What is the next step after a CT scan showing occlusive disease at the origin of the left vertebral artery with atherosclerotic changes at the carotid bifurcations?

From the Guidelines

The next step after this CT angiogram should be a consultation with a vascular neurologist or stroke specialist to discuss management of the identified left vertebral artery occlusive disease and atherosclerotic changes. The patient should be started on antiplatelet therapy (such as aspirin 81mg daily or clopidogrel 75mg daily) if not already taking it, as suggested 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. Along with antiplatelet therapy, a statin medication like atorvastatin 40-80mg daily should be initiated to stabilize the atherosclerotic plaques. Aggressive management of vascular risk factors is essential, including:

• Blood pressure control (target <130/80 mmHg)
• Diabetes management if applicable
• Smoking cessation
• Lifestyle modifications including regular exercise and a heart-healthy diet The specialist may recommend additional testing such as carotid duplex ultrasound for monitoring of the atherosclerotic changes over time, as suggested 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. While the occlusive disease in the left vertebral artery is significant, the patient maintains adequate circulation through the right vertebral artery and both carotid arteries, which explains why no acute stroke was identified. Regular follow-up imaging in 6-12 months may be warranted to monitor disease progression. It is also important to note that catheter-based contrast angiography may be required before revascularization for patients with symptomatic posterior cerebral ischemia, as stated in 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.

From the Research

Next Steps After CT Scan

The CT scan findings indicate occlusive disease at the origin of the left vertebral artery, atherosclerotic changes at the carotid bifurcations with no significant stenosis, and decreased caliber of the left vertebral artery. Based on these findings, the next steps could be:

• Monitoring and medical management of atherosclerotic disease, as suggested by 2
• Consideration of endovascular techniques, such as angioplasty and stenting, for the treatment of vertebral artery occlusive disease, as discussed in 3
• Evaluation of the patient's risk factors for atherosclerotic disease, such as hypertension, diabetes mellitus, coronary artery disease, and active cigarette smoking, as identified in 4

Considerations for Treatment

When considering treatment options, the following factors should be taken into account:

• The severity of stenosis and the presence of bilateral vertebral artery disease, as associated with symptomatic VAOD in 4
• The risk of periprocedural complications and restenosis, as discussed in 3
• The patient's demographics, comorbidities, and periprocedural risks of stroke and death, as emphasized in 2

Further Evaluation and Management

Further evaluation and management may involve:

• Follow-up angiography to monitor the progression of disease and the effectiveness of treatment, as recommended in 3
• Intensive medical therapy to manage atherosclerotic risk factors and prevent further disease progression, as suggested in 2
• Consideration of surgical or endovascular interventions, such as carotid endarterectomy or stenting, for the treatment of carotid stenosis, as discussed in 5 and 2