New standards for intracranial atherosclerotic disease treatment.
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ABSTRACT: To determine the prognosis of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy. The outcome of patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy is unknown. These patients may represent the target group for investigation of more aggressive therapies such as intracranial angioplasty. The authors performed a chart review and telephone interview of patients with symptomatic intracranial atherosclerosis identified in the Stanford Stroke Center clinical database. A Cox regression model was created to identify factors predictive of failure of antithrombotic therapy. The authors generated Kaplan-Meier survival curves to determine the timing of recurrent TIA, stroke, or death after failure of antithrombotic therapy. Fifty-two patients had symptomatic intracranial atherosclerosis and fulfilled entry criteria. Twenty-nine of the 52 patients (55.8%) had cerebral ischemic events while receiving an antithrombotic agent (antiplatelet agents [55%], warfarin [31%], or heparin [14%]). In a Cox regression model, older age was an independent predictor of failure of antithrombotic therapy, and warfarin use was associated with a decrease in risk. Recurrent TIA (n = 7), nonfatal/fatal stroke (n = 6/1), or death (n = 1) occurred in 15 of 29 (51.7%) of the patients who failed antithrombotic therapy. The median time to recurrent TIA, stroke, or death was 36 days (95% CI 13 to 59). Patients with symptomatic intracranial atherosclerosis who fail antithrombotic therapy have extremely high rates of recurrent TIA/stroke or death. Recurrent ischemic events typically occur within a few months after failure of standard medical therapy. The high recurrence risk observed warrants testing of alternative treatment strategies such as intracranial angioplasty.Neurology 09/2000; 55(4):490-7. · 8.30 Impact Factor
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ABSTRACT: Angioplasty and stent placement have been reported for the treatment of intracranial stenosis. This study was undertaken to assess the efficacy and long-term clinical outcome of angioplasty without stent placement for patients with symptomatic intracranial stenosis. A retrospective study was done to evaluate 36 patients with 37 symptomatic atherosclerotic intracranial stenosis who underwent primary balloon angioplasty. All patients had symptoms despite medical therapy. Thirty-four patients were available for follow-up ranging from 6 to 128 months. Mean follow-up was 52.9 months. Mean pretreatment stenosis was 84.2% before angioplasty and 43.3% after angioplasty. The periprocedural death and stroke rate was 8.3% (two deaths and one minor stroke). Two patients had strokes in the territory of angioplasty at 2 and 37 months after angioplasty. The annual stroke rate in the territory appropriate to the site of angioplasty was 3.36%, and for those patients with a residual stenosis of > or =50% it was 4.5%. Patients with iatrogenic dissection (n=11) did not have transient ischemic attacks or strokes after treatment. Results of long-term follow-up suggest that intracranial angioplasty without stent placement reduces the risk of further stroke in symptomatic patients.American Journal of Neuroradiology 03/2005; 26(3):525-30. · 3.68 Impact Factor
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ABSTRACT: Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has not been compared with medical management in a randomized trial. We randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery to aggressive medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days. Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P=0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P=0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group. In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.).New England Journal of Medicine 09/2011; 365(11):993-1003. · 54.42 Impact Factor
New standards for intracranial atherosclerotic disease
Thanh N. Nguyen1*, Marc A. Lazzaro2 and Adnan I. Qureshi3
1 Departments of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine, Boston, MA, USA
2 Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
3 Zeenat Qureshi Stroke Research Center, University of Minnesota, Saint Paul, MN, USA
The stenting versus aggressive medical therapy
for intracranial artery stenosis (SAMMPRIS)
trial compared aggressive medical therapy to
aggressive medical therapy and percutaneous
angioplasty and stenting (PTAS) in patients
with symptomatic intracranial atheroscle-
rotic disease (ICAD; Chimowitz et al., 2011).
The trial was halted when a higher 30-day rate
of stroke and death was present in the PTAS
compared to the aggressive medical therapy
group (14.7 vs. 5.8%, p = 0.002).
SAMMPRIS highlights the evolving defi-
nition and improving efficacy of aggressive
medical therapy including aspirin and clopi-
dogrel, statin, and antihypertensive treat-
ments. SAMMPRIS sets the new standard
for periprocedural stroke and death rates
which neurointerventionalists and devices
must achieve to demonstrate superiority
of PTAS to aggressive medical therapy. The
data from SAMMPRIS may allow a better
understanding of underlying mechanism for
adverse events such as intracranial hemor-
rhages related to PTAS and result in new
strategies for preventing such events.
The results should not undermine the
high risk of recurrent stroke in patients with
symptomatic ICAD despite aggressive med-
ical treatment. Several subgroups of ICAD
patients at high risk of ischemic events have
been identified such as those with high grade
stenosis, posterior circulation involvement,
precipitation of ischemic symptoms by sys-
temic blood pressure changes, and recurrent
ischemic events (Thijs and Albers, 2000).
Until the next stent emerges, intracranial
angioplasty (Marks et al., 2005; Nguyen
et al., 2011) may be an alternative for this
subgroup and should be evaluated against
aggressive medical therapy in a randomized
Chimowitz, M. I., Lynn, M. J., Derdeyn, C. P., Turan, T.
N., Fiorella, D., Lane, B. F., Janis, S., Lutsep, H. L.,
Barnwell, S. L., Waters, M. F., Hoh, B. L., Hourihane,
J. M., Levy, E. I., Alexandrov, A. V., Harrigan, M. R.,
Chiu, D., Klucznik, R. P., Clark, J. M., McDougall, C.
G., Johnson, M. D., Pride, L., Torbey, M. T., Zaidat,
O. O., Rumboldt, Z., Cloft, H. J., and SAMMPRIS
Trial Investigators. (2011). Stenting versus aggressive
medical therapy for intracranial artery stenosis. N.
Engl. J. Med. 365, 993–1003.
Marks, M. P., Marcellus, M. L., Do, H. M., Schraedley-
Desmond, P. K., Steinberg, G. K., Tong, D. C., and
Albers, G. W. (2005). Intracranial angioplasty with-
out stenting for symptomatic atherosclerotic stenosis:
long-term follow-up. Am. J. Neuroradiol. 26, 525–530.
Nguyen, T., Zaidat, O. O., Gupta, R., Nogueira, R. G.,
Tariq, N., Kalia, J. S., Norbash, A. M., and Qureshi, A.
I. (2011). Balloon angioplasty for intracranial athero-
sclerotic disease. Stroke 42, 107–111.
Thijs, V. N., and Albers, G. W. (2000). Symptomatic
intracranial atherosclerosis: outcome of patients who
fail antithrombotic therapy. Neurology 55, 490–498.
Received: 01 November 2011; accepted: 17 November 2011;
published online: 20 December 2011.
Citation: Nguyen TN, Lazzaro MA and Qureshi AI (2011)
New standards for intracranial atherosclerotic disease treat-
ment. Front. Neur. 2:77. doi: 10.3389/fneur.2011.00077
This article was submitted to Frontiers in Endovascular
and Interventional Neurology, a specialty of Frontiers in
Copyright © 2011 Nguyen, Lazzaro and Qureshi. This is
an open-access article distributed under the terms of the
Creative Commons Attribution Non Commercial License,
which permits non-commercial use, distribution, and repro-
duction in other forums, provided the original authors and
source are credited.
www.frontiersin.org December 2011 | Volume 2 | Article 77 | 1
published: 20 December 2011