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In Reply We read with interest the letter by Walcott et al and thank them for their insightful comments. They note that whereas in carotid stenosis, artery-to-artery embolism is a common culprit, hypoperfusion as determined by the Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke protocol is the main pathological mechanism in patients with vertebrobasilar disease and low-flow status. In their experience, a number of patients with medically refractory vertebrobasilar disease symptoms were successfully treated with surgical revascularization in the form of a microsurgical bypass and they make the valid point that despite its greater complexity, microsurgical revascularization is a valuable option when an endovascular intervention is not viable.
Charbel FT, Amin-Hanjani S. Hemodynamics in Symptomatic Atherosclerotic Vertebrobasilar Occlusive Disease—Reply. JAMA Neurol. 2016;73(6):759-760. doi:10.1001/jamaneurol.2016.0527