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Vertebrobasilar atherosclerotic disease: is it time to revisit angioplasty?
  1. Sepideh Amin-Hanjani1,
  2. Adnan H Siddiqui2,3,
  3. Tanya N Turan4,
  4. Henry Woo5,
  5. Shyam Prabhakaran6,
  6. Colin P Derdeyn7,
  7. Fady T Charbel1
  1. 1Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
  2. 2Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University of Buffalo, State University of New York, Buffalo, New York, USA
  3. 3Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA
  4. 4Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
  5. 5Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA
  6. 6Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  7. 7Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Sepideh Amin-Hanjani, Department of Neurosurgery, Neuropsychiatric Institute (MC 799), University of Illinois at Chicago, 912 South Wood Street, Rm 451N, Chicago, IL 60612-5970, USA; hanjani{at}uic.edu

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Atherosclerotic occlusive disease of the vertebrobasilar (VB) system is an important cause of posterior circulation ischemic stroke, responsible for approximately one-third of cases,1 and associated with high morbidity. Despite medical therapy, the risk of recurrent stroke is significant, particularly for intracranial VB disease, ranging from 10% to 15% per year.2 The role of hemodynamic insufficiency in the etiology of stroke from VB stenosis/occlusion has long been purported, but until recently, there have been few data to directly support this mechanism. Traditional tissue-based imaging techniques for evaluation of hemodynamic compromise, including MR and CT perfusion, have significant limitations in assessing the more compact posterior circulation territory. Thus measurement of large vessel flow in the stenotic artery and major collateral vessels is an attractive surrogate strategy for hemodynamic assessment, which can be performed non-invasively using phase contrast quantitative magnetic resonance angiography (QMRA). Such measurements can be performed using phase contrast imaging sequences available on standard MR scanners. Previous retrospective data from a single-center cohort of 50 patients with symptomatic VB disease assessed by QMRA showed that flow compromise was a strong indicator of the risk of recurrent stroke:3 patients with normal flow (n=31) had a stroke-free survival of 100%, whereas the low-flow group had a stroke free-survival of 71% (p=0.003, log-rank test).

Subsequently, data from the prospective multisite observational Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study demonstrated that distal …

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