Interventional cardiology techniques mainly influenced the underlying concept of treating high-grade ICAS by endovascular means. During the initial phase of this experience, dedicated balloon catheters for intracranial angioplasty were not yet available [
5]. If well-selected patients were treated in experienced centers, high success rates and severe complication rates below 10% were achieved with balloon-expandable coronary stents [
6,
7]. It became evident that the results in terms of periprocedural safety were good in elective cases, while the acute stroke setting was associated with a much higher complication rate [
8]. The Pharos Vitesse stent (Micrus) was the first balloon-expandable stent with a dedicated indication for ICAS and was a derivative of a coronary stent. The initial results were quite promising [
9]. In the VISSIT trial, patients were randomized for balloon-expandable stent treatment plus medical treatment or medical treatment alone. The stent group patients had a significantly higher rate of primary safety endpoint occurrence than the patients in the medical arm, including an 8.6% rate of intracranial hemorrhage [
10]. A similar sequence of results had previously been observed for the Wingspan stent (Stryker). This is a combination of a non-compliant balloon and a self-expanding nitinol stent. The stent structure is the same as Neuroform, but the radial force is increased [
11]. Again, the initial results were good, even though a completely new treatment technique had to be adopted [
12]. In the SAMMPRIS trial medical treatment with aspirin and clopidogrel, vascular risk factor management and lifestyle modification were randomized against the same regimen plus balloon angioplasty and Wingspan implantation. In the Wingspan vs. the conservative management groups, any stroke rate was 26% vs. 19%, with hemorrhage rates of 13% vs. 4%, respectively [
3]. Besides, follow-up examinations revealed a high rate of symptomatic in-stent stenosis of 14% at 3 years [
13]. Concerns related to methodological aspects of SAMMPRIS have been published [
14,
15]. On 15 September 2016, the Federal Joint Committee (Gemeinsamer Bundesausschuss) on behalf of the German Federal Ministry of Health ruled that the usage of stents for the treatment of intracranial stenosis is no longer covered by the health insurance companies concerned [
16]. Exempted are patients with a ≥ 70% intracranial stenosis who had an infarct related to this stenosis and suffered from a second infarct despite intensive medical treatment. In addition, patients with an acute intracranial occlusion without a therapeutic alternative or after the failure of such an alternative are also included in the exemption.