The angiographic method chosen is influenced by other conditions of the patient (Fig. 3). In patients with extensive arteriosclerosis and renal insufficiency MRA without contrast material is reasonable selleck chemical to be performed (Class IIa, Level of Evidence: C). DSA may also be considered in case of renal dysfunction because of the advantage of limiting the amount of potentially nephrotoxic contrast material (Class IIb, Level of Evidence: C). When MRA is contraindicated, e.g. in patients with claustrophobia or implanted pacemaker, CTA can be effective for patient’s evaluation

(Class IIa, Level of Evidence: C). When duplex US, CTA, or MRA suggests complete carotid occlusion, catheter-based contrast angiography might be reasonable to decide whether carotid lumen is suitable for revascularization

procedure (Class IIb, Level of Evidence: C). Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid atherosclerosis. It is recommended if the degree of stenosis is more than 70% measured by non-invasive methods (Class I, Level of Evidence A) [9], or more than 50% with catheter angiography (Class I, Level of Evidence: B) [10] in symptomatic patients (TIA or ischemic stroke within the past 6 months) at average or low surgical risk with an anticipated perioperative stroke or mortality rate less than 6%. Carotid artery stenting (CAS) is an alternative method of CEA, which might be considered for patients with severe (>70%) stenosis, especially if Alectinib mouse the stenosis is difficult to access surgically (Class IIb, Level of Evidence: B) [11]. Non-invasive control of the extracranial arteries can be useful BCKDHB 1 month, 6 months and annually after revascularization (CEA/CAS) to ascertain the patency and to exclude the development of ipsi- or contralateral lesions (Class IIa, Level of Evidence: C).

Vertebral artery atherosclerosis is responsible for approximately 20% of posterior circulation stroke, which can be an underestimation because of the difficult visualization of vertebral arteries by ultrasonography [12]. The symptoms of vertebral artery disease include dizziness, vertigo, diplopia, tinnitus, blurred vision, perioral numbness, ataxia, bilateral sensory deficits and syncope. After clinical history and examination of the patient non-invasive imaging is needed in the initial evaluation process. In patients with symptoms suggesting posterior circulation deficits MRA or CTA should be preferred over ultrasonography to detect vertebral artery disease (Class I, Level of Evidence: C). If the location and degree of stenosis cannot be defined with certainty by these non-invasive methods and the patient with vertebrobasilar insufficiency symptoms may be a candidate to undergo revascularization procedure, catheter-based contrast angiography is reasonable to assess the pathoanatomy of the artery (Class IIa, Level of Evidence: C).