CLINICAL STUDIES ANGIOPLASTY FOR INTRACRANIAL SYMPTOMATIC VERTEBROBASILAR ISCHEMIA Daryl R. Gress, M.D. Neurovascular Service, Department of Neurology, University of California, San Francisco, San Francisco, California Wade S. Smith, M.D., Ph.D. Neurovascular Service, Department of Neurology, University of California, San Francisco, San Francisco, California Chris F. Dowd, M.D. Interventional Neurovascular Radiology Division, Department of Radiology, University of California, San Francisco, San Francisco, California Van V. Halbach, M.D. Interventional Neurovascular Radiology Division, Department of Radiology, University of California, San Francisco, San Francisco, California Randall J. Finley, M.D. Albert Einstein College of Medicine, Bronx, New York Randall T. Higashida, M.D. Interventional Neurovascular Radiology Division, Department of Radiology, University of California, San Francisco, San Francisco, California Reprint requests: Daryl R. Gress, M.D., Department of Neurology, Box 0114, UCSF Medical Center, 505 Parnassus, San Francisco, CA 94143-0114. Email: daryl.gress@ucsfmedctr.org Received, October 20, 2001. Accepted, February 20, 2002. OBJECTIVE: Although anterior circulation disease has both medical and surgical treatment options, management of vertebrobasilar disease has predominantly had only medical options. Some patients remain symptomatic despite medical treatment, and angioplasty has been demonstrated to relieve critical stenoses. However, the relative safety and effectiveness of medical and surgical treatments is not clearly known. This report reviews the clinical characteristics, indications, and procedural risks of intra- cranial angioplasty in a series of patients with symptomatic posterior circulation ischemia. METHODS: All patients undergoing angioplasty for critical intracranial vertebral or basilar artery stenosis at the University of California at San Francisco Medical Center between June 1986 and July 1999 were included in a retrospective record review. Clinical features and procedural complications were recorded. RESULTS: Angioplasty was performed on 25 vessel lesions in 25 patients in whom medical therapy had failed. The patients ranged in age from 50 to 87 years. Of the 25 stenoses, 10 were intracranial vertebral, 9 vertebrobasilar junction, and 6 basilar in location. Angioplasty was effective in reducing the degree of stenosis by more than 40% in all 25 vessels. The overall risk of stroke or death was 28%, and the risk of disabling stroke or death was 16%. CONCLUSION: Intracranial posterior circulation angioplasty is effective in the reduc- tion of stenosis and can be performed with relative safety. Angioplasty can be con- sidered as a treatment option in patients with recurrent ischemic symptoms despite medical therapy. KEY WORDS: Angioplasty, Basilar stenosis, Embolism, Low-flow ischemia, Stroke, Vertebral stenosis Neurosurgery 51:23-29, 2002 DOI: 10.1227/01.NEU.0000017463.79737.97 www.neurosurgery-online.com A significant portion of stroke is caused by occlusive disease of the extracranial and intracranial vessels. Surgical end- arterectomy has been clearly demonstrated to diminish stroke risk in symptomatic cervical carotid disease (13), although surgical options in posterior circulation disease are limited. Percutaneous transluminal angioplasty has become a viable technique to treat severe, he- modynamically significant lesions in extracra- nial vessels. Early work established the feasi- bility of angioplasty for the treatment of cerebral ischemia related to atherosclerotic stenotic lesions of cervical carotid (1), subcla- vian (7), and vertebral origin (6). Angioplasty of intracranial vertebral and basilar artery le- sions can now be readily performed (8). Cere- brovascular occlusive disease leads to stroke by several mechanisms. In the posterior circu- lation, thrombus forms in relation to severe stenosis, and subsequent embolism is the most common stroke mechanism, although in some instances, hemodynamically significant steno- sis without adequate collateral blood flow can also lead to low-flow ischemia and stroke (2). Medical therapy, including antiplatelet or an- ticoagulant agents, may decrease the risk of thromboembolism but may not prevent low- flow ischemia. The best medical therapy for symptomatic intracranial stenoses remains unclear, and although preliminary retrospec- tive evidence favors anticoagulation over an- tiplatelet therapy, this question is the subject of an ongoing trial (3). Angioplasty provides a direct treatment of the occlusive lesion and may decrease stroke from either mechanism. NEUROSURGERY VOLUME 51 | NUMBER 1 | JULY 2002 | 23