REstoring Flow by REvascularization With Submaximal Angioplasty in Hemodynamic IntraCranial Atherosclerotic Stenosis

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• Inclusion:
• Non-severe recent stroke (within 30 days) attributed to 70-99% stenosis of intracranial artery (internal carotid, middle cerebral, vertebral, basilar); must be confirmed by CTA (or DSA if already available) for enrollment into the trial.
• Hemodynamic compromise based on borderzone infarct pattern* for the anterior circulation (internal carotid and middle cerebral artery stenosis) and by low flow state on QMRA** for the posterior circulation (vertebral and basilar artery stenosis).
• Target vessel with minimal nominal diameter of 2mm
• Target length of stenosis <18mm
• Symptoms within 30 days of enrollment
• Age ≥30 and ≤90 years old#
• Able to provide informed consent
  • *Sole or predominant borderzone infarct pattern of qualifying event, as defined by SAMMPRIS cohort analysis **Low flow state as determined by optimized flow algorithm as defined by the VERiTAS Study
  • #Those 30-49 years of age must also have the presence of established atherosclerotic disease in another vascular bed (coronary, extracranial carotid, peripheral) or the presence of 2 or more risk factors (hypertension, diabetes mellitus, hyperlipidemia, tobacco abuse within the last 2 years).
  • Exclusion:
• Major disabling stroke mRS >3; progressive or fluctuating deficit within 24 hours
• Hemorrhagic infarction (based on CT) within 14 days of enrollment
• Any large stroke (>5cm) to be at risk for hemorrhagic conversion
• Any neurological disease which would confound follow-up assessment
• Any co-morbid disease condition with <12 month life expectancy
• Known cardiac disease associated with elevated cardioembolic risk, specifically, atrial fibrillation, prosthetic valve, endocarditis, left atrial/ventricular thrombus, cardiomyopathy with EF<25%, cardiac myxoma
• Blood dyscrasias, specifically polycythemia vera, essential thrombocytosis, sickle cell disease
• Active bleeding diathesis, h/o major systemic hemorrhage within 30 days, active PUD, platelets<100K (severe liver impairment (AST or ALT>3 x normal, cirrhosis)
• Non-atherosclerotic stenosis including dissection, fibromuscular dysplasia, vasculitis, radiation induced vasculopathy, suspected recanalized embolus, suspected vasospastic process
• Mori C classification of stenosis (i.e. diffuse lesion, extremely angulated >90⁰, excessive proximal tortuosity) Previous treatment of target lesion with stent, angioplasty or other mechanical device
• Extracranial vertebral artery or carotid artery tortuosity, stenosis or occlusion prohibiting access to the target lesion (not exclusionary if does not prohibit access to target lesion)
• Unable or unwilling to undergo MRI
• Unable to undergo cerebral angiography
• Pregnancy
• Concurrent participation in another study which would conflict with the current study
• Allergy or contraindication to aspirin or Plavix
• Indication for warfarin or NOAC beyond enrollment (e.g. venous thrombo-embolism, atrial fibrillation)
• Thrombolytic therapy within 24 hours