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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 …
Contributors SA-H: conception and design, drafting; final approval; accountable for content. AHS, TNT, HW, SP: design, revision; final approval; accountable for content. CPD: conception, revision; final approval; accountable for content. FTC: conception and design, revision; final approval; accountable for content.
Competing interests SA-H—grant funding: NIH/NINDS (NS 059745); material research support (no direct funds): VasSol, Inc. AHS—consultant: Codman, Medtronic, GuidePoint Global Consulting, Penumbra, Stryker, Microvention, W.L. Gore Associates, Three Rivers Medical, Inc, Corindus, Inc, Amnis Therapeutics, Ltd, CereVasc, LLC, Pulsar Vascular, The Stroke Project, Inc, Cerebrotech Medical Systems, Inc, Rapid Medical, Neuravi, Silk Road Medical, Rebound Medical; Financial interest: StimSox, Valor Medical, NeuroTechnology Investors, Cardinal, Medina Medical Systems, Buffalo Technology Partners, Inc, International Medical Distribution Partners; National Steering Committee: 3D Separator Trial, SWIFT PRIME and SWIFT DIRECT Trials, CONFIDENCE Study, LARGE Trial, POSITIVE Trial, COMPASS Trial, INVEST Trial; board membership: Intersocietal Accreditation Committee. SP—grant funding: NIH/NINDS (NS 084288). CPD—STRATIS trial PI, Medtronic; 3D Separator DSMB, Penumbra. FTC—shareholder: VasSol, Inc.
Provenance and peer review Not commissioned; externally peer reviewed.