Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: case series and review of the literature

Percutaneous Transluminal Angioplasty for Atherosclerotic Stenosis of Vertebral Artery Origin

Background: In patients with vertebral artery origin (VAO) stenosis and concomitant stenoses of other cerebral feeding arteries, data on the risk of percutaneous transluminal angioplasty (PTA) alone and with stent placement (PTAS) for VAO stenosis are limited. We aimed to determine how the presence of polystenotic lesions in other cerebral feeding arteries and concomitant carotid artery stenting (CAS) affect the periprocedural risk and long-term effect of PTA/S for atherosclerotic VAO stenosis. Methods: In a retrospective descriptive study, consecutive patients treated with PTA/S for ≥70% VAO stenosis were divided into groups with isolated VAO stenosis and multiple stenoses. We investigated the rate of periprocedural complications in the first 72 h and the risk of restenosis and ischemic stroke (IS)/transient ischemic attack (TIA) during the follow-up period. Results: In a set of 66 patients aged 66.1 ± 9.1 years, polystenotic lesions were present in 56 (84.8%) patients. 21 (31.8%) patients underwent endovascular treatment for stenosis of one or more other arteries in addition to VAO stenosis (15 underwent CAS). During the periprocedural period, no patient suffered from an IS or died, and, in the polystenotic group with concomitant CAS, there was one case of TIA (1.6%). During a mean follow-up period of 36 months, we identified 8 cases (16.3%) of ≥50% asymptomatic VA restenosis, and, in the polystenotic group, 4 (8.9%) cases of IS. Conclusion: The presence of severe polystenotic lesions or concomitant CAS had no adverse effect on the overall low periprocedural risk of PTA/S of VAO stenosis or the risk of restenosis during the follow-up period.

Endovascular Approach in Treating Vertebrobasilar Insufficiency: A Systematic Review

Vertebrobasilar insufficiency (VBI) is a significant medical condition that results from a lack of adequate blood flow to the posterior circulation of the brain. The first-line treatment involves the use of antiplatelet therapy, but in cases where patients are not responsive to drug therapy, surgical management is the next viable option. In the past, open endarterectomy was the preferred surgical approach for treating critical VBI patients. However, due to its high mortality rates and severe peri-procedural complications, its usage has decreased. Instead, the endovascular approach has emerged as an alternative surgical option for resolving VBI. This review explores the current literature to assess the effectiveness of endovascular interventions in treating VBI patients. It also highlights potential complications and adverse effects associated with these treatments while identifying gaps in the current research that warrant further investigation. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extensively search relevant literature on endovascular approaches for treating VBI patients on PubMed, BioMed Central, and ClinicalTrials.gov. The findings suggest that endovascular treatments have demonstrated significant technical success in treating VBI, with low mortality rates and minor adverse effects, such as intracranial hemorrhage and restenosis. The overall incidence of these complications is relatively low. Combining medical therapies with endovascular interventions has improved outcomes and reduced restenosis rates. However, there are methodological limitations and inconsistencies in the current literature that necessitate further investigation. Future research should focus on larger, randomized clinical trials and direct comparisons with other treatment options to obtain more conclusive evidence.

Vertebral Artery Interventions: A Comprehensive Updated Review

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

Treatment of posterior circulation stroke: acute management and secondary prevention

One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulation stroke differs from that of stroke in general and highlight recent advances.

Effectiveness of acute revascularization of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower hemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy.

Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions and short-term dual anti-platelet therapy. Randomized controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

Vertebral artery stenting to prevent recurrent stroke in symptomatic vertebral artery stenosis: the VIST RCT

BACKGROUND

Symptomatic vertebral artery (VA) stenosis has been associated with a markedly increased early risk of recurrent stroke. VA stenosis can be treated with stenting; however, there are few data from randomised controlled trials evaluating the efficacy of this treatment, and recent studies in intracranial stenosis have suggested that stenting may be associated with increased risk.

OBJECTIVE

The Vertebral artery Ischaemia Stenting Trial (VIST) was established to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for recently symptomatic VA stenosis.

DESIGN

VIST was a prospective, randomised, open, parallel, blinded end-point clinical trial.

SETTING

The trial was performed in 14 hospitals in the UK.

PARTICIPANTS

Recruitment began on 23 October 2008 and follow-up ended on 1 March 2016, by which time every patient had been followed up for at least 1 year. Participants had to have symptomatic vertebral stenosis of at least 50% resulting from presumed atheromatous disease. Both patients and clinicians were aware of treatment allocation; however, an independent adjudication committee, masked to treatment allocation, assessed all primary and secondary end points.

INTERVENTIONS

Participants were randomly assigned (1 : 1) to either vertebral angioplasty/stenting plus BMT (n = 91) or BMT alone (n = 88). A total of 182 patients were initially enrolled; however, three patients (two who withdrew after randomisation and one who did not attend after the initial randomisation visit) did not contribute any follow-up data and were excluded. None of these three patients had outcome events.

MAIN OUTCOMES AND MEASURES

The primary end point was the occurrence of fatal or non-fatal stroke in any arterial territory during follow-up.

RESULTS

The median follow-up was 3.5 (interquartile range 2.1-4.7) years. Of the 61 patients who were stented, 48 (78.7%) had extracranial stenosis and 13 (21.3%) had intracranial stenosis. No perioperative complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point occurred in five patients (including one fatal stroke) in the stent group and in 12 patients (including two fatal strokes) in the medical group (giving a hazard ratio of 0.40, 95% confidence interval 0.14 to 1.13; p = 0.08), with an absolute risk reduction of 25 strokes per 1000 person-years.

LIMITATIONS

The study was underpowered because it failed to reach target recruitment. The high rate of non-confirmation of stenosis in the stented group of the trial was a second limitation.

CONCLUSIONS

The trial found no difference in risk of the primary end point between the two groups.

FUTURE

Post hoc analysis suggested that stenting could be associated with a reduced recurrent stroke risk in symptomatic VA and further studies are now required to confirm these findings, particularly in extracranial VA stenosis where complication rates with stenting were confirmed to be very low.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95212240.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 41. See the NIHR Journals Library website for further project information. In addition, funding for the pilot phase was provided by the Stroke Association.

Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients

Background and Purpose

To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation.

Methods

Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT.

Results

Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups.

Conclusion

Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.

Validation and comparison of drug eluting stent to bare metal stent for restenosis rates following vertebral artery ostium stenting: A single-center real-world study

BACKGROUND AND PURPOSE

While drug-eluting stents (DES) have been widely applicated in coronary stenosis, uncertainty persists concerning the relative performance and clinical benefit in patients undergoing vertebral artery stenting when compared with a bare metal stent (BMS). We sought to compare in-stent restenosis (ISR) rates of DES and BMS in the treatment of vertebral artery ostium (VAO) stenosis.

MATERIALS AND METHODS

This study analyzed a single-center prospective cohort. Over 1.5-year period (January 2014-June 2015), 137 consecutive patients underwent VAO stenting involving deployment of 76 DES and 74 BMS. Patient demographics, comorbidities, stenosis severity, stent diameters and lengths, periprocedural complications, imaging and duplex ultrasonography follow-up and recurrent symptoms were assessed.

RESULTS

Technical success was achieved in all patients. Mean VAO stenosis at presentation were 82.4 ± 7.2% in the DES group and 83.3 ± 7.5% in the BMS group and were reduced to 12.5 ± 4.5% and 11.3 ± 4.0%. Mean stent diameter was 3.53 ± 0.40 mm in DES and 5.05 ± 0.40 mm in BMS (p < 0.0001). Mean follow-up was 12.3 months for DES and 11.7 months for BMS. The use of DES was associated with significant lower ISR rates compared with BMS (18.4% vs. 31.1%; OR = 2.628, p = 0.021). Recurrent symptoms rates were similar in DES vs. BMS (2.6% vs 2.7%, p = 0.680). Stent type and stent diameter were independent risk factors for ISR (P = 0.026).

CONCLUSION

Our results suggest superior efficacy of deploying DES for the treatment of VAO stenosis with lower ISR rates as compared to BMS, but do not support significant differences in periprocedural risk and recurrent symptoms rate.

Incidence, risk, and treatment of binary restenosis after vertebral artery stenting

BACKGROUND

In-stent restenosis (ISR) is the major concern of vertebral artery stenting (VAS). We aimed to investigate the feasibility and outcome of redo angioplasty for ISR of vertebral artery.

METHOD

The patients were retrospectively reviewed for the significant ISR (>50%). Redo angioplasty including balloon angioplasty and stenting was performed for symptomatic ISR (>50%) or asymptomatic ISR (≥70%). The clinical follow-up was performed on the 1, 3, 6, and 12 months and then yearly in the clinic or by telephone. The angiographic follow-up was performed at 6-12 months after redo angioplasty.

RESULT

A total of 72 patients had significant ISR and 48 redo angioplasty (92.3%, 48/52) were successfully achieved with 13 located in the V4 and 35 in the ostium of vertebral artery. Twenty-six lesions were implanted by the second stent and the others received balloon angioplasty. No stroke or transient ischemic attack (TIA) occurred in the perioperative time. One patient died 2 months after redo angioplasty due to nonstroke cause. Redo angioplasty nonsignificantly decreased the stroke or TIA compared with medical treatment. Sixteen patients developed the binary restenosis, which was lower in the patients receiving stent implantation than balloon angioplasty.

CONCLUSION

Redo angioplasty was a feasible method for the ISR of VAS and redo stenting might be the first choice.

Endovascular treatment of patients with high-risk symptomatic intracranial vertebrobasilar stenoses: long - term outcomes

Background and purpose

We present the long-term outcome after endovascular treatment of symptomatic intracranial posterior circulation stenoses.

Methods

30 patients with symptomatic intracranial posterior circulation stenoses exceeding 70% underwent endovascular treatment between 2006 and 2012. Data regarding presentation, follow-up, procedure details, complications and imaging follow-up were reviewed. All surviving patients underwent a phone interview to establish their current Modified Ranking Scales (MRS).

Results

Stenoses of the intracranial vertebral artery (24 patients) and basilar artery (6 patients) were treated with stents (10 patients), angioplasty alone (13 patients) or both (5 patients). Two procedures failed. One patient (3.3%) died after the procedure, two had stroke (6.6%) and one a subarachnoid haemorrhage without ensuing deficit. Two patients (6.7%) had asymptomatic complications (dissection and pseudoaneurysm). The median clinical follow-up time was 7 years. Of the 29 patients who survived the procedure, 6 died due to unrelated causes. Three patients (10%) had recurrent strokes and two (6.7%) a transient ischaemic attack in the posterior circulation. Two patients had subsequent middle cerebral artery strokes. Five (16.7%) patients had recurrent stenoses and three (10%) occlusions of the treated artery. Retreatment was performed in six patients, three (10%) with PTA and three (10%) with stenting. Current MRS scores were as follows: nine MRS 0, eight MRS 1, four MRS 2 and one MRS 4.

Conclusions

Long-term follow-up after endovascular treatment of high-risk symptomatic intracranial posterior circulation stenoses shows few stroke recurrences. Treatment of intracranial vertebral artery stenosis may be beneficial in appropriately selected patients.

Endovascular therapy of subclavian artery occlusive disease involving the vertebral artery origin

Background: While the majority of subclavian artery (SA) lesions are localized in the proximal segment, the evidence in patients with medial SA disease involving the vertebral artery (VA) origin are scarce.

PATIENTS AND METHODS

We retrospectively analyzed all patients who underwent percutaneous revascularization of the SA at our institution.

RESULTS

A total of 196 patients were retrospectively analyzed. The majority of SA lesions (n = 163, 83 %) were located in the proximal segment, whereas 28 lesions (14 %) were located in the medial segment, and only 5 lesions (3 %) involved the distal segment. Procedural success was high for both stenosis (96 %) and occlusion (89 %) and did not differ depending on lesion location. Revascularization techniques in the medial segment included stenting of the SA only (13 patients), additional VA balloon-dilatation (6 patients), and bifurcation stenting of the SA and VA using T-stenting technique (9 patients). Outcome after a median of 12 months showed no significant differences in freedom from restenosis between proximal and medial lesions (90 % vs. 95 %; p = 0.67).

CONCLUSIONS

Endovascular revascularization of SA disease with medial segments involving the VA origin required more complex techniques and showed long-term patency rates comparable to those in lesions located within the proximal SA.

Comparison of drug-eluting and bare metal stents for extracranial vertebral artery stenting

Introduction

Drug-eluting stents of the first (DES I) and second generation (DES II) proved superior to bare metal stents (BMS) in the coronary territory. However, there are limited data on whether they have any advantage over BMS in vertebral artery stenosis (VAS).

Aim

To compare outcomes of DES (DES I, DES II) and BMS in the treatment of symptomatic extracranial VAS.

Material and methods

During 13-year study period (2003–2016), 392 consecutive patients underwent VAS angioplasty in 428 arteries, including implantation of 148 DES (DES I: 21; DES II: 127 lesions), and 280 BMS.

Results

The technical success rates for DES and BMS groups were 96.7% and 94.6% (p = 0.103), with similar periprocedural complication rates (1.4% vs. 2.2%; p = 0.565). VAS degree was reduced from 86 ±9.7 to 2.7 ±5.0% in DES (p < 0.001) and from 84.1 ±9.4 to 4.3 ±6.9% in BMS (p < 0.001). Angiography confirmed in-stent restenosis/occlusion (ISR/ISO) 50–99% in 53 (14.2%) and 21 (5.6%) out of 373 patients (409 arteries) with at least 6-month follow-up. ISR/ISO rates were similar in DES vs. BMS (22.8% vs. 19.4%; p = 0.635), as well as in DES I vs. DES II (6/19; 31.6% vs. 25/92; 27.2%, p = 0.325). Stainless steel (24/135; 17.8%) and cobalt-chromium (23/121;19%) BMS had significantly lower incidence of ISR/ISO, as compared to platinum-chromium (7/18; 38.9%), p = 0.034. ISR/ISO was associated with age (p = 0.01) and CRP level > 5 mg/l (p = 0.043), while greater stent length was associated with ISR only in the DES group (p = 0.024).

Conclusions

Our results do not support significant differences in ISR/ISO rates between DES and BMS, although differences between particular stent types and ISR rates require further investigation.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting

Introduction: Vertebral artery stenosis can lead to posterior circulation TIAs and stroke. Stenting is often performed to treat symptomatic vertebral artery stenosis. As with carotid stenting, embolic protection devices (EPD) are increasingly used when stenting a vertebral artery stenosis. In general, EPDs may rarely become detached or retained in the circulation during stent revascularization. We discuss a 77-year-old male with a history of cerebral atherosclerosis and prior left occipital lobe and right insular infarcts who presented with increasing left sided weakness and was found to have severe stenosis of the proximal left vertebral artery. We report the only known case and successful endovascular bailout for an irretrievable EPD occurring during vertebral artery stenting.

Methods: Systematic reviews of the medical literature were performed using PubMed and multiple combinations of keywords to search for irretrievable EPDs in either the carotid or vertebral arteries. The bibliographies of the results were used to identify additional publications until this process was exhausted.

Results: No prior reports were found for retained or detached vertebral artery EPD. A total of six cases were found where an EPD was lost in the carotid circulation. In three of the cases, a carotid arteriotomy was required to retrieve the EPD. In two other cases, diagnostic catheters were used to retrieve the EPD. In our case, an EverFlex Biliary Stent was used to flatten the irretrievable EPD into the vertebral artery wall while preserving robust vertebral artery perfusion. 21-month clinical and 16-month imaging follow-up demonstrated durable vertebral artery patency and no ischemic symptoms.

Conclusion: Successful bailout strategy for a retained vertebral artery EPD during stenting may be achieved with a self-expanding stent. The resultant revascularization remained durable and without clinical sequelae.

Recent advances in the management of symptomatic vertebral artery stenosis

PURPOSE OF REVIEW

Vertebrobasilar stenosis accounts for 20% of posterior circulation strokes and is associated with high risk of early stroke recurrence. We review data from randomized controlled trials examining whether stenting may reduce this risk, including the recently published Vertebral Artery Ischaemia Stenting Trial (VIST).

RECENT FINDINGS

VIST and VAST (Vertebral Artery Stenting Trial), having recruited both intracranial and extracranial vertebral stenosis and showed a low rate of perioperative stroke for extracranial (0 and 2%, respectively), but a higher rate for intracranial stenosis (15 and 22%, respectively). In VIST, the primary endpoint of stroke occurred in five patients in the stent group vs. 12 in the medical group (hazard ratio 0.40; 95% confidence interval 0.14-1.13, P = 0.08), although when days from last symptoms were adjusted for, the hazard ratio was 0.34 (95% confidence interval 0.12-0.98; P = 0.046). SAMMPRIS (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis) recruited only intracranial vertebral stenosis and showed a better outcome with intensive medical therapy than stenting.

SUMMARY

Stenting of extracranial stenosis can be performed with a low operative risk. VIST suggests it may reduce longer term stroke risk, but this needs confirming in larger trials. For intracranial stenosis, due to a higher operative risk, current evidence favours medical treatment. SAMMPRIS have emphasized the need for intensive medical therapy whether or not stenting is performed.

Endovascular treatment of symptomatic vertebral artery stenosis: A systematic review and meta-analysis

BACKGROUND

The study aim was to evaluate the safety and efficacy of endovascular treatment (EVT) versus medical treatment (MT) in patients with symptomatic vertebral artery (VA) stenosis.

METHODS

Randomized controlled trials with active and control groups receiving EVT plus MT and MT alone in patients with vertebro-basilar transient ischemic attack (TIA) or stroke and VA stenosis were identified. Primary endpoints included the occurrence of any stroke, any vertebro-basilar stroke, vertebro-basilar ischemic stroke, and vertebro-basilar TIA. Secondary endpoints were myocardial infarction, vascular death, and composite vascular outcome. All endpoints were assessed at short and long-term. Risk ratios (RRs) with 95% confidence intervals (CIs) have been estimated.

RESULTS

Four trials were included involving 370 participants, 194 and 176 for EVT and MT arms, respectively. There was no overall effect of EVT on the occurrence of any stroke [short-term: RR 3.05 (95% CI 0.33-28.49); long-term: RR 0.75 (95% CI 0.40-1.40)], any vertebro-basilar stroke [short-term RR 3.05 (95% CI 0.33-28.49); long-term RR 0.91 (95% CI 0.42-1.99)], vertebro-basilar ischemic stroke [short-term: RR 1.02 (95% CI 0.07-15.88); long-term RR 1.27 (95% CI 0.36-4.50)], vertebro-basilar TIA [short-term: RR 5.00 (95% CI 0.28-90.18); long-term: RR 0.85 (95% CI 0.39-1.81)]. There were no differences across the treatments in any secondary outcome.

CONCLUSIONS

There were no clear-cut benefits or harms for EVT versus MT alone in patients with symptomatic VA stenosis.

A review of the diagnosis and management of vertebral basilar (posterior) circulation disease

We have reviewed the English literature published in the last 70 years on Diseases of the Vertebral Basilar Circulation, or Posterior Circulation Disease (PCD). We have found that errors have been made in the conduct and interpretation of these studies that have led to incorrect approaches to the management of PCD. Because of the difficulty in evaluating the PC, the management of PCD has been incorrectly applied from anterior circulation disease (ACD) experience to PCD. PCD is a common form of stroke affecting 20-40% patients with stroke. Yet, the evidence is strong that the Anterior Circulation (AC) and Posterior Circulations (PC) differ in their pathology, in their clinical presentations, in the rapidity of development of symptoms, in optimal imaging methods, and in available treatments. There appears to be two categories of patients who present with PCD. The first, acute basilar artery occlusion has a more rapid onset. The diagnosis must be made quickly and if imaging proves a diagnosis of Basilar Artery Occlusion (BAO), the treatment of choice is Interventional removal of the basilar artery thrombosis or embolus. The second category of PCD and the most commonly seen PCD disease process presents with non-specific symptoms and early warnings of PCD that now can be related to ischemic events in the entire PC vessels. These warning symptoms and signs occur much earlier than those in the AC. IA angiography is still the gold standard of diagnosis and is superior in definition to MR and CT angiography which are commonly used as a convenient screening imaging tool to evaluate PCD but are both inferior to IA angiography in definition for lesions below 3-4 mm. In at least two reported studies 7T MR angiography appears superior to other imaging modalities and will become the gold standard of imaging of PCD in the future. Medical treatments applied to the ACD have not been proven of value in specific forms of PCD. Interventional therapy was promising but of unproven value in Randomized Controlled Trials (RCT) except for the treatment of Basilar Artery Occlusion (BAO). Surgical revascularization has been proved to be highly successful in patients, who are refractory to medical therapy. These studies have been ignored by the scientific community basically because of an incorrect interpretation of the flawed EC-IC Bypass Trial in 1985 as applying to all stroke patients. Moreover, the EC-IC Bypass Study did not include PCD patients in their study population, but the study results were extrapolated to patients with PCD without any scientific basis. This experience led clinicians to an incorrect bias that surgical treatments are of no value in PCD. Thus, incorrectly, surgical treatments of PCD have not been considered among the therapeutic possibilities for PCD. QMRA is a new quantitative MR technique that measures specific blood flow in extra and intracranial vessels. QMRA has been used to select those patients who may benefit from medical, or interventional, or surgical treatment for PCD based on flow determinations with a high success rate. QMRA accurately predicts the flows in many large and small vessels in the PC and AC and clearly indicates that both circulations are intimately related. From medical and surgical studies, the longer one waits for surgical treatment the higher the risk of a poor outcome results. This observation becomes obvious when the rapidity of development of PCD is compared with ACD. Recent advances in endovascular therapy in the treatment of acute basilar thrombosis is a clear sign that early diagnosis and treatment of PCD will reduce the morbidity and mortality of these diseases. In this review it is evident that there are multiple medical and surgical treatments for PCD depending upon the location of the lesion(s) and the collateral circulation demonstrated. It is clear that the AC and PC have significant differences. With the exception of the large population studies from Oxford England, the reported studies on the management of PCD in the literature represent small selected subsets of the universe of PC diseases, the information from which is not generalizable to the universe of PCD patients. At this point in the history of PCD, there are not large enough databases of similar patients to provide a basis for valid randomized studies, with the exception of the surgical studies. Thus, a high index of suspicion of the early warning symptoms of PCD should lead to a rapid individual clinical assessment of patients selecting those with PCD. Medical, interventional, and/or surgical treatments should be chosen based on knowledge presented in this review. Recording the results in a national Registry on a continuing basis will provide the data that may help advance the management of PCD based on larger data bases of well documented patient information to guide the selection of future therapies for PCD treatments. It is also clear that the management of patients within the complex of diseases that comprise PCD should be performed in centers with expertise in the imaging, medical, interventional and surgical approaches to diseases of the PCD.

Visual field impairment predicts recurrent stroke after acute posterior circulation stroke and transient ischemic attack

AIMS

To evaluate whether visual field impairment (VFI) can predict stroke recurrence in patients with vertebral-basilar (VB) stroke.

METHODS

A total of 326 patients were eligible for a VFI evaluation within 1 week of stroke onset. One-year follow-up data were obtained after VB stroke and other vascular events. All predictors were determined using Cox regression models.

RESULTS

The overall incidence of recurrent VB stroke and transient ischemic attack (TIA) was 29% (n = 92). After multivariate adjustment, severe and moderate VFI were predictors of recurrent VB stroke and TIA.

CONCLUSIONS

VFI is an independent predictor of recurrent VB stroke and TIA.

Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial

Objective:

To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis.

Methods:

VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant.

Results:

Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05).

Conclusions:

Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk.

ISRCTN.com identifier:

ISRCTN95212240.

Classification of evidence:

This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

Simultaneous vertebral and subclavian artery stenting

Introduction

Vertebrobasilar territory ischemia leads to disabling neurological symptoms and may be caused both by vertebral artery (VA) and subclavian artery (SA) stenosis. The coexisting symptomatic ipsilateral VA and proximal SA stenosis should be considered as a true bifurcation lesion for percutaneous treatment.

Aim

To evaluate the safety and efficacy of simultaneous angioplasty of vertebral and subclavian stenosis.

Material and methods

Fifteen patients (age 69.5 years, 46.7% men, all symptomatic from posterior circulation (history of stroke, transient ischemic attack, chronic ischemia symptoms)) were scheduled for simultaneous SA/VA angioplasty. Clinical and duplex ultrasound follow-up was conducted 1, 6 and 12 months after the procedure.

Results

The technical success rate was 100%. Single balloon-mounted stent angioplasty was performed for all VAs and for 13 (86.7%) SAs. In 4 cases a simultaneous radial and femoral approach was required. The mean North American Symptomatic Carotid Endarterectomy Trial (NASCET) VA stenosis was reduced from 88.7 ±9.7% to 5.7 ±6.8% and SA stenosis from 80 ±12.2% to 11 ±12.3% (p < 0.01). No periprocedural death, stroke, myocardial infarction or transient ischemic attack occurred. During follow-up (range: 6–107 months) in 10 of 15 (66.7%) patients relief of chronic ischemic symptoms was observed. No stroke/TIA occurred. One cardiovascular and 2 non-cardiovascular deaths were recorded. There was 1 symptomatic vertebral and 1 subclavian in-stent restenosis, and 2 cases of asymptomatic VA in-stent occlusion occurred.

Conclusions

Simultaneous vertebral and subclavian artery stenting is safe and effective. The restenosis rate remains at an acceptable level and it may be treated successfully with drug-eluting balloon angioplasty. In selected patients a dual radial and femoral approach may facilitate the procedure.

Large Artery Atherosclerotic Occlusive Disease

PURPOSE OF REVIEW

Extracranial or intracranial large artery atherosclerosis is often identified as a potential etiologic cause for ischemic stroke and transient ischemic attack. Given the high prevalence of large artery atherosclerosis in the general population, determining whether an identified atherosclerotic lesion is truly the cause of a patient's symptomatology can be difficult. In all cases, optimally treating each patient to minimize future stroke risk is paramount. Extracranial or intracranial large artery atherosclerosis can be broadly compartmentalized into four distinct clinical scenarios based upon the individual patient's history, examination, and anatomic imaging findings: asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease. This review provides a framework for clinicians evaluating and treating such patients.

RECENT FINDINGS

Intensive medical therapy achieves low rates of stroke and death in asymptomatic carotid stenosis. Evidence indicates that patients with severe symptomatic carotid stenosis should undergo carotid revascularization sooner rather than later and that the risk of stroke or death is lower using carotid endarterectomy than with carotid stenting. Specific to stenting, the risk of stroke or death is greatest among older patients and women. Continuous vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy is the mainstay for stroke prevention in the setting of intracranial and vertebral artery origin atherosclerosis.

SUMMARY

Lifelong vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy are the key elements to reduce future stroke risk in the setting of large artery atherosclerosis. When considering a revascularization procedure for carotid stenosis, patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully considered.

Use of Embolic Protection Devices in Peripheral Interventions

The use of embolic protection devices (EPDs) when treating coronary saphenous vein bypass grafts, performing carotid arterial stenting and treating acute coronary syndromes is well accepted. We will review currently available devices and approaches to reduce distal embolisation, first discussing their uses in carotid interventions and then in vertebral and peripheral vascular interventions.

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

Posterior circulation cerebrovascular syndromes: diagnosis and management

One in five strokes affects the posterior circulation. Diagnosing posterior circulation stroke can be challenging, as the vascular anatomy can be variable, and because presenting symptoms are often non-specific and fluctuating. Nevertheless, making the correct diagnosis is important, as these strokes have a high chance of recurrence, can be life threatening, and can lead to equally life-threatening complications. Investigation and management largely follow those for stroke in general, although some specific differences exist. These include the preferred use of MRI for diagnosing posterior fossa lesions, the management of basilar artery thrombosis, which may have a longer time window for recanalisation therapy, and the use of endovascular therapies for secondary prevention, which, so far, have not shown any benefit in the treatment of vertebral or basilar artery stenosis. In this review, we summarise the anatomy, aetiology and presentation of posterior circulation stroke, and discuss current approaches to management.

The Use of Aspiration Catheter Systems for Embolic Protection during Intracranial Vertebral Artery Angioplasty and Stenting

BACKGROUND

Posterior circulation strokes comprise approximately 20-25% of all strokes of ischemic origin. Strokes affecting this area carry a significantly higher risk for subsequent stroke or death as compared to anterior circulation strokes. Embolic protection device (EPD) use for carotid artery stenosis has translated into percutaneous interventions of proximal vertebral artery (VA) stenosis. However, the use of EPDs when treating intracranial lesions has yet to be studied and may not be feasible as the vessel caliber is frequently smaller than in existing devices.

OBJECTIVE

The aim of this study is to describe a proximal aspiration technique used during the treatment of intracranial VA and basilar artery (BA) atherosclerotic disease.

METHODS

Proximal embolic protection was utilized during the treatment of intracranial VA/BA stenosis with angioplasty and stenting in patients with medically refractory disease.

RESULTS

Three patients with severe symptomatic posterior circulation stenosis refractory to medical management were treated with angioplasty and stenting utilizing proximal aspiration. Pre- and post-treatment angiograms and MRIs were compared. Treated vascular stenoses were significantly improved, without new neurological deficits or ischemic injury identified on imaging.

CONCLUSIONS

The proposed technique of proximal embolic protection may help overcome the challenge of embolus propagation inherent to the treatment modality that was encountered during the treatment of intracranial VA/BA stenosis.

Stenting for symptomatic intracranial vertebrobasilar artery stenosis: 30-day results in a high-volume stroke center

OBJECTIVES

Symptomatic intracranial vertebrobasilar artery stenosis (IVBS) carries a high annual risk of recurrent stroke. Endovascular therapy was a promising technique but recent trials suggest it may carry a risk of periprocedual complications especially in inexperienced hands. This prospective study was to evaluate the safety of endovascular therapy for severe symptomatic IVBS in a high volume stroke centre.

PATIENTS AND METHOD

Patients with symptomatic IVBS caused by 70-99% stenosis despite medical treatment of at least one antiplatelet agent and statin were enrolled. The patients were treated either with balloon-mounted stent or balloon pre-dilation plus self-expanding stent as determined by the operators following a guideline. The primary outcome was 30-day stroke, transient ischemic attack (TIA) and death after stenting. The secondary outcome was successful stent deployment. The baseline characteristics and outcomes of patients with basilar artery (BA) lesions and patients with vertebral artery V4 segment lesions (BA group vs V4 group) were compared. And the outcome of different Mori type lesions was also compared.

RESULT

From September 2013 to September 2014, 105 patients with stroke or TIA due to intracranial IVBS were screened and 97 patients were treated by stenting, including 52 patients with BA stenosis and 45 patients with V4 stenosis. The rate of 30-day stroke, TIA and death was 7.1%. All the three strokes happened in the BA group and were perforator strokes. The successful stent deployment rate was 100%. General anesthesia was more preferred in the BA group than in the V4 groups (96.2% vs 75.6%, p=0.005). The Apollo stent was used more for Mori A lesions (30.5% vs 7.9%, p=0.011) and had lower degree of residual stenosis (8.6% vs 12.6%, p=0.014) than Wingspan stent. Mori C lesions were more likely to have higher degree of residual stenosis than Mori A lesion (15.3% vs 7.4%, p=0.005).

CONCLUSION

The short-term safety of endovascular stenting for patients with severe symptomatic IVBS in a high volume stroke centre was acceptable. Mori A lesions may have lower residual stenosis rate than the Mori C type lesions.

Balloons in endovascular neurosurgery: history and current applications

The use of balloons in the field of neurosurgery is currently an essential part of our clinical practice. The field has evolved over the last 40 years since Serbinenko used balloons to test the feasibility of occluding cervical vessels for intracranial pathologies. Since that time, indications have expanded to include sacrificing cervical and intracranial vessels with detachable balloons, supporting the coil mass in wide-necked aneurysms (balloon remodeling technique), and performing intracranial and cervical angioplasty for atherosclerotic disease, as well as an adjunct to treat arteriovenous malformations. With the rapid expansion of endovascular technologies, it appears that the indications and uses for balloons will continue to expand. In this article, we review the history of balloons, the initial applications, the types of balloons available, and the current applications available for endovascular neurosurgeons.

Posterior circulation infarction in patients with traumatic cervical spinal cord injury and its relationship to vertebral artery injury

STUDY DESIGN

Prospective study.

OBJECTIVE

To ascertain the prevalence of posterior circulation stroke in traumatic chronic spinal cord injured (SCI) patients and associated traumatic vertebral artery injuries (VAI).

METHODS

All adult patients with cervical SCI and American Spinal Injury Association Impairment Scale (AIS) grade A or B referred for follow-up magnetic resonance imaging of their spinal cord were invited to take part in the study between January 2010 and December 2012 at the National Spinal Injury Centre. Two additional sequences were added to the existing imaging protocol to evaluate the brain and vertebral arteries.

RESULTS

Ninety-eight patients were recruited. All imaging were analysed independently by three consultant radiologists. Posterior circulation infarcts were noted in seven (7%) patients. Significant VAI was noted in 13 patients (13%) with 10 occlusions and 3 with high-grade stenosis. However, only one patient had co-existent posterior circulation infarct and significant VAI.

CONCLUSION

There is an increased prevalence of posterior circulation infarction in SCI patients. The relationship with associated traumatic VAI requires further investigation.

Basilar artery thrombosis in the setting of antiphospholipid syndrome

Antiphospholipid syndrome is an autoimmune disorder characterized by arterial or venous thrombosis, recurrent first-trimester pregnancy loss, and multiple additional clinical manifestations. We describe a man with severe atherosclerotic basilar artery stenosis and superimposed in situ thrombus who was found to have antiphospholipid syndrome.

Large artery atherosclerosis: carotid stenosis, vertebral artery disease, and intracranial atherosclerosis

PURPOSE OF REVIEW

Large artery atherosclerosis is an important cause of ischemic stroke. Recent randomized clinical trials have helped clarify the treatment options for conditions such as carotid stenosis and intracranial atherosclerosis. This review outlines the primary findings of these trials and provides current recommendations for treatment.

RECENT FINDINGS

Carotid revascularization is preferred in patients with severe symptomatic carotid stenosis. Carotid endarterectomy achieves lower rates of stroke or death than carotid artery stenting. The risk of stroke or death with stenting is higher among older patients and women. Intensive medical therapy achieves low stroke and death rates in asymptomatic stenosis. Medical therapy and treatment of atherosclerotic risk factors are the mainstay of therapy for intracranial atherosclerosis, and medical therapy is recommended for patients with vertebral artery origin atherosclerosis.

SUMMARY

Contemporary medical therapy is paramount in large artery atherosclerosis. Patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully weighed while choosing a revascularization procedure for carotid stenosis.

Advances and Innovations in Revascularization of Extracranial Vertebral Artery

Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients.

Percutaneous Treatment of Vertebral Artery Stenosis

Endovascular treatment of the ostial and proximal portions of the vertebral artery is a safe and effective technique for alleviating symptoms and improving cerebral blood flow to the posterior circulation. Vertebral artery angioplasty can be performed with high technical and clinical success rates, low complication rates, and durable long-term results. Although restenosis rates range from 0% to 48%, the durability of vertebral artery angioplasty is evidenced by low restenosis rates in multiple large series reported in the literature using multiple treatment options, including balloon angioplasty alone, bare metal stents, and drug-coated stents.

A single center experience of stenting in symptomatic intracranial atherosclerosis

Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has been compared with medical management in a randomized trial (SAMMPRIS), where aggressive medical management was superior to PTAS with the use of the Wingspan stent system, however in our experience we have had good results and have experienced no complications with this therapy. In a retrospective, single-center study we enrolled seven consecutive patients with a symptomatic angiographically proven atherosclerotic intracranial arterial stenosis of the anterior and posterior circulation. All cases received adjuvant therapy (aspirin and clopidogrel or ticlopidine) before and after deployment of the device. The procedures were performed with the patient under general anesthesia. We use the Wingspan stent system. The occlusion site was middle cerebral artery (MCA) in three patients, proximal internal carotid artery (ICA) in one patient and vertebrobasilar artery in three patients. Primary interventional successful revascularization was achieved in all cases. Four patients had no residual stenosis, and the other three had 20%, 30% and 40% residual stenosis (Table 1). All patients showed a clinical improvement after stent deployment. No peri-interventional events or neurologic complications occurred directly related to the technique. Patency rate was 100% at the last examination in six cases, one case had a pre-occlusive stenosis, requiring angioplasty. No patients died during the follow-up period, and 100% of patients showed good functional outcome at three months (modified Rankin Scale score ≤ 2). Although the SAMMPRIS study showed that aggressive medical management was superior to PTAS, our results suggest that intracranial stenting is safe and effective, probably due to an extraordinary selection of candidates and to an exquisite technique.

Angioplasty and stenting of symptomatic vertebral artery stenosis. Clinical and angiographic follow-up of 206 cases from Northwest Iran

Percutaneous transluminal angioplasty (PTA) has recently become a noteworthy treatment option for significant stenosis involving the vertebral artery (VA) in selected patients. We conducted a prospective study to evaluate the efficacy, safety and mid-term follow up results of 206 cases received PTA with or without stent implant to treat their symptomatic atherosclerotic VA stenosis in all segments (V1-V4). In a prospective mono-arm trial from October 2008 to July 2012 in a single center, 239 lesions affecting the intra or extracranial VA (171 in V1, 17 in V2, 14 in V3, 21 in V4 and 16 in combined segments) were treated by PTA with or without stent implant. Non-disabling stroke patients who had failed conservative medical treatment and had angiographic evidence of >50% stenosis in the dominant VA with clinical signs and symptoms of VB stenosis were included in this study. They were mean followed for 13.15±5.24 months after treatment. Overall, 206 patients underwent the procedure. A stent was implemented in 199 patients (96.6%). The periprocedural complication rate was 7.2%. The procedural (technical) success rate was 97.6%. Of the total 239 lesions, 223 were treated with stent implant. Clinical success was achieved in all 206 symptomatic patients after the procedure. Restenosis occurred in 15.9% after a mean 10.8 (6-24) months. Of those, 63.1% and 34.2% had mild and moderate stenosis that was treated medically, whereas one case (2.6%) with severe restenosis underwent balloon angioplasty. No deaths occurred during the follow-up period. The follow-up complication rate was 6.3%. TIA occurred in 4.4%, a minor stroke in 1.4% and a major stroke in one patient. The overall patient event-free survival was 92.4%. These results demonstrate the safety and feasibility of PTA with or without stent implant, with a high technical success rate, a low complication rate, a low restenosis rate and durable clinical success in patients with symptomatic VA stenosis. This approach seems to improve patients' immediate and mid-term clinical results. Randomized controlled trials are necessary to further validate this treatment option.

Acute interventional recanalisation of vertebrobasilar stenoses by angioplasty: complications and 12 months follow up

INTRODUCTION

In acute symptomatic vertebrobasilar artery stenosis, the use of mechanical recanalisation remains controversial. The complication rate of acute interventional recanalisation (aIR) has to be considered, as evidence from randomised trials is lacking. In a single centre retrospective case series, we here describe complications and outcome after aIR.

METHODS

We retrospectively assessed aIR in a tertiary care centre and included the following parameters: indication for aIR, national institute of health stroke scale (NIHSS) score on admission, recanalisation by thrombolysis in myocardial infarction score (TIMI) grades, post-interventional complications, mortality, NIHSS and modified Rankin scale at follow-up and rate of restenosis.

RESULTS

We identified 14 aIR (14 percutaneous transluminal angioplasty with or without stent implantation in 12 patients; 6/12 with thrombolysis; n = 6 vertebral artery, n = 8 basilar artery; 4 women, mean age 67 years). Mortality was 25 % (3/12) after 7 days and 42 % (5/12) after 12 months. In 12/14, interventions are complete (TIMI 3, 86 %), in 2/14, a partial recanalisation (TIMI 2, 14 %) was achieved. In one case, a peri-interventional fatal intracerebral haemorrhage occurred (1/12, 8 %). At late follow-up (mean 342 days), one re-occlusion (1/7, 14 %) and one recurrent stroke (1/12, 8 %) were observed.

CONCLUSIONS

In our single centre series of vertebrobasilar aIR recanalisation rate was high. However, procedural safety and clinical outcome varied considerably. The results of aIR need to be assessed in multicentric registers to define the procedural risk and outcome in the clinical setting.

[Recent studies on intracranial stenosis]

CLINICAL ISSUE

Symptomatic intracranial stenoses are associated with a high risk of stroke. Medical management with platelet inhibitors or anticoagulation has not been shown to substantially lower this risk. Hence, alternative treatment options are desperately needed.

TREATMENT INNOVATIONS

The concept of percutaneous intervention using balloon angioplasty with or without stenting is appealing at first sight which is why intracranial balloons and stents were developed.

PERFORMANCE

Initial studies using dedicated intracranial stents were more promising; however, the only randomized trial recently published using a dedicated intracranial self-expanding stent demonstrated a high periprocedural complication rate. EVALUATION AND PRACTICAL RECOMMENDATIONS: Due to study design limitations it would be premature to categorically denounce an interventional option for the treatment of symptomatic intracranial stenoses. More importantly, the results of the randomized SAMMPRIS trial should stimulate the development of safer technology and patient selection to minimize procedural risks. This will perhaps allow significant risk reduction of this potentially devastating intracranial condition when it cannot otherwise be addressed.