New Standards for Intracranial Atherosclerotic Disease Treatment

Article (PDF Available)inFrontiers in Neurology 2:77 · December 2011with11 Reads
DOI: 10.3389/fneur.2011.00077 · Source: PubMed
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. December 2011 | Volume 2 | Article 77 | 1
General Commentary
publishe d: 20 Dec ember 2011
doi: 10.338 9/fneur.2011.00077
  • [Show abstract] [Hide abstract] ABSTRACT: Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) are a last resort for patients with high-grade intracranial stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.
    Article · Aug 2015

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