What is the recommended treatment and management plan for a patient with moderate to severe stenosis of the left P2/P3 segment, likely with a history of cerebrovascular disease risk factors such as hypertension, diabetes, or hyperlipidemia, and currently presenting with minimal chronic microvascular ischemic changes and minimal global parenchymal volume loss?

Management of Moderate to Severe Left P2/P3 Posterior Cerebral Artery Stenosis

For your moderate to severe narrowing in the left posterior brain artery (P2/P3 segment), aggressive medical management with blood pressure control, high-dose statin therapy, and antiplatelet medication is the recommended treatment—not surgery or stenting. 1, 2

Understanding Your Scan Results

Your CT scan shows:

• A significant narrowing (moderate to severe stenosis) in one of the arteries at the back of your brain (left P2/P3 segment) that supplies blood to the back part of your brain 2
• The good news: No blockages in your other major brain arteries, no aneurysms (bulges), and no blood clots 2
• Minor age-related changes: Small areas of chronic damage from reduced blood flow and mild brain volume loss, which are common with aging and vascular risk factors 3

Why Surgery or Stenting Is NOT Recommended

Revascularization procedures (stenting or surgery) are explicitly not recommended for intracranial (inside the skull) arterial stenosis like yours. 2 The evidence shows that aggressive medical therapy is superior to interventional procedures for this type of narrowing, as procedures carry significant risks of stroke and complications without proven benefit 2, 4

Your Treatment Plan: Aggressive Medical Management

1. Blood Pressure Control (Critical Priority)

• Target: Less than 140/90 mmHg 1, 2
• This is the single most important modifiable risk factor for preventing stroke with intracranial stenosis 5, 6
• Your doctor will likely prescribe or adjust blood pressure medications to achieve this target consistently 5

2. High-Dose Statin Therapy (Mandatory)

• Target: LDL cholesterol below 70 mg/dL (1.8 mmol/L) 1, 2
• Statins work by stabilizing the plaque in your artery, not just lowering cholesterol 1, 7
• This is required even if your cholesterol levels are currently "normal"—the goal is plaque stabilization 1
• High-dose statin therapy has been shown to slow progression and even regress arterial narrowing 7

3. Antiplatelet Therapy

• Single antiplatelet agent (aspirin 81-325 mg daily OR clopidogrel 75 mg daily) 1, 2
• This prevents blood clots from forming in the narrowed artery 2
• Dual antiplatelet therapy (two medications) is NOT recommended as it increases bleeding risk without proven additional benefit in asymptomatic disease 1

4. Diabetes Control (If Applicable)

• Aggressive diabetes management is essential, as diabetes is strongly associated with severe intracranial stenosis 2, 6
• Target HbA1c should follow standard diabetes guidelines 5

5. Lifestyle Modifications (Non-Negotiable)

• Smoking cessation (if applicable) with counseling and medication support 1
• Physical activity: At least 150 minutes per week of moderate-intensity exercise 5, 2
• Diet: Low in saturated fat and sodium, high in fruits and vegetables 5
• Weight management if overweight or obese 7

Monitoring and Follow-Up

Surveillance Schedule

• Regular follow-up imaging to monitor for progression of the stenosis 8
• Symptom monitoring: Report immediately if you develop new neurological symptoms such as vision changes, weakness, numbness, difficulty speaking, or balance problems 2

Warning Signs Requiring Immediate Medical Attention

Any new symptoms suggesting stroke or TIA (mini-stroke):

• Sudden vision loss or double vision (especially important given the location of your stenosis in the posterior circulation)
• Sudden weakness or numbness on one side
• Sudden difficulty speaking or understanding speech
• Sudden severe headache
• Sudden loss of balance or coordination

Why This Approach Works

The annual risk of stroke with symptomatic intracranial stenosis can exceed 20% without treatment, but aggressive medical management significantly reduces this risk. 4 Recent evidence demonstrates that medical therapy alone is superior to endovascular treatment for intracranial stenosis 2, 4

The combination of blood pressure control, statin therapy, and antiplatelet medication addresses the underlying atherosclerotic process causing the narrowing 7, 4. These medications work together to:

• Stabilize the plaque in your artery 1, 7
• Prevent blood clots 2
• Reduce inflammation 7
• Slow or reverse progression of the narrowing 7

Critical Points to Remember

• This is NOT a surgical condition—medical management is the proven treatment 2, 4
• Medication adherence is critical—missing doses significantly increases your stroke risk 2
• Blood pressure control is your most important target—check it regularly at home if possible 5, 3
• Do not stop medications without consulting your doctor, even if you feel well 2
• The minimal chronic changes seen on your scan indicate you've likely had this narrowing for some time, making aggressive risk factor control even more important going forward 3