Tandem Intracranial Stent Deployment for Treatment of an Iatrogenic, Flowlimiting, Basilar Artery Dissection: Technical Case Report Adel M. M alek , M .D ., P h .D ., R a n d a ll T. H ig a sh id a , M .D ., Van V. H alb a ch , M .D ., Constantine C. Phato u ro s, M .B .B .S ., F .R .A .C .R ., Philip M. M eyers, M .D ., C h ris to p h e r F. D o w d , M .D . Department of Radiology, Division of Interventional Neurovascular Radiology (AMM, RTH, WH, CCP, PMM, CFD), and Department of Neurosurgery (RTH, VVH, CFD), University of California, San Francisco, San Francisco, California OB)ECTIVE AND IM PO RTANCE: Intimal dissection constitutes one of the complications associated with angioplasty of intracranial vessels. W e present a case of iatrogenic dissection of the entire basilar artery, which was induced by angioplasty and stenting of symptomatic, focal, intracra­ nial vertebral artery stenosis, and its successful treatment with tandem deployment of a downstream stent. CLINICAL PRESENTATION: A 61 -year-old, hypertensive, renal transplant recipient presented with orthostatic vertebrobasilar insufficiency that was refractory to medical management, including anticoagulation therapy. Angiography revealed an occluded right vertebral artery and focal, high-grade, left intracranial vertebral artery stenosis. Magnetic resonance ,magmg showed multiple posterior fossa infarctions. The left intracranial vertebral artery stenosis was successfully treated with primary stent deployment and balloon angioplasty, with symptom resolution. On postprocedure Day 2, the patient noted worsening right hemiparesis. INTERVENTION: Subsequent angiography revealed a flow-limiting, windsocklype, basilar artery dissection beginning at the distal end of the left vertebral artery stent and extending to the origin of the left posterior cerebral artery. A tandem stent was navigated intracranially and deployed past the first one, successfully sealing the dissection inflow zone and reconstituting normal flow to the top of the basilar artery. A clinical follow-up examination at 3 m°nths revealed no further orthostatic symptoms and only mild residual r'£ht-sided weakness. INCLUSION: This is the first description of iatrogenic stent-induced dis­ section of the entire basilar artery that was successfully treated by inflow zone control via tandem intracranial stent deployment. 'Neurosurgery 45:919-924, 1999) Kev words: Balloon angioplasty, Endovascular surgery, Intracranial atherosclerosis, Vertebral stenosis N e u ro su rg e ry , Vol. 45 , No. 4, October 1999 ransluminal vertebral and basilar angioplasty has been shown to ben­ efit select patients with posterior circu­ lation ischemia who have experienced failure of maximal medical m anagement (1, 7, 14). Recent advances in stent tech­ nology have produced more compact and flexible designs that enable intracra­ nial navigation (10) and offer the ability to provide a scaffold to hinder resteno­ sis and vessel recoil after angioplasty (11). Despite its potential benefits in se­ lect cases, intracranial angioplasty with stent placement remains a high-risk pro­ cedure, which can be complicated by thrombus formation and vessel dissec­ tion (7). We describe a case of extensive basilar artery dissection, originating proximal to the vertebrobasilar junction and extending distally to the origin of the left posterior cerebral artery. Dissec­ tion was induced by balloon angio­ plasty and stent placement for treatment of intracranial vertebral atherosclerotic stenosis. We report our clinical and en­ dovascular management. T CASE REPORT Clinical presentation A 61-year-old man with a history of longstanding systemic hypertension and hypertensive nephrosclerosis, who had received a cadaveric kidney transplant, presented with a 1-w eek com p lain t of progressive loss of balance and ataxia. These symptoms were initially associated with generalized headache and malaise and eventually led to nausea and vomit­ ing. Symptoms were clearly exacerbated by sitting or standing, forcing the patient to remain in bed, despite systemic intra­ venous anticoagulation therapy using heparin. A cardiac ultrasonographic ex­ amination revealed left ventricular hy­ pertrophy and an ejection fraction of 70% but no evidence of mural or valvu­ lar thrombus. Of particular interest, the patient had undergone construction of a brachial Gore-Tex hemodialysis arterio­ venous fistula (W.L. Gore & Associates, Inc., Flagstaff, AZ) (ipsilateral to the stenosed vertebral artery), which was still patent. During the neurological exami- 919 920 Malek et al FIGURE 1. A and B, digital subtracted angiograms of the left vertebral artery (A, anteroposterior projection; B, lateral projection), revealing hemodynamically significant (70% ) stenosis (arrowheads) in the intracranial portion. C, axial magnetic resonance imaging study, showing regions of strong signal in the left cerebellum consistent with infarction. nation, which was performed with the patient supine, the patient was awake, alert, and oriented, with normal mental status, normal cranial nerve function, normal extraocular movement, and no evidence of nystagmus. Motor and sen­ sory examination results were normal for all extremities. There was no dysmetria or incoordination in the extremities. When sitting, the patient became ataxic and nauseated and had a tendency to fall backward in his bed. Gait could not be tested. Magnetic resonance imaging scans of the brain showed multiple pos­ terior fossa infarctions in the left cere­ bellum (Fig. 1). An angiogram obtained at the referring institution showed oc­ clusion of the right vertebral artery in the intracranial segment, with flow sta­ sis, and 70% stenosis of the intracranial left vertebral artery. Intervention The patient showed no improvement in his orthostatic vertebrobasilar insuf­ ficiency with systemic anticoagulation therapy. Therefore, the decision was made to proceed with an endovascular revascularization procedure. The pa­ tient was placed under endotracheally administered general anesthesia. Sys­ temic heparin administration was in­ creased to yield an activated clotting time of more than 250 seconds. Diagnostic an­ giography confirmed right vertebral ar­ tery occlusion and 70% stenosis of the intracranial segment of the left vertebral artery (Fig. 2), proximal to the origin of the posterior inferior cerebellar artery. A 7-French guide catheter (BriteTip; Cordis Endovascular, Miami Lakes, FL) was se­ lectively placed in the proximal to midcervical portion of the left vertebral arteiy, with care being taken to avoid flow stasis. A RapidTransit microcatheter (Cordis En­ dovascular) was inserted coaxially with a 0.014-inch microguidewire (Transend 14; Scimed Life Sciences, Maple Grove, MN), to cross the lesion, and was placed in the midbasilar section. The microguidewire was then replaced by a 0.014-inch-diameter, Neurosurgery , Vol. 45, No. 4, October 1999 300-cm, exchange microguidewire (Stab> lizer; Cordis Endovascular), the tip of which was selectively navigated into the left Pi segment of the posterior cerebral artery; tlx RapidTransit microcatheter was then with­ drawn. A balloon-mounted, low-profile coronary stent measuring 4.0 mm in di­ ameter and 14 mm in length (GFX; Ar­ terial Vascular Engineering, Santa Rosa, CA) was carefully navigated across the lesion. The stent position was confirmed by digital subtraction angiography be­ fore balloon inflation to 12 atmospheres and primary stent placement (Fig 2). After stent placement, the balloon was deflated and carefully withdrawn. Post­ deploym ent digital subtraction angiog­ raphy showed excellent resolution of the stenosis, with the presence of a small, non-hemodynamically significant, dissec­ tion flap The patient was aroused from anes­ thesia and transferred to the intensive care unit according to the routine pro­ cedure. He continued to receive heparin therapy, as well as daily doses of clopidogrel (Plavix; Sanofi Pharmaceuticals, New York, NY) (75 mg) and aspirin (323 mg). Immediately postoperatively, the patient was noted to have transient right arm weakness (3-4 on a scale of 0-3), which was completely resolved by 6 hours after the procedure. On postpro­ cedure Day 1, he was able to sit in a chair without any complaints of ataxia, nausea, or vomiting. However, in tlx evening of p>ostp>rocedure Day 2, he was noted to have worsening right arm weakness, despite exhibiting a thera­ peutic partial thromboplastin time. Th? hemiparesis progressed to complete hemiplegia in the subsequent 12-hour period. The patient underwent com 1 * U rPputed tomographic scanning, wrticn vealed a region o f low attenuation in t e left pons that was consistent with is chemia or infarction (Fig. 3). The patient was taken to the angHV raphy suite, where left vertebral artep injection showed intermittent occlusio^ of the left posterior cerebral arter) an^ an extensive basilar artery dissecho^ flap, originating distal to the stent a extending to the origin of the left pt- ^ rior cerebral artery. The possibi it) ^ thrombus at the basilar apex was sidered; therefore, a 6-French gl catheter (Envoy; Cordis Endovascu Tandem Intracranial Stenting for Basilar Artery Dissection * 9 2 1 stent (Fig. 4). After its position was con­ firmed by digital subtraction angiogra­ phy to be downstream from the first stent and across the inflow zone of the dissection flap, the second stent was de­ ployed, and the balloon was carefully withdrawn through the second stent and then through the first stent. Digital subtraction angiography after deploy­ ment showed excellent resumption of steady flow to both posterior cerebral and superior cerebellar arteries. Digital subtraction angiography in the lateral projection confirmed decreased filling and contrast stasis within the false lu­ men (compare Figs. 4D and 3C). The right hemiplegia of the patient was not immediately resolved after the second procedure. The patient contin­ ued to receive heparin, as well as Plavix and aspirin, and experienced a slow re­ covery, showing mild im provem ent in right arm (2-3 on a scale of 0 -5 ) and leg (1 -2 on a scale of 0 -5 ) motor function before discharge to a rehabilitation facil­ ity. Significant recovery occurred after discharge from the hospital to the acute rehabilitation facility. Follow-up monitoring The patient returned 3 months after discharge from the hospital; he had been receiving Coum adin (DuPont Pharmaceuticals, W ilmington, DE) (in­ D issectio n ternational normalized ratio, 3), Plavix, and aspirin. His right-sided hemiparesis had nearly fully resolved, enabling him to walk independently and perform all JRE 2. A, digital subtracted angiogram w ith left vertebral artery injection activities of daily living without assis­ ‘roposterior projection), showing the Stabilizer exchange microguidewire in tance. He denied headache, dizziness, }1 segment of the left posterior cerebral artery, with the GFX stent (4 mm x numbness, and difficulty with sw allow ­ im) across the stenosis. B, digital unsubtracted fluorogram, demonstrating the ing or speech. His mental status was ted balloon during angioplasty and stent deployment. C and D, digital subtracted normal, with excellent cognition. He ograms obtained after angioplasty and stent deployment, showing an excellent had intact sensation but mild residual ographic result in the anteroposterior projection (C) but revealing a small, nonleft facial weakness and right hem ipare­ limiting, dissection flap distal to the stent in the lateral projection (D). E, corresis (4 on a scale of 0 -5 in the upper iding unsubtracted lateral angiogram of a left vertebral artery injection. extremities and 4 + on a scale of 0 -5 in the lower extremities), with resultant cerebral artery. A decision was then Uas placed in the left vertebral artery minimal circumduction on the right and made to seal the inflow zone of the dis­ ar>d a RapidTransit microcatheter was decreased arm swing. section. A 300-mm, 0.014-inch, exchange carefully navigated to the midbasilar microguidewire (Stabilizer; Cordis En­ St‘gment, over a 0.014-inch microguidedovascular) was navigated into the true D ISC U SSIO N vx*re- A total of 400,000 units of urokilumen of the basilar artery and into the Percutaneous transluminal angio­ Ptlse (Abbokinase; Abbott Laboratories, origin of the left posterior cerebral ar­ plasty for treatment of intracranial ath­ Abbott Park, IL) was infused through tery. A second flexible stent (3.5 mm in erosclerosis has been shown to be ben­ ^ e mkrocatheter. Posturokinase digital diameter, 14 mm in length, GFX; Arte­ eficial in selected cases of symptomatic ^^btraction angiography showed no de­ rial Vascular Engineering) was then intracranial stenosis that is refractory to tectable change in the pattern of inter­ navieated to traverse the first mittent occlusion of the left posterior %/„/ 4c Mn 4 ^ October 1999 N e u ro s u rg e ry , V ol. 45, /\o. 922 Malek et al FIG URE 3. A, axial computed tomographic scan of the brain obtained on postprocedure Day 2, revealing the new finding of a left pontine focus of ischemia or infarction (arrow). B, subsequent digital subtracted angiogram with left vertebral artery injection (anteroposterior projection), showing intermittently poor filling of the left posterior cerebral Dissection artery (arrow), with no significant Stent 1 improvement after selective infusion of 400,000 units of urokinase into the basilar apex. C, digital subtracted angiogram (lateral projection), revealing a sharply delineated (arrows) intimal dissection starting in the left vertebral artery, beyond the previously deployed stent. The dissection involves the entire basilar artery and ends at the origin of the left P1 segment. D, schematic illustration of the relative inflow zone of the dissection, with respect to the deployed stent. maximal medical management (3), de­ spite a 30-day morbidity rate of 11.7%. For a series of 12 patients who under­ went balloon angioplasty for treatment of arteriosclerotic disease of the distal vertebral and basilar arteries at our cen­ ter, Terada et al. (14) reported successful outcomes for 8 patients and a technical complication rate of 30%, including two dissections and two throm boem bolic events. This case report illustrates a num­ ber of unusual and important features of vessel dissection in the vertebrobasilar system. The first point concerns the extent of propagation of the dissection to the apex of the basilar artery and its impinge­ ment on the left PI origin. Although an­ giography performed after the neurolog­ ical worsening on postprocedure Day 2 suggested thrombotic occlusion, the dy­ namic and intermittent filling of the left PI segment during contrast injection, the lack of improvement in response to thrombolysis, and the angiographic dem­ onstration of the large extent of the dis­ section flap enabled recognition of the ac­ tual reason for the dynamic occlusion. The second point involves localization of the inflow zone of the dissection, which is responsible for the "windsock" effect. The third critical point concerns the correct identification of the true lumen within the basilar artery before deployment of the second stent. Observation of the dissection and the true lumen is not readily achieved without the use of high-resolution digital subtraction angiography. Spontaneous dissections of the ex­ tracranial portion of the vertebral artery are associated with a higher risk of ische­ mic complications, particularly involving the brainstem (4). Intimal dissection is a well-recognized complication of percuta­ neous balloon angioplasty for treatment of atherosclerosis and is usually an ac­ ceptable consequence if it is not flowlimiting. Although the current case in­ volves atherosclerotic stenosis, there have N e u ro su rg e ry , Vol. 45 , No. 4, October 1999 been a number of recent reports of stentdeployed in the intracranial vertebral ar­ tery as a scaffolding for treatment of side wall pseudoaneurysms (9,13) or fusifom aneurysms (6). Although there aresigmt icant differences in the physical property and architecture of the coronary and ce­ rebral vasculatures, some operators argue that the lack of dissection after percutane­ ous transluminal angioplasty in the coro­ nary circulation indicates a greater pro pensity for restenosis (12). Oversizing of the first stent used to treat the stenosis may have contributed to the initial dissection. Another possi­ bility may have been a rapid rate of inflation. Blankenship et al. (2) reported an inverse relationship between the rate of inflation and the risk of dissection. Such a relationship seems counterintui­ tive, however. The Arterial Vascular En­ gineering stent is premounted on its de­ livery balloon catheter. During inflation, the balloon is designed to expand ini­ tially at the distal and proximal ends (resembling a dumbbell) and then in the center section containing the stent. This sequential expansion is intended to de­ crease the risk of stent migration or slip­ page across the area of stenosis during deployment. We hypothesize that a rapid rate of inflation might transient overexpand the proximal and distal ends of the delivery balloon before stent expansion, as illustrated in Figure 5P The Arterial Vascular Engineering stent used in this case is considered a second generation, low-profile stent; it is fie*1' ble and can be used to navigate tortuous vessels. It was previously placed within a W iktor-type stent to treat a residua, dissection in the coronary circulation that was not adequately covered by tht primary stent (5). It is doubtful that the uneventful passage of the second stent within the first w'ould have been possl b l e w i t h a n e a r li e r - g e n e r a t io n device, h the vertebrobasilar system. It is theoretically possible that t presence of a brachial hemodialysisar teriovenous fistula, with c o n s e q u e n t low downstream subclavian resistan might have contributed to the s\np toms exhibited by the patient. K°ha al. (8) reported a case of subclav ian s induced by such an ipsilateral is Tandem Intracranial Stenting for Basilar Artery Dissection 9 2 3 FIGURE 4. A, left, digital unsubtracted B angiogram (lateral projection), showing Stent 2 the Stabilizer exchange microguidewire within the true (posterior) lumen, ending in the left P1 segment, along with the Stent 2 outline of the anterior false lumen; right, digital subtracted angiogram (anteroposterior projection), revealing the undeployed second GFX stent (3.5 mm x Stent 1 14 mm) (Stent 2) across the inflow zone of the dissection, downstream from the / previously placed proximal stent (Stent 1). B, digital subtracted (left) and Dissection Flap unsubtracted (right) angiograms (anteroposterior projection), showing the stent after deployment. C and D, digital subtracted angiograms (C, anteroposterior projection; D, lateral projection), showing Stent 2 resolution of the dynamic occlusion of the left P1 segment and excellent filling of both posterior cerebral and superior Stent 2 Stent 1 cerebellar arteries, as well as the tandem Stent 1 Sealed Inflow Zone distal stent deployed at the site of the inflow zone of the dissection, with a significant decrease in the size of the anterior compartment, or false lumen, of the basilar artery dissection (D; compare with Fig. 3C). E, schematic illustration of the relative positions of the two stents with respect to each other and to the inflow zone of the dissection, which has been sealed by the deployment of Stent 2. FIGURE 5. A, axial computed tomographic scan, showing the two deployed stents and their relative positions with respect to the foramen magnum and the clivus. B, schematic illustration of the inflation pattern of the balloon-mounted stent and the dumbbell shape assumed by the distal and Microwire proximal portions of the balloon during initial inflation. Dumbbell-Shape O 1. Initial inflation 2. Late inflation 3. Deployed stent N e u ro su rg e ry , Vol. 45 , No. 4, October 1999 However, Doppler insonation of the left vertebral artery after deployment of the first stent showed no effect of pressurecuff occlusion proximal to the fistula on sys­ tolic or diastolic velocities, arguing against such a phenomenon in this patient. C O N C LU SIO N In summary, intracranial vertebral ar­ tery balloon angioplasty and stenting is a high-risk procedure reserved for pa­ tients who have experienced failure of maximal medical therapy. The com pli­ cation and m anagement presented in this report highlight the importance of careful selection and sizing of balloon and stent catheters and meticulous angio­ graphic analysis. The need for proper pre­ operative analysis is made more pressing by the availability of a new generation of flexible stents that enable endovascular surgeons to readily navigate areas of the cerebral circulation that were previously considered unreachable. 924 Malek et al 13. Sekhon LH, M organ M K, Sorby W, G rinnell V: AC KN O W LED G M EN TS C om bin ed endovascular stent im plantation and We thank Drs. Daryl Gress, Wade Smith, and Vineeta Singh for assistance with the clinical treatment of the patient. endosaccu lar coil placem ent for the treatm ent of a wide-necked vertebral artery aneurysm: Tech­ nical case report. Neurosurgery 43:380-384, 1998. 14. Terada T, Higashida RT, H albach W , Dowd CF, Nakai E, Yokote H, Itakura T, H ieshim a GB: R eceived, February 23, 1999. Accepted, June 1, 1999. Reprint requests: Adel M. Malek, M.D., Ph.D., Department of Neurosurgery, Brigham and W om en's and Children's Hospitals, Bader 3, 300 Longwood Avenue, Boston, MA 02115. REFERENCES 1. Ahuja A, Guterman LR, Hopkins LN: Angio­ plasty for basilar artery atherosclerosis: Case re­ port. J Neurosurg 77:941-944, 1992. 2. Blankenship JC, Ford AC, Henry SD, Frey CM : Coronary dissection resulting from angioplasty with slow oscillating vs. rapid inflation and slow vs. rapid deflation. Cathet Cardiovasc Diagn 34: 202-209, 1995. 3. Clark WM, Barnwell SL, Nesbit G, O'Neill OR, Wynn ML, Coull BM: Safety and efficacy of percu­ taneous transluminal angioplasty for intracranial atherosclerotic stenosis. Stroke 26:1200-1204, 1995. 4. de Bray JM , Penisson-Besnier I, Dubas F, Emile J: Extracranial and intracranial vertebrobasilar dissections: Diagnosis and prognosis. J Neurol N eurosurg Psychiatry 6 3 :46 -5 1, 1997. 5. H am on M, M onassier JP: Stenting within a stent for treatment of residual dissection. Cathet Cardiovasc Diagn 40 :319-321, 1997. 6. Higashida RT, Sm ith W, G ress D, Urwin R, Dowd CF, Balousek PA, H albach VV: Intravas­ cular stent and endovascular coil placem ent for a ruptured fusiform aneurysm of the basilar artery: Case report and review of the literature. J N eurosurg 87:944-949, 1997. 7. Kellogg JX, Nesbit G M , Clark W M , Barnwell SL: The role of angioplasty in the treatment of cerebro­ vascular disease. Neurosurgery 43:549-556, 1998. 8. Kotval PS, Shah PM, Berman H: Doppler d iag ­ nosis of subclavian steal due to arteriovenous h e m o d ia ly sis fistula in the ip silateral arm . J U ltraso u n d Med 8 :6 9 7 - 7 0 0 , 1989. 9. Lylyk P, Ceratto R, Hurvitz D, Basso A: Treat­ ment of a vertebral dissecting aneurysm with stents and coils: Technical case report. N euro­ surgery 43:385-388, 1998. 10. Mericle RA, Lanzino G, Wakhloo AK, Guterman LR, Hopkins LN: Stenting and secondary coil­ ing of intracranial internal carotid artery an eu ­ rysm: Technical case report. N eurosurgery 43: 1229-1234, 1998. 11. Phatouros CC, Higashida RT, M alek AM , Smith WS, Mully TW , D eA rm ond SJ, Dowd Transluminal angioplasty for arteriosclerotic dis­ ease of the distal vertebral and basilar arteries. J Neurol Neurosurg Psychiatry 60:377-381, 1996. CO M M ENTS Malek et al. describe a 61-year-old, hy­ pertensive, renal transplant recipient who was experiencing orthostatic vertebro­ basilar insufficiency that was medically intractable. The patient continued to ex­ hibit symptoms, despite the best medical therapy, and underwent vertebral artery angioplasty and stent deployment. During that original procedure, he experienced a dissection, which was shown, in subse­ quent angiograms, to extend into the distal basilar circulation. Quite ingeniously, these investigators located the true lumen and re­ constituted the former vessel with deploy­ ment of a tandem stent. This was obviously performed as a salvage procedure, and the patient did exhibit residual neurological deficits; however, it is likely that the out­ come would have been worse if this proce­ dure had not been performed. Other important points can be ob­ tained from this report, most importantly that overextension of a stent can lead to dissection, which is their hypothesis. I think that individuals who perform these procedures should pay great attention to this finding, which is supported by the interventional cardiac literature. Oversizing of the first stent, as well as the weight of inflation of the balloon delivery device, might have contributed to the initial dissection, as the authors pointed out. However, as they also note, the complication and treatment of this patient emphasize the importance of stent and balloon sizing. As the technol­ ogy improves, reports of this technique will become more commonplace. CF, an R o b ert H. R o se n w a sse r acutely throm bosed basilar artery: C ase report and review of the literature. N eurosurgery 44: 66 7 -6 7 3 , 1999. Philadelphia, Peimsi/lvania Halbach VV: Endovascular stenting of 12. R ozenm an Y, Gilon D, Nassar H, G otsm an MS: Creation and healing of severe coronary dissec­ tion by the use of oversized balloons for the treatment of restenosis after an initially success­ ful angioplasty. Cathet Cardiovasc Diagn 31: 3 4 -3 6 , 1994. ing results. Many of the early reports ot intracranial carotid artery (2) and extracra­ nial vertebral artery (3) stenting were for salvage therapy in cases of angioplasty, induced dissection. We encountered similar problems m the extracranial vertebral artery of a pa­ tient who developed a dissection associ­ ated with primary stent placement. We also treated the dissection distal to the stent with placement of a second stent (4) We agree that careful sizing and a slow rate of balloon inflation may guard against iatrogenic dissection by allowing the slow expansion of the normal vessel adjacent to the diseased vessel (with plaque). Rapid inflation results in the stretching of vessel regions that differ in compliance (i.e., normal vessel versus plaque) and may increase the risk of dis­ section at their interface. However, this concept is merely anecdotally supported for the cerebral circulation, and a recent prospective study comparing fast versus slow balloon inflation found no statisti­ cally significant difference between the two techniques with respect to dissection in the coronary vasculature (1). It is im­ portant to carefully examine poststent an­ giograms, to rule out dissection, before the guidewire is removed. Any significant dissection should be stented immediately if possible. The authors are fortunate that they were able to locate the true lumen ot the dissected vessel 1 day after the initial procedure. The authors report excellent technical and clinical results for a chal­ lenging case. R ic h a r d D. Fessler L. N e ls o n Hopkins Buffalo, New York 1. B lankenship JC, Krucoff MW, Werns S A nd erson HV, Landau C, White HJ, Green C Sp okojn y AM , Bach RG, Raymond RE, Pinks^or J, R aw ert M, Talley JD: Comparison of $c oscillating versu s fast balloon inflation strat^ gies for coronary angioplasty. Am ] Car 8 3 :6 7 5 -6 8 0 , 1999. , 2. Dorros G, Cohn JM, Palmer L: Stent depto)^ resolves a petrous carotid artery angioplasty & tion. A JN R Am J Neuroradiol 19:392-394,1 ^ 3. F eld m an RL, Rubin JJ, Kuykendall RC- s ^ The authors describe the m anage­ ment of an iatrogenic basilar artery dis­ section after primary stenting of verte­ bral artery stenosis. Dissection after balloon angioplasty is a well-described complication, with potentially devastat­ Neurosurgery , Vol. 45, No. 4, October 1999 coronary Palm az-Schatz stent in the PerClQ . ous treatm ent of vertebral artery sttn C ath et C ard io v asc Diagn 38:312—315, H ^ 4. Fessler RD, Wakhloo AK, Lanzino G, ^ Guterman LR, Hopkins LN: Stent placemen^ vertebral artery occlusive disease: Preliminap ^ ical experience. Neurosurg Focus 5:Arti e