Brief Answer:
Best therapy based upon how the artery got to 90%

Detailed Answer:
Good afternoon sir and thank you for writing your question on this network.

Your question is not quite as straight forward in response as it may have been 20 years ago because the absolute deluge of information that has been produced over the past 2 decades on the natural history and ways of measuring intravascular blood flows through normal as well as diseased blood vessels under a variety of circumstances and scenarios....it's almost mind boggling how information has exploded on the topic. It is also unfortunately the case that there remains a HUGE amount of general ignorance among both specialist and non-specialist physicians as to the myriad of options available on the surgical and/or invasive fronts...and even on the medical treatment fronts that really has changed the landscape of both survival as well as morbidity from intracranial vascular disease. The trick is to know which studies are done well and which are done without good controls or screening procedures in order to legitimately interpret the results.

As "bad" as that number of 90% may sound....you've really not provided key information to know whether I (or any other doctor) should be proceeding expeditiously to make certain critical decisions need to be made vs. just advising you to be calm, take a deep breath or 2 and keep living your life as you would've before you were given that information. If you are writing to in reference to yourself and are an outpatient then, I'm pretty sure you've not suffered a recent major stroke since you're writing is quite normal and you're even using a computer. If you're talking about someone else who is not in perfect health or has neurological or cerebrovascular disease in the form of prior strokes, etc. then.....look at the options below.

In other words, what were the problems you were experiencing to took you in to get this study that demonstrated this high grade stenosis? Vertigo? Sudden episodes of nausea or vomiting? Robotic or unbalanced walking, veering while walking? Slurred speech, funny feelings in the face, arm, or leg? Or was this an INCIDENTAL finding?

Another question would be what type of study picked up on this particular problem? MRA study? CT angiogram? Intra-arterial angiogram? Cranial Doppler? The most PRECISE and "believable" study of those 4 in terms of the actual amount or percentage of stenosis would be the Intra-arterial angiogram with XXXXXXX injection with the least precise for numbers purposes problems being the cranial Doppler or digital ultrasound although if one adds COLOR DUPLEX to that study the sensitivity improves to an impressive amount. MRI/MRA (even if combined) has a disadvantage of OVERCALLING the amount of stenosis in cases where it is high grade (i.e. >75%) so the 90% that's being called in your case may not be nearly as high if your study was an MR. The problem with doing the conventional angiogram in the territory of the vertebral artery is that there is about a 2% risk of knocking off a piece of plaque that can zip right up into that artery and acutely plug up whatever small space is left (unless there's great collateral circulation....which most of the time there is....). Anyways, I always try to stick with NON-INVASIVE studies first and decide on invasive studies depending on the need to know.

A final question to be would be, if the ANGIOGRAM with XXXXXXX injection were the study performed, was there collateral circulation noted at the area of blockage? And if so, was there a rough estimate of how much of the total volume of blood arriving at the stenosed region was being diverted? And how mature was the vascular network formed from that collateral circulation? If the answer to this question is that there was a mature network of collateral circulation seen at the site of blockage which was handling at least 90% of the arriving blood flow without any regurgitation or stasis (i.e. STAGNANT FLOW) then, the risk of manipulating this nearly blocked artery with any type of mechanical device such as a stent or surgically is extremely risky and could a major stroke on the table. I would not recommend such a procedure under those circumstances.

If on the other hand the blockage seems to have evolved over a very short course of time or was detected as a result of you having lost consciousness, suffered a stroke, or even a TIA demonstrating posterior fossa neurological signs and symptoms then, perhaps a more aggressive approach such as stent placement or balloon angioplasty might be reasonable combined with ANTIPLATELET therapy.

If you are what we refer to as an ASYMPTOMATIC patient which means that this finding was discovered just as a coincidental finding when someone got an MRI or an MRA of your neck for some other reason and you've not demonstrated, complained, or even have any neurological signs referable to vascular deficiency in the territory of the brainstem managed by this artery then, current standards of care DO NOT recommend any sort of intervention. This is in large part due to the assumption that since there are no symptoms that you have presented the likelihood of this being an ACUTE BLOCKAGE from a blood clot coming up from the heart or elsewhere...is highly unlikely and that the narrowing down of the artery has taken a LONG LONG TIME to form giving the collateral circulation plenty of time to form and become fully functional. Again, it may be somewhat emotional to some people to sound so "UNpassionate" about wanting to rush in like it was a 5 alarm fire and "DO SOMETHING"....but the good practice of medicine requires that we keep levels heads and think long and hard before messing around with stable systems that the body has found a solution for already. I much rather put my confidence in Mother Nature's COLLATERAL CIRCULATION system that she's produced for me than having some human being (not matter how astute and careful they may be) going into such a risky vascular area thinking they can do better...stakes are too great....make sense?

However, if the clot that formed is one which hit acutely causing you to pass out or suffer from signs and symptoms of either a TIA or a stroke then, the approach may be that of an open surgical revascularization process or an endovascular procedure which can be either a stent, angioplasty, or endarterectomy or ROTO-ROOTING as surgeons may playfully toss out with residents on rounds (i.e. digging a clot out of an artery). And then, there are other surgical procedures which we won't get too far into because I'm not a neurosurgeon but rather a neurologist so am MOST familiar with the primary surgical procedures but not some of the newer (some unproven) techniques.

But, here is something to keep in mind....in virtually all cases of vertebral artery stenosis that are high grade....MEDICAL THERAPY (using antiplatelet or other agents) is generally my first choice before going to the surgical interventions. That is because of this little pearl of wisdom. It is pretty universally accepted (and has been shown) that if the opposite vertebral artery (in your case the LEFT side) is in good shape...meaning <50% blocked that it BY ITSELF can supply enough blood to easily supply the next big artery up the chain NO MATTER how blocked the right side. Again, read that carefully. If the GOOD side is of normal caliber then, it by itself will supply MORE THAN ENOUGH blood to the rest of the circulation in the back of the brain and certainly in conjunction with collateral circulation from the diseased side as well as whatever small of blood is getting through the blocked artery can keep normal functions in perpetuity going.

This means that when someone tells you that you have a high grade stenosis of the vertebral artery there should be 2 immediate questions popping up.

1. Just how accurate is the percentage being stated (that depends on how they got the number according to what I wrote up top)
2. How good is the opposite vertebral artery.

Now, of course, if the opposite vertebral is in bad shape as well (i.e. >50% blocked) then, all that's going for you are the collateral circulations which still may be enough but then, the decision to treat or not depends upon symptoms and how your arteries got to the diseased state. If it's because of smoking, out of control hypertension, out of control diabetes, out of control high cholesterol or high fat diets, etc. well, then, there are some problems that you need to resolve in order to try and stop the progression of disease as well as putting a treatment in place going forward to minimize complications through 2 diseased arteries feeding the brain.

However, as stated above....my first GOTO is virtually always going to be to prescribe a MEDICATION of an antiplatelet nature with or without aspirin on board....I don't necessarily use ANTICOAGULANTS because the literature is not yet clearly defined on the use of anticoagulants for vertebral artery stenosis against antiplatelet agents.....UNLESS one is talking about a patient who has atrial fibrillation or has a demonstrated intracardiac blood clot, or someone who has had a heart attack in the past and now may have poor ventricular wall motion which risks the FORMATION of blood clots within the heart, etc. So in those cases the likely choice medically speaking is going to be some type of anticoagulant medication (coumadin, Xaralto, Eliquis, etc.) and possibly aspirin as well. Make sense?

If the patient fails this line of therapy by having some symptoms that suggest a lack of blood flow to the posterior circulation such as ongoing symptoms of dizziness, vertigo, bouts of nausea/vomiting, fogginess in thinking, or loss of balance upon standing that slowly resolves or gets worse until the patient sits down...well then, that patient buys themselves a SURGICAL CONSULTATION with their friendly neighborhood neurovascular surgeon at which point we can discuss surgical options.

And so now, you have a bit more information to work with alongside your doctor. I think I would be wary of people trying to convince that strictly based upon a single number of 90% that this represents an absolute life or death emergency and requires immediate intervention. I think I've demonstrated with information that you really should look into the validity of the numbers being given since the range of error can be substantial depending upon the type of study which obtained the blockage %. Ultrasound and Doppler tend to UNDERestimate lesion caliber while MRI/MRA studies tend to OVERESTIMATE. Intra-arterial with XXXXXXX injection (referred to also as digital subtraction) is considered the GOLD STANDARD of diagnostic studies....BUT, it carries a risk of complication which can be minor or cause death on the table since blocking any number of critical arteries by a piece of plaque or other debris can occur even in the most careful and experienced hands. I always try and manage people with NON-invasive diagnostic techniques.

And so kind person, if I've provided useful or helpful information to your question could you do me the utmost of favors by CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you feel it is deserving? I am definitely interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

This query required 60 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Best therapy based upon how the artery got to 90%

Detailed Answer:
Good afternoon sir and thank you for writing your question on this network.

Your question is not quite as straight forward in response as it may have been 20 years ago because the absolute deluge of information that has been produced over the past 2 decades on the natural history and ways of measuring intravascular blood flows through normal as well as diseased blood vessels under a variety of circumstances and scenarios....it's almost mind boggling how information has exploded on the topic. It is also unfortunately the case that there remains a HUGE amount of general ignorance among both specialist and non-specialist physicians as to the myriad of options available on the surgical and/or invasive fronts...and even on the medical treatment fronts that really has changed the landscape of both survival as well as morbidity from intracranial vascular disease. The trick is to know which studies are done well and which are done without good controls or screening procedures in order to legitimately interpret the results.

As "bad" as that number of 90% may sound....you've really not provided key information to know whether I (or any other doctor) should be proceeding expeditiously to make certain critical decisions need to be made vs. just advising you to be calm, take a deep breath or 2 and keep living your life as you would've before you were given that information. If you are writing to in reference to yourself and are an outpatient then, I'm pretty sure you've not suffered a recent major stroke since you're writing is quite normal and you're even using a computer. If you're talking about someone else who is not in perfect health or has neurological or cerebrovascular disease in the form of prior strokes, etc. then.....look at the options below.

In other words, what were the problems you were experiencing to took you in to get this study that demonstrated this high grade stenosis? Vertigo? Sudden episodes of nausea or vomiting? Robotic or unbalanced walking, veering while walking? Slurred speech, funny feelings in the face, arm, or leg? Or was this an INCIDENTAL finding?

Another question would be what type of study picked up on this particular problem? MRA study? CT angiogram? Intra-arterial angiogram? Cranial Doppler? The most PRECISE and "believable" study of those 4 in terms of the actual amount or percentage of stenosis would be the Intra-arterial angiogram with XXXXXXX injection with the least precise for numbers purposes problems being the cranial Doppler or digital ultrasound although if one adds COLOR DUPLEX to that study the sensitivity improves to an impressive amount. MRI/MRA (even if combined) has a disadvantage of OVERCALLING the amount of stenosis in cases where it is high grade (i.e. >75%) so the 90% that's being called in your case may not be nearly as high if your study was an MR. The problem with doing the conventional angiogram in the territory of the vertebral artery is that there is about a 2% risk of knocking off a piece of plaque that can zip right up into that artery and acutely plug up whatever small space is left (unless there's great collateral circulation....which most of the time there is....). Anyways, I always try to stick with NON-INVASIVE studies first and decide on invasive studies depending on the need to know.

A final question to be would be, if the ANGIOGRAM with XXXXXXX injection were the study performed, was there collateral circulation noted at the area of blockage? And if so, was there a rough estimate of how much of the total volume of blood arriving at the stenosed region was being diverted? And how mature was the vascular network formed from that collateral circulation? If the answer to this question is that there was a mature network of collateral circulation seen at the site of blockage which was handling at least 90% of the arriving blood flow without any regurgitation or stasis (i.e. STAGNANT FLOW) then, the risk of manipulating this nearly blocked artery with any type of mechanical device such as a stent or surgically is extremely risky and could a major stroke on the table. I would not recommend such a procedure under those circumstances.

If on the other hand the blockage seems to have evolved over a very short course of time or was detected as a result of you having lost consciousness, suffered a stroke, or even a TIA demonstrating posterior fossa neurological signs and symptoms then, perhaps a more aggressive approach such as stent placement or balloon angioplasty might be reasonable combined with ANTIPLATELET therapy.

If you are what we refer to as an ASYMPTOMATIC patient which means that this finding was discovered just as a coincidental finding when someone got an MRI or an MRA of your neck for some other reason and you've not demonstrated, complained, or even have any neurological signs referable to vascular deficiency in the territory of the brainstem managed by this artery then, current standards of care DO NOT recommend any sort of intervention. This is in large part due to the assumption that since there are no symptoms that you have presented the likelihood of this being an ACUTE BLOCKAGE from a blood clot coming up from the heart or elsewhere...is highly unlikely and that the narrowing down of the artery has taken a LONG LONG TIME to form giving the collateral circulation plenty of time to form and become fully functional. Again, it may be somewhat emotional to some people to sound so "UNpassionate" about wanting to rush in like it was a 5 alarm fire and "DO SOMETHING"....but the good practice of medicine requires that we keep levels heads and think long and hard before messing around with stable systems that the body has found a solution for already. I much rather put my confidence in Mother Nature's COLLATERAL CIRCULATION system that she's produced for me than having some human being (not matter how astute and careful they may be) going into such a risky vascular area thinking they can do better...stakes are too great....make sense?

However, if the clot that formed is one which hit acutely causing you to pass out or suffer from signs and symptoms of either a TIA or a stroke then, the approach may be that of an open surgical revascularization process or an endovascular procedure which can be either a stent, angioplasty, or endarterectomy or ROTO-ROOTING as surgeons may playfully toss out with residents on rounds (i.e. digging a clot out of an artery). And then, there are other surgical procedures which we won't get too far into because I'm not a neurosurgeon but rather a neurologist so am MOST familiar with the primary surgical procedures but not some of the newer (some unproven) techniques.

But, here is something to keep in mind....in virtually all cases of vertebral artery stenosis that are high grade....MEDICAL THERAPY (using antiplatelet or other agents) is generally my first choice before going to the surgical interventions. That is because of this little pearl of wisdom. It is pretty universally accepted (and has been shown) that if the opposite vertebral artery (in your case the LEFT side) is in good shape...meaning <50% blocked that it BY ITSELF can supply enough blood to easily supply the next big artery up the chain NO MATTER how blocked the right side. Again, read that carefully. If the GOOD side is of normal caliber then, it by itself will supply MORE THAN ENOUGH blood to the rest of the circulation in the back of the brain and certainly in conjunction with collateral circulation from the diseased side as well as whatever small of blood is getting through the blocked artery can keep normal functions in perpetuity going.

This means that when someone tells you that you have a high grade stenosis of the vertebral artery there should be 2 immediate questions popping up.

1. Just how accurate is the percentage being stated (that depends on how they got the number according to what I wrote up top)
2. How good is the opposite vertebral artery.

Now, of course, if the opposite vertebral is in bad shape as well (i.e. >50% blocked) then, all that's going for you are the collateral circulations which still may be enough but then, the decision to treat or not depends upon symptoms and how your arteries got to the diseased state. If it's because of smoking, out of control hypertension, out of control diabetes, out of control high cholesterol or high fat diets, etc. well, then, there are some problems that you need to resolve in order to try and stop the progression of disease as well as putting a treatment in place going forward to minimize complications through 2 diseased arteries feeding the brain.

However, as stated above....my first GOTO is virtually always going to be to prescribe a MEDICATION of an antiplatelet nature with or without aspirin on board....I don't necessarily use ANTICOAGULANTS because the literature is not yet clearly defined on the use of anticoagulants for vertebral artery stenosis against antiplatelet agents.....UNLESS one is talking about a patient who has atrial fibrillation or has a demonstrated intracardiac blood clot, or someone who has had a heart attack in the past and now may have poor ventricular wall motion which risks the FORMATION of blood clots within the heart, etc. So in those cases the likely choice medically speaking is going to be some type of anticoagulant medication (coumadin, Xaralto, Eliquis, etc.) and possibly aspirin as well. Make sense?

If the patient fails this line of therapy by having some symptoms that suggest a lack of blood flow to the posterior circulation such as ongoing symptoms of dizziness, vertigo, bouts of nausea/vomiting, fogginess in thinking, or loss of balance upon standing that slowly resolves or gets worse until the patient sits down...well then, that patient buys themselves a SURGICAL CONSULTATION with their friendly neighborhood neurovascular surgeon at which point we can discuss surgical options.

And so now, you have a bit more information to work with alongside your doctor. I think I would be wary of people trying to convince that strictly based upon a single number of 90% that this represents an absolute life or death emergency and requires immediate intervention. I think I've demonstrated with information that you really should look into the validity of the numbers being given since the range of error can be substantial depending upon the type of study which obtained the blockage %. Ultrasound and Doppler tend to UNDERestimate lesion caliber while MRI/MRA studies tend to OVERESTIMATE. Intra-arterial with XXXXXXX injection (referred to also as digital subtraction) is considered the GOLD STANDARD of diagnostic studies....BUT, it carries a risk of complication which can be minor or cause death on the table since blocking any number of critical arteries by a piece of plaque or other debris can occur even in the most careful and experienced hands. I always try and manage people with NON-invasive diagnostic techniques.

And so kind person, if I've provided useful or helpful information to your question could you do me the utmost of favors by CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you feel it is deserving? I am definitely interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

This query required 60 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Ahhhh....The Devil is in the DETAILS

Detailed Answer:
I'm really a glutton for details. I find it so difficult to answer questions as you had asked initially with XXXXXXX answers since it's rarely accurate for the individual unless you know their history. And so the plot thickens. Also, you said you suffered a TGA event. TGA stands for TRANSIENT GLOBAL AMNESIA.....Did you mean TIA (Transient ISCHEMIC ATTACK)? BTW, that term is one now that is questioned and falling out of favor since there are radiographic ways of actually detecting STROKE DAMAGE that then, makes the incident a STROKE which may not have left the person with any detectable clinical residua....but the fact that it showed on the scan makes the term TIA actually incorrect. TECHNOLOGY! Ugghh... At any rate, let's just go with TIA which would imply NO STROKE either clinically or radiographically.

So in 2012 there is detected narrowing of the right subclavian artery from where the vertebral artery originates (BTW, you don't have a vertebral artery with an anomalous origin or anything like that do you?).

Then, in 2016 you suffered a lacunar infarct affecting thalamic penetrators on the right (left side of body affected?) and the right subclavian was shown to be stable while 36% right carotid plaqueing and narrowing was detected.

In 2017, repeat CT with angio demonstrated no significant narrowing of the vertebral arteries.

In Feb. 2019 symptoms of hand and leg weakness occurs (side unspecified in your message but shall I assume LEFT given the findings of RIGHT vascular progression of plaque disease and narrowing?). Now, subclavian, carotid on the right are up to 50% and the right vertebral which was not at any clinically significant level per previous findings in 2017 is now up to 90%. You also mention at this juncture that the vertebral artery is noted as hypoplastic but was that known BEFORE the tagging of the 90% stenosis? Was in known in 2017 to be hypoplastic? If that was not documented is is possible that the 90% stenosis called recently is IN PART due to the fact that it is a HYPOPLASTIC VESSEL? Or is it a truly hypoplastic vessel which is something you're born with....which is now 90% stenosed? Radiology would have to ferret those questions out for you more than anything....or we would need to get all the scans, study them, and see what was called, when, etc.

In 2019 we have a call that the LEFT vertebral artery is NORMAL caliber. Also, there appears to be microvascular changes (not surprising due to normal aging given your lack of vascular risk factors). The treating doctor (primary or neurologist?) stated that the cause of the stroke was likely due to small vessel ischemic disease (which side of the brain was the stroke on? Right??). You said that your symptoms of weakness of the leg and hand were transient but that the MRI did not demonstrate damage. Did they also perform a DIFFUSION/PERFUSION WEIGHTED STUDY to prove that no breach of the blood/brain barrier had occurred?

So my question is this- what medication regimens have you been on since 2012 for prophylactic measures against future small vessel ischemic disease? Aspirin, Plavix, Aggrenox? Have any other diagnostic measures been taken to identify other possible sources of stroke such as the heart? Have you had any screening of the abdominal aorta or the lower extremities to look for peripheral arterial disease (PAD)? It certainly seems like a quick evolution of events in terms of what happened to the right vertebral artery...but again, I'm not clear on the side of the body you had this last event. If it doesn't correspond to the side or TERRITORY of perfusion of the vertebral artery then, it might not be relevant no matter how fast it developed. Also, we need to keep in mind what I stated before about having one normal vertebral artery and one diseased artery. Conventional wisdom states that the GOOD vertebral artery can supply ample and adequate flow volume to supply the rest of the posterior circulation without having to perform potentially dangerous surgical or even endovascular procedures.

If you've been on BEST MEDICAL TREATMENT since 2012 after the first stroke and especially after the 2nd event in 2016 but still broke through with another TIA recently.....AND IF, it can be established with a high degree of probability that these last 2 events were caused by flow issues and/or pieces of plaque that may have broken off from the right vertebral artery then, I would say you could be a candidate for a surgical approach to remedy this vessel.

Once again, if I've provided information of value could you consider CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you have no further questions. Your case turns out to be complex and interesting because not only is it not black and white to me that surgical manipulation of the right vertebral artery is indicated....I think it would be very interesting and NECESSARY to try and discover why atheroslcerosis progressed so rapidly in a person who apparently has the least number of risk values aside from normal aging.

I see that you are in the Toronto area which is not that far from XXXXXXX OH which is where we are located. Although an in person evaluation would clearly be the BEST form of evaluation of your condition as well as being able to perform diagnostic studies to corroborate that might be costly if you are depending upon your National Health Service as your primary source of medical coverage. I don't believe anything you do in the U.S. would be covered under that plan unless you obtained special dispensation before going and having things done. Another option would be to do a FULL RECORDS review of not only reports and documents but of the original DISKS with the imaging information on them in order to assess the timeline and review the scans for additional details that may not have been called the first time around. If you would have any interest in pursuing either of those options please feel free to give us a call at Parma Neurology during business hours at 440.842.3816 and we'll be happy to give you details on how any of this can be arranged.

I am at least interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out even you decide not to get any further or more indepth evaluations done on this side of the Great Lakes! LOL

You can always reach me at the above URL for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

This query required 130 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Ahhhh....The Devil is in the DETAILS

Detailed Answer:
I'm really a glutton for details. I find it so difficult to answer questions as you had asked initially with XXXXXXX answers since it's rarely accurate for the individual unless you know their history. And so the plot thickens. Also, you said you suffered a TGA event. TGA stands for TRANSIENT GLOBAL AMNESIA.....Did you mean TIA (Transient ISCHEMIC ATTACK)? BTW, that term is one now that is questioned and falling out of favor since there are radiographic ways of actually detecting STROKE DAMAGE that then, makes the incident a STROKE which may not have left the person with any detectable clinical residua....but the fact that it showed on the scan makes the term TIA actually incorrect. TECHNOLOGY! Ugghh... At any rate, let's just go with TIA which would imply NO STROKE either clinically or radiographically.

So in 2012 there is detected narrowing of the right subclavian artery from where the vertebral artery originates (BTW, you don't have a vertebral artery with an anomalous origin or anything like that do you?).

Then, in 2016 you suffered a lacunar infarct affecting thalamic penetrators on the right (left side of body affected?) and the right subclavian was shown to be stable while 36% right carotid plaqueing and narrowing was detected.

In 2017, repeat CT with angio demonstrated no significant narrowing of the vertebral arteries.

In Feb. 2019 symptoms of hand and leg weakness occurs (side unspecified in your message but shall I assume LEFT given the findings of RIGHT vascular progression of plaque disease and narrowing?). Now, subclavian, carotid on the right are up to 50% and the right vertebral which was not at any clinically significant level per previous findings in 2017 is now up to 90%. You also mention at this juncture that the vertebral artery is noted as hypoplastic but was that known BEFORE the tagging of the 90% stenosis? Was in known in 2017 to be hypoplastic? If that was not documented is is possible that the 90% stenosis called recently is IN PART due to the fact that it is a HYPOPLASTIC VESSEL? Or is it a truly hypoplastic vessel which is something you're born with....which is now 90% stenosed? Radiology would have to ferret those questions out for you more than anything....or we would need to get all the scans, study them, and see what was called, when, etc.

In 2019 we have a call that the LEFT vertebral artery is NORMAL caliber. Also, there appears to be microvascular changes (not surprising due to normal aging given your lack of vascular risk factors). The treating doctor (primary or neurologist?) stated that the cause of the stroke was likely due to small vessel ischemic disease (which side of the brain was the stroke on? Right??). You said that your symptoms of weakness of the leg and hand were transient but that the MRI did not demonstrate damage. Did they also perform a DIFFUSION/PERFUSION WEIGHTED STUDY to prove that no breach of the blood/brain barrier had occurred?

So my question is this- what medication regimens have you been on since 2012 for prophylactic measures against future small vessel ischemic disease? Aspirin, Plavix, Aggrenox? Have any other diagnostic measures been taken to identify other possible sources of stroke such as the heart? Have you had any screening of the abdominal aorta or the lower extremities to look for peripheral arterial disease (PAD)? It certainly seems like a quick evolution of events in terms of what happened to the right vertebral artery...but again, I'm not clear on the side of the body you had this last event. If it doesn't correspond to the side or TERRITORY of perfusion of the vertebral artery then, it might not be relevant no matter how fast it developed. Also, we need to keep in mind what I stated before about having one normal vertebral artery and one diseased artery. Conventional wisdom states that the GOOD vertebral artery can supply ample and adequate flow volume to supply the rest of the posterior circulation without having to perform potentially dangerous surgical or even endovascular procedures.

If you've been on BEST MEDICAL TREATMENT since 2012 after the first stroke and especially after the 2nd event in 2016 but still broke through with another TIA recently.....AND IF, it can be established with a high degree of probability that these last 2 events were caused by flow issues and/or pieces of plaque that may have broken off from the right vertebral artery then, I would say you could be a candidate for a surgical approach to remedy this vessel.

Once again, if I've provided information of value could you consider CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you have no further questions. Your case turns out to be complex and interesting because not only is it not black and white to me that surgical manipulation of the right vertebral artery is indicated....I think it would be very interesting and NECESSARY to try and discover why atheroslcerosis progressed so rapidly in a person who apparently has the least number of risk values aside from normal aging.

I see that you are in the Toronto area which is not that far from XXXXXXX OH which is where we are located. Although an in person evaluation would clearly be the BEST form of evaluation of your condition as well as being able to perform diagnostic studies to corroborate that might be costly if you are depending upon your National Health Service as your primary source of medical coverage. I don't believe anything you do in the U.S. would be covered under that plan unless you obtained special dispensation before going and having things done. Another option would be to do a FULL RECORDS review of not only reports and documents but of the original DISKS with the imaging information on them in order to assess the timeline and review the scans for additional details that may not have been called the first time around. If you would have any interest in pursuing either of those options please feel free to give us a call at Parma Neurology during business hours at 440.842.3816 and we'll be happy to give you details on how any of this can be arranged.

I am at least interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out even you decide not to get any further or more indepth evaluations done on this side of the Great Lakes! LOL

You can always reach me at the above URL for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

This query required 130 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Many thanks for your clarifications

Detailed Answer:
Actually, your offer to reimburse for additional information is very generous indeed, however, per the rules governing of this site I believe you are allowed up to 3 questions before you are asked to close the thread, rate your responding doctor, and then, if you would like to open a NEW line of questions you may do so by SPECIFICALLY addressing the doctor you had. Or you have the option of asking for a separate opinion from anyone else in the forum simply by posting a new question which can be seen and answered by any physician credentialed to pick up the inquiry.

Therefore, I am very happy to continue answering your questions by following the rules of this website but am very honored that you find the responses worthy of additional remuneration. A HUGE THANK YOU!

As I had indicated in my previous response I am available for a more conventional and formal doctor/patient relationship not based upon telemedicine platform but this will be more costly, however, in the end is really the ultimate way for a doctor/patient relationship to be established (in my opinion). That would mean being able to see and examine you as an office patient or it could be in the form of a comprehensive records review but for either of those two things to happen you would want to contact us here in the U.S. at 440.842.3816 (Parma Neurology) and obtain details during normal business hours M-F and then, you could decide where to go from there.

Now, let's look at the additional information you've provided in order to try and make sense of some of these things going on with your vertebral artery.

Frankly, I don't have any solid explanation as to why there would be a 90% stenosis of only 1 vertebral artery over the course of 12 months or less whereas nothing seems to be happening to the fellow vertebral artery. Although it is not uncommon at all for there to be focal plaqueing of one artery vs. another....it is very uncommon for one to be virtually occluded with the opposite to be absolutely clean UNLESS there are flow dynamic considerations whereby the right vertebral artery is under some high restrictive pattern of extravascular compression which could be causing the equivalent of a LOCAL HYPERTENSIVE situation right where the artery takes off from the subclavian? I really can't say without physically looking at the films and even perhaps reviewing them with a neuroradiologist. It makes even less sense this should be happening in light of your statement that you do not have any sign of elevated cholesterol.

I am concerned about your being placed on a STATIN without more explanation as to why you are growing such an occlusion in the face of normal cholesterol numbers. To be fair I've not seen those numbers (not doubting what you're saying, however, I would want to see your cholesterol panel numbers such as LDL, HDL, RATIO, and perhaps other fractions of the cholesterol which are not typically requested such as IDL, VLDL, etc).

There is another explanation to the focal stenotic state of the right vertebral which would involve invoking a theory that perhaps at some point in the past (within the last year) you may have had a SPONTANEOUS DISSECTION of the vertebral on the right (tear in the inner lining of the blood vessel) which then, bled into the wall of the artery resulting in a significant EXPANSION of the wall of the blood vessel since we now have a TRAPPED blood clot. The problem with that theory is that typically, vertebral artery dissections are dramatic events that people don't forget and they involve strokes in a high number of cases to cause significant debility and are not things that simply "fly under the radar." There are headaches, facial pains, nausea, vomiting, pulsatile tinnitus in one ear, dizziness, vertigo, swallowing problems, speech problems, poor balance and coordination. And these generally don't rocket scientists to notice just from the people around you....and especially yourself. They can occur spontaneously due to acquired genetic types of conditions involving collagen vascular diseases and you seem to be pretty healthy otherwise. Or they occur as a result of a trauma to the head or neck. Car accidents, whiplash effect, or FORCEFUL AND PROLONGED COUGHING spasms that may be as a result of a respiratory infection, bronchitis, sinusitis, etc. (a bit rarer to occur this way than by more direct traumatic blows to the head and neck...nonetheless). If you suffered any of these things within the last 12 months....it is theoretically possible that you may have caused this arterial lining tear and the resulting occlusive phenomenon.

Of course, how about the most common reason why something is NOT 90% that wasn't even close a year ago? Well, the number is INCORRECT and I think I mentioned that in my 1st response. Therefore, one way to solve that problem is to ask another neuroradiologist to read the original data images without giving them any real history and just ask them for an assessment of the neck vessels. See what they say. Or the way to do it which is logistically easier is to simply REPEAT THE STUDY. I will tell you that CT ANGIOGRAPHY uses a LOT of X-ray radiation that I don't constantly patients to and so when possible I'm using either transcranial Doppler, Cervical Duplex COLOR scanning (better sensitivity than NONcolor) or in very necessary cases Digital Subtraction Angiography (DSA) with XXXXXXX contrast...but again, lots of the iodine they use for this procedure even in healthy individuals is a risk. You will also want to make sure your doctor INDICATES to the angiographer that you do have an alleged 90% blockage of the right vertebral artery which means they will exercise even more caution as they approach that area with the catheter that they will be snaking up through your groin.

I would also find out from radiology if there are noninvasive methods of verifying that the occlusion we are looking at as the 90% stenosis is actual ATHEROSCLEROTIC plaque. Ultrasound should be able to distinguish this from anything else such as blood from a dissection or something outside the blood vessel squeezing down on it to cause the stenosis....mentioned above.

The other detail is remember which I also wrote in the 1st response is that MRI/MRA tends to OVERESTIMATE the amount of blockage or stenosis of a blood vessel so that 90% may really only be 60-70%...or even less as I've seen. The other detail is that if the vessel is truly HYPOPLASTIC then, perhaps there is more of an APPEARANCE of a high grade stenosis when actually a very low grade exists due to error magnification of the stricture. Remember, the machine is literally assessing and reconstructing millimeters at a time images that could have a little motion artifact from yourself or the machine itself which vibrates when magnets are turned on or off (assuming it's MRI/MRA we're talking about)...so for all these reasons, if it were me and I wanted to avoid doing any invasive I would simply repeat the study...Furthermore, I would ask it to be with a technique called FAT SUPPRESSION with gadolinium contrast which will take out more noise from the area of stenosis and may reveal more tissue characterization of the area of blockage or stenosis.

If you were experiencing general weakness in BOTH legs and fatigue then, it does not XXXXXXX that the MRI was negative. I don't think I would've been so ready to perform an MRI in that situation knowing that there was a high probability of coming out negative...very high based upon symptoms. Remember, we as physicians have to focus on what is scientific and anatomical fact and not get caught up too much in emotional swings of ear/anxiety which patients may demonstrate and which could taint our diagnostic or procedural decisions. The right vertebral artery was not involved in the latest episode of April by anatomical dictum.

You in fact, did some have at least a diffusion weighted analysis when they diagnosed the lacunar stroke in 2012 (most of the time PERFUSION analysis is done at the same time)...it's in the report's remarks that you wrote to me. That's why I asked if they did that subsequently on the stroke with the weakness of the leg and hand. It would've had to have been specifically ordered by the physician or SUSPECTED by the radiologist based upon information he was being given by the referring doctor. The report would likely contain the results of such an analysis. It is too late to go back now and recupe the event of Feb. 2019 or 2016.

Once again, thank you for your clarifications and the opportunity to be opining on your case. I am very interested in knowing how things progress down the road and look forward to hearing if you might be interested in being either seen at Parma Neurology or have us complete a formal records review with comments and recommendations.

Cheers!

This query required 210 minutes of professional time to research, assimilate, and file a response.

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Brief Answer:
Many thanks for your clarifications

Detailed Answer:
Actually, your offer to reimburse for additional information is very generous indeed, however, per the rules governing of this site I believe you are allowed up to 3 questions before you are asked to close the thread, rate your responding doctor, and then, if you would like to open a NEW line of questions you may do so by SPECIFICALLY addressing the doctor you had. Or you have the option of asking for a separate opinion from anyone else in the forum simply by posting a new question which can be seen and answered by any physician credentialed to pick up the inquiry.

Therefore, I am very happy to continue answering your questions by following the rules of this website but am very honored that you find the responses worthy of additional remuneration. A HUGE THANK YOU!

As I had indicated in my previous response I am available for a more conventional and formal doctor/patient relationship not based upon telemedicine platform but this will be more costly, however, in the end is really the ultimate way for a doctor/patient relationship to be established (in my opinion). That would mean being able to see and examine you as an office patient or it could be in the form of a comprehensive records review but for either of those two things to happen you would want to contact us here in the U.S. at 440.842.3816 (Parma Neurology) and obtain details during normal business hours M-F and then, you could decide where to go from there.

Now, let's look at the additional information you've provided in order to try and make sense of some of these things going on with your vertebral artery.

Frankly, I don't have any solid explanation as to why there would be a 90% stenosis of only 1 vertebral artery over the course of 12 months or less whereas nothing seems to be happening to the fellow vertebral artery. Although it is not uncommon at all for there to be focal plaqueing of one artery vs. another....it is very uncommon for one to be virtually occluded with the opposite to be absolutely clean UNLESS there are flow dynamic considerations whereby the right vertebral artery is under some high restrictive pattern of extravascular compression which could be causing the equivalent of a LOCAL HYPERTENSIVE situation right where the artery takes off from the subclavian? I really can't say without physically looking at the films and even perhaps reviewing them with a neuroradiologist. It makes even less sense this should be happening in light of your statement that you do not have any sign of elevated cholesterol.

I am concerned about your being placed on a STATIN without more explanation as to why you are growing such an occlusion in the face of normal cholesterol numbers. To be fair I've not seen those numbers (not doubting what you're saying, however, I would want to see your cholesterol panel numbers such as LDL, HDL, RATIO, and perhaps other fractions of the cholesterol which are not typically requested such as IDL, VLDL, etc).

There is another explanation to the focal stenotic state of the right vertebral which would involve invoking a theory that perhaps at some point in the past (within the last year) you may have had a SPONTANEOUS DISSECTION of the vertebral on the right (tear in the inner lining of the blood vessel) which then, bled into the wall of the artery resulting in a significant EXPANSION of the wall of the blood vessel since we now have a TRAPPED blood clot. The problem with that theory is that typically, vertebral artery dissections are dramatic events that people don't forget and they involve strokes in a high number of cases to cause significant debility and are not things that simply "fly under the radar." There are headaches, facial pains, nausea, vomiting, pulsatile tinnitus in one ear, dizziness, vertigo, swallowing problems, speech problems, poor balance and coordination. And these generally don't rocket scientists to notice just from the people around you....and especially yourself. They can occur spontaneously due to acquired genetic types of conditions involving collagen vascular diseases and you seem to be pretty healthy otherwise. Or they occur as a result of a trauma to the head or neck. Car accidents, whiplash effect, or FORCEFUL AND PROLONGED COUGHING spasms that may be as a result of a respiratory infection, bronchitis, sinusitis, etc. (a bit rarer to occur this way than by more direct traumatic blows to the head and neck...nonetheless). If you suffered any of these things within the last 12 months....it is theoretically possible that you may have caused this arterial lining tear and the resulting occlusive phenomenon.

Of course, how about the most common reason why something is NOT 90% that wasn't even close a year ago? Well, the number is INCORRECT and I think I mentioned that in my 1st response. Therefore, one way to solve that problem is to ask another neuroradiologist to read the original data images without giving them any real history and just ask them for an assessment of the neck vessels. See what they say. Or the way to do it which is logistically easier is to simply REPEAT THE STUDY. I will tell you that CT ANGIOGRAPHY uses a LOT of X-ray radiation that I don't constantly patients to and so when possible I'm using either transcranial Doppler, Cervical Duplex COLOR scanning (better sensitivity than NONcolor) or in very necessary cases Digital Subtraction Angiography (DSA) with XXXXXXX contrast...but again, lots of the iodine they use for this procedure even in healthy individuals is a risk. You will also want to make sure your doctor INDICATES to the angiographer that you do have an alleged 90% blockage of the right vertebral artery which means they will exercise even more caution as they approach that area with the catheter that they will be snaking up through your groin.

I would also find out from radiology if there are noninvasive methods of verifying that the occlusion we are looking at as the 90% stenosis is actual ATHEROSCLEROTIC plaque. Ultrasound should be able to distinguish this from anything else such as blood from a dissection or something outside the blood vessel squeezing down on it to cause the stenosis....mentioned above.

The other detail is remember which I also wrote in the 1st response is that MRI/MRA tends to OVERESTIMATE the amount of blockage or stenosis of a blood vessel so that 90% may really only be 60-70%...or even less as I've seen. The other detail is that if the vessel is truly HYPOPLASTIC then, perhaps there is more of an APPEARANCE of a high grade stenosis when actually a very low grade exists due to error magnification of the stricture. Remember, the machine is literally assessing and reconstructing millimeters at a time images that could have a little motion artifact from yourself or the machine itself which vibrates when magnets are turned on or off (assuming it's MRI/MRA we're talking about)...so for all these reasons, if it were me and I wanted to avoid doing any invasive I would simply repeat the study...Furthermore, I would ask it to be with a technique called FAT SUPPRESSION with gadolinium contrast which will take out more noise from the area of stenosis and may reveal more tissue characterization of the area of blockage or stenosis.

If you were experiencing general weakness in BOTH legs and fatigue then, it does not XXXXXXX that the MRI was negative. I don't think I would've been so ready to perform an MRI in that situation knowing that there was a high probability of coming out negative...very high based upon symptoms. Remember, we as physicians have to focus on what is scientific and anatomical fact and not get caught up too much in emotional swings of ear/anxiety which patients may demonstrate and which could taint our diagnostic or procedural decisions. The right vertebral artery was not involved in the latest episode of April by anatomical dictum.

You in fact, did some have at least a diffusion weighted analysis when they diagnosed the lacunar stroke in 2012 (most of the time PERFUSION analysis is done at the same time)...it's in the report's remarks that you wrote to me. That's why I asked if they did that subsequently on the stroke with the weakness of the leg and hand. It would've had to have been specifically ordered by the physician or SUSPECTED by the radiologist based upon information he was being given by the referring doctor. The report would likely contain the results of such an analysis. It is too late to go back now and recupe the event of Feb. 2019 or 2016.

Once again, thank you for your clarifications and the opportunity to be opining on your case. I am very interested in knowing how things progress down the road and look forward to hearing if you might be interested in being either seen at Parma Neurology or have us complete a formal records review with comments and recommendations.

Cheers!

This query required 210 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
You're welcome....You're welcome and You're MOST Welcome!

Detailed Answer:
I'm very happy to hear that you have been given enough food for thought to make better informed decisions as to what can be done for your condition. I hope your doctors will avail themselves to you for discussions and consideration of some of the information you are now aware of with respect to your cerebrovascular disease as well as what how it relates to your symptoms.

BTW, I believe that the abbreviation TGA is an error and should've been transcribed as TIA.

TGA stands for Transient GLOBAL AMNESIA whereas TIA stands for Transient ISCHEMIC ATTACK. TGA events show absolutely nothing amiss when it comes to any type of imaging or electrical study of the brain. It is a condition where a person suddenly and inexplicably loses their ability to create short term memories for about 24 hrs or less. Then, just as spontaneously as they went out...they return as if nothing happened. It is not believed to be a psychiatric diagnosis though nobody quite knows what to call it if not psychiatric, possibly epileptic and less likely stroke.

I have had TGA patients where you could literally walk into their rooms, introduce yourself as Dr. XXXXXXX shake their hands, repeat your name once more, walk out of their rooms, turn and walk right back in to say HELLO to someone who will absolutely not recognize you but be just as cordial and friendly to make your acquaintance as they were 30 seconds ago. It's that quick, that bizarre, and I seriously doubt you had anything like that, correct? So, TGA is likely a typographical error. LOL....

I look forward to hearing from you in the future with any other questions, comments, or dilemmas. Keep in mind that Parma Neurology is always an option if you feel the necessity to obtain more in-depth answers or recommendations. And as far as diagnostic testing is concerned we have the ability of setting up and coordinating tests for patients who are out of state on the very same day of their arrival and office consultation.

Cheers!

This query required 270 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
You're welcome....You're welcome and You're MOST Welcome!

Detailed Answer:
I'm very happy to hear that you have been given enough food for thought to make better informed decisions as to what can be done for your condition. I hope your doctors will avail themselves to you for discussions and consideration of some of the information you are now aware of with respect to your cerebrovascular disease as well as what how it relates to your symptoms.

BTW, I believe that the abbreviation TGA is an error and should've been transcribed as TIA.

TGA stands for Transient GLOBAL AMNESIA whereas TIA stands for Transient ISCHEMIC ATTACK. TGA events show absolutely nothing amiss when it comes to any type of imaging or electrical study of the brain. It is a condition where a person suddenly and inexplicably loses their ability to create short term memories for about 24 hrs or less. Then, just as spontaneously as they went out...they return as if nothing happened. It is not believed to be a psychiatric diagnosis though nobody quite knows what to call it if not psychiatric, possibly epileptic and less likely stroke.

I have had TGA patients where you could literally walk into their rooms, introduce yourself as Dr. XXXXXXX shake their hands, repeat your name once more, walk out of their rooms, turn and walk right back in to say HELLO to someone who will absolutely not recognize you but be just as cordial and friendly to make your acquaintance as they were 30 seconds ago. It's that quick, that bizarre, and I seriously doubt you had anything like that, correct? So, TGA is likely a typographical error. LOL....

I look forward to hearing from you in the future with any other questions, comments, or dilemmas. Keep in mind that Parma Neurology is always an option if you feel the necessity to obtain more in-depth answers or recommendations. And as far as diagnostic testing is concerned we have the ability of setting up and coordinating tests for patients who are out of state on the very same day of their arrival and office consultation.

Cheers!

This query required 270 minutes of professional time to research, assimilate, and file a response.

---