormalities such as tumors, strokes, or brain atrophy that might explain the memory symptoms.
- The patient should ensure they're available for follow-up communication regarding scheduling these tests and subsequent appointments to review results.
It is also important to note that the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease recommends that duplex ultrasonography is used to detect carotid stenosis in patients who develop focal neurological symptoms corresponding to the territory supplied by the left or right internal carotid artery 1. However, the 2018 Canadian Stroke Best Practice Recommendations provide more up-to-date guidance on the use of carotid ultrasound and CT scans in the diagnostic workup of patients with suspected vascular cognitive impairment 1.
From the Research
Carotid Atherosclerotic Disease and Memory Loss
- The patient's memory loss may be related to carotid atherosclerotic disease, which can cause vascular events such as stroke 2.
- A carotid ultrasound can help assess vascular causes of memory loss by identifying high-risk plaque features associated with plaque rupture 3.
- A CT scan of the head can evaluate structural causes of memory loss, such as tumors or vascular malformations.
Management of Carotid Stenosis
- The management of carotid stenosis depends on the presence of symptoms and the degree of stenosis 2.
- For symptomatic carotid stenosis, carotid endarterectomy or carotid stenting are recommended interventions 2.
- For asymptomatic carotid stenosis, the optimal management is controversial, but statin treatment may help stabilize the plaque and reduce the risk of vascular events 4.
- Antiplatelet therapy, such as aspirin or clopidogrel, may also be recommended to reduce the risk of vascular events in patients with carotid stenosis 3, 5, 6.
Role of Imaging in Carotid Atherosclerotic Disease
- Imaging techniques, such as Doppler embolic signal detection, can help evaluate the efficacy of antiplatelet therapy in patients with carotid stenosis 6.
- Advanced imaging techniques, such as B-mode ultrasound, may also help identify patients at high risk of cerebrovascular and coronary events 4.
- Carotid ultrasound and CT scans can help assess the degree of stenosis and identify high-risk plaque features associated with plaque rupture 3, 2.