Abstract
Intracranial atherosclerotic disease is a common cause of stroke worldwide, causing approximately 10 % of strokes in the USA and up to 50 % in Asian populations. Recurrent stroke risks are particularly high in those with a stenosis of 70 % or more and a recent transient ischemic attack or stroke. Warfarin has been associated with higher major hemorrhage rates and no reduction of recurrent stroke compared to aspirin in patients with symptomatic intracranial stenosis. After early trials showed the feasibility of stenting, two randomized trials compared stenting plus medical management to medical management alone in symptomatic intracranial stenosis. Stenting was linked with increased risk and showed no benefit in any subpopulation of patients. Aggressive medical management in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial was associated with half the risk of stroke compared to that in similar patients in a previous symptomatic intracranial stenosis trial after adjustment of confounding characteristics. Aggressive medical management comprises risk factor control, including a target systolic blood pressure <140 mmHg, a low density lipoprotein <70 mg/dL, hemoglobin A1C <7.0 %, and lifestyle management that incorporates exercise, smoking cessation and weight management, and the use of antithrombotics.
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Gorelick P, Wong KS, Bae HJ, Pandey D. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke. 2008;39:2396–9.
Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107–16.
Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, et al. Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis (WASID). N Engl J Med. 2005;352:1305–16.
Kasner SE, Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, et al. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation. 2006;113:555–63.
Mazighi M, Tanasescu R, Ducrocq X, Vicaut E, Bracard S, Houdart E, et al. Prospective Study of atherothrombotic intrancranial stenoses, the GESICA study. Neurology. 2006;66:1187–91.
The SSYLVIA Study Investigators. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA). Stroke. 2004;35:1388–92.
Zaidat OO, Klucznik R, Alexander MJ, Chaloupka J, Lutsep H, Barnwell S. The NIH registry on use of the Wingspan stent for symptomatic 70–99% intracranial arterial stenosis. Neurology. 2008;70:1518–24.
Fiorella DJ, Turk AS, Levy EI, Pride Jr GL, Woo HH, Albuquerque FC. US Wingspan registry 12-month follow-up results. Stroke. 2011;42:1976–81.
Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus aggressive medical therapy for intracranial stenosis. N Engl J Med. 2011;365:993–1003.
Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial stenosis (SAMMPRIS): the final results of a randomized trial. Lancet. 2014;383:333–41. This paper provided the final results of a randomized trial comparing stenting with the Wingspan self-expanding stent plus aggressive medical therapy to medical therapy alone in patients with symptomatic high grade intracranial stenosis.
Zaidat OO, Fitzsimmons B-F, Woodward BK, Wang Z, Killer-Oberpfalzer M, Wakhloo A, et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: The VISSIT randomized clinical trial. JAMA. 2015;313:1240–8. This randomized trial compared stenting with the Vitesse balloon-expandable stent plus medical therapy to medical therapy alone in patients with symptomatic high-grade intracranial stenosis.
Fiorella D, Derdeyn CP, Lynn ML, Barnwell SL, Hoh BL, Levy EI, et al. Detailed analysis of periprocedural strokes in patients undergoing intracranial stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS). Stroke. 2012;43:2682–8.
Lutsep HL, Barnwell SL, Larsen DT, Lynn MJ, Hong M, Turan TN, et al. Outcome in patients previously on antithrombotic therapy in the SAMMPRIS trial: subgroup analysis. Stroke. 2015;46:775–9.
Lutsep HL, Lynn MJ, Cotsonis GA, Derdeyn CP, Turan TN, Fiorella D, et al. Does the stenting versus aggressive medical therapy trial support stenting for subgroups with intracranial stenosis? Stroke. 2015;46:3282–4.
Chaturvedi S, Turan TN, Lynn MJ, Derdeyn CP, Fiorella D, Janis LS, et al. Do patient characteristics explain the differences in outcome between medically treated patients in SAMMPRIS and WASID? Stroke. 2015;46:2562–7.
Chaturvedi S, Turan TN, Lynn MJ, Kasner SE, Romano J, Cotsonis G, et al. Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology. 2007;69:2063–8.
Chimowitz MI, Derdeyn CP. Endovascular therapy for atherosclerotic intracranial arterial stenosis. JAMA. 2015;313:1219–20.
Turan TN, Lynn ML, Nizam A, Lane B, Egan BM, Le N-A, et al. Rationale, design, and implementation of aggressive risk factor management in the SAMMPRIS trial. Circ Cardiovasc Qual Outcomes. 2012;5:e51–60.
Turan TN, Nizam A, Lynn MJ, Montgomery J, Derdeyn CP, Fiorella D, et al. Relationship between risk factor control and vascular events in the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) trial. Stroke. 2014;45:AWP130 (abstract).
Wong KS, Chen C, Fu J, Chang HM, Suwanwela NS, Huang YN, et al. Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded endpoint trial. Lancet Neurol. 2010;9:489–97.
Liu L, Wong KSL, Leng X, Pu Y, Wang Y, Jing X, et al. Dual antiplatelet therapy in stroke and ICAS: subgroup analysis of CHANCE. Neurology. 2015;85:1154–62.
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160–236.
Chiu D, Klucznik RP, Turan TN, Lynn MJ, McCane CD, Katz LB, et al. Enrollment volume effect on risk factor control and outcomes in the SAMMPRIS trial. Neurology. 2015;85:2090–7.
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David A. Hoak and Helmi L. Lutsep declare that they have no conflict of interest.
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Hoak, D.A., Lutsep, H.L. Management of Symptomatic Intracranial Stenosis. Curr Cardiol Rep 18, 83 (2016). https://doi.org/10.1007/s11886-016-0762-5
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DOI: https://doi.org/10.1007/s11886-016-0762-5