Intracranial atherosclerotic disease (ICAD) accounts for 10% of ischemic strokes. The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) proposed an expansive indication for intracranial stenting. The study terminated prematurely because aggressive medical management proved superior to percutaneous transluminal angioplasty and stenting with the use of the Wingspan system for secondary prevention of stroke. These results prompted the FDA's Neurological Devices Advisory Committee to consider revoking the Wingspan's humanitarian device exemption. The SAMMPRIS trial, however, did not distinguish PTAS risk profile based on collateral circulation and location of the lesion. We present a case series of patients with vertebrobasilar ischemia and progressive neurological deficits in the setting of an absent collateral circulation and ICAD-induced vertebrobasilar occlusion. We propose PTAS as a unique endovascular solution for lesions proximal to AICA and medical management or stand alone angioplasty for lesions distal to AICA due to risk of perforator stroke. We present three cases of patients with NIHSS > 15 and progressive obtundation with V4 ICAD who experienced dramatic reversal of their symptoms with PTAS. All are mRS 0 at 3 months. All patients were treated awake. We further present a fourth patient with basilar ICAD between the SCA and AICA managed conservatively after an initial decompensation with distal microcatheter access; plaque instability with lesion crossing portended poorly for subsequent PTAS due to perforator and AICA ostia proximity. The fourth patient, who was being managed for secondary stroke prevention analogous to SAMMPRIS, is mRS 0 at 3 months without PTAS. We thus distinguish between secondary stroke prevention and vertebrobasilar ischemia; the case series presents a framework based on location and collateral circulation for post-SAMMPRIS applications for PTAS.

Competing interests None.