Policy
INDICATIONS FOR NECK CTA
Patients with claustrophobia, limited ability to cooperate or an implanted device may be better suited for CTA, whereas those with extensive calcification, renal disease or iodine contrast allergy should have MRA (Adla, 2015).

For evaluation of known or suspected extracranial vascular disease

Cerebrovascular Disease

• Recent ischemic stroke or transient ischemic attack (Robertson, 2020; Salmela, 2017; Sanelli, 2014).
• Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia, weakness in both sides of the body, or abnormal speech (Yang, 2005; Lima-Neto, 2017; Searls, 2012)
• Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) (Brott, 2011; DaCosta, 2019; Marquardt, 2010)
• Symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) (Brott, 2011; Chaturvedi, 2005; Rerkasem, 2011)

Aneurysm screening

• Screening for aneurysm in Loeys-Dietz syndrome**, fibromuscular dysplasia or spontaneous coronary arteries dissection (SCAD) (Hayes, 2018; Hitchock, 2014; Macaya, 2019; MacCarrick, 2014)

**For Loeys-Dietz imaging should be repeated at least every two years

Tumor/pulsatile mass

• Pulsatile mass on exam (Aulino, 2019)
• Known carotid body tumors, or other masses such as a paraganglioma, arteriovenous fistula pseudoaneurysm, atypical lymphovascular malformation (Nguyen, 2011).

Note: Ultrasound (US) may be used to identify a mass overlying or next to an artery in initial work up of a pulsatile mass.

Other extracranial vascular disease

Takayasu arteritis based on findings in other blood vessels on previous imaging (Zhu, 2012)

• Giant cell arteritis with suspected extracranial involvement (Abdel Razek, 2014; Halbach, 2018; Khan, 2015; Koster, 2018)
• Subclavian steal syndrome when ultrasound is positive or indeterminate OR for planning interventions (Potter, 2014)
• Suspected carotid or vertebral artery dissection; due to trauma or spontaneous due to weakness of vessel wall (Franz, 2012; Shakir, 2016)
• Horner’s syndrome (miosis, ptosis, and anhidrosis) (Kim, 2012) 
• For evaluation of pulsatile tinnitus (subjective or objective) for vascular etiology (Pegge, 2017)
• Known extracranial vascular disease that needs follow-up or further evaluation

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure

Post-operative/procedural evaluation (e.g., carotid endarterectomy):

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

INDICATIONS FOR COMBINATION STUDIES
Neck CTA/Brain CTA

• Recent ischemic stroke or transient ischemic attack (TIA) (Robertson, 2020; Salmela, 2017; Wintermark, 2013)
• Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia, weakness in both sides of the body, or abnormal speech (Lima-Neto 2017; Searls, 2012)
• Suspected carotid or vertebral artery dissection; due to trauma or spontaneous due to weakness of vessel wall (Franz, 2012; Shakir, 2016)
• Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate (Brott, 2011; DaCosta, 2019; Marquardt, 2010)
• Symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate (Brott, 2011; Chaturvedi, 2005; Rerkasem, 2011)
• Pulsatile tinnitus (subjective or objective) for vascular etiology (Pegge, 2017)

BACKGROUND
For vascular disease, MRA and CTA are generally comparable. No current literature compares the efficacy of contrast enhanced CT to CTA or MRI and MRA for evaluation of pulsatile neck mass, so any are approvable (Guneyli, 2014). CTA may be complementary to CT in the following settings: evaluation of a pulsatile neck mass to assess vascular detail when needed; assessment of relevant vascular anatomy for pre-procedural evaluation; vascular supply to tumors and vessel encasement and narrowing by tumors; extent of disease in vasculitis; and to help determine the nature and extent of congenital or acquired vascular anomalies.

CTA and dissection — Craniocervical dissections can be spontaneous or traumatic. Patients with blunt head or neck trauma who meet Denver Screening criteria should be assessed for cerebrovascular injury (although about 20% will not meet criteria). The criteria include: focal or lateralizing neurological deficits (not explained by head CT), infarct on head CT, face, basilar skull, or cervical spine fractures, cervical hematomas that are not expanding, glasgow coma score less than 8 without CT findings, massive epistaxis, cervical bruit or thrill (Franz, 2012; Liang, 2013; Mundinger, 2013; Simon, 2021). Spontaneous dissection presents with headache, neck pain with neurological signs or symptoms. There is often minor trauma or precipitating factor (e.g., exercise, neck manipulation). Dissection is thought to occur due to weakness of the vessel wall, and there may be an underlying connective tissue disorder. Dissection of the extracranial vessels can extend intracranially and/or lead to thrombus, which can migrate into the intracranial circulation causing ischemia. Therefore, MRA of the head and neck is warranted (Nash, 2019; Shakir, 2016).

CTA and recent stroke or transient ischemic attack (TIA) — A stroke or central nervous system infarction is defined as "brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. … Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, whereas silent infarction causes no known symptoms" (Sacco, 2013). If imaging or pathology is not available, a clinical stroke is diagnosed by symptoms persisting for more than 24 hours. Ischemic stroke can be further classified by the type and location of ischemia and the presumed etiology of the brain injury. These include large-artery atherosclerotic occlusion (extracranial or intracranial), cardiac embolism, small-vessel disease and less commonly dissection, hypercoagulable states, sickle cell disease and undetermined causes (Kernan, 2014). TIAs in contrast, "are a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction on imaging" (Easton, 2009). On average, the annual risk of future ischemic stroke after a TIA or initial ischemic stroke is 3 – 4%, with an incidence as high as 11% over the next 7 days and 24 – 29% over the following 5 years. This has significantly decreased in the last half century due to advances in secondary prevention (Hong, 2011).

When revascularization therapy is not indicated or available in patients with an ischemic stroke or TIA, the focus of the work-up is on secondary prevention. This includes noninvasive vascular imaging to identify the underlying etiology, assess immediate complications and risk of future stroke. The majority of stroke evaluations take place in the inpatient setting. Admitting TIA patients is reasonable if they present within 72 hours and have an ABCD(2) score ≥ 3, indicating high risk of early recurrence, or the evaluation cannot be rapidly completed on an outpatient basis (Easton, 2009). Minimally, both stroke and TIA should have an evaluation for high-risk modifiable factors, such as carotid stenosis atrial fibrillation, as the cause of ischemic symptoms (Kernan, 2014). Diagnostic recommendations include neuroimaging evaluation as soon as possible, preferably with magnetic resonance imaging, including DWI; noninvasive imaging of the extracranial vessels should be performed, and noninvasive imaging of intracranial vessels is reasonable (Wintermark, 2013).

Patients with a history of stroke and recent work up with new signs or symptoms indicating progression or complications of the initial CVA should have repeat brain imaging as an initial study. Patients with remote or silent strokes discovered on imaging should be evaluated for high-risk modifiable risk factors based on the location and type of the presumed etiology of the brain injury (Easton, 2009; Hong, 2011; Kernan, 2014; Sacco, 2013; Wintermark, 2013).

References

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Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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