Current management of symptomatic intracranial stenosis

Final Results of Cilostazol-Aspirin Therapy against Recurrent Stroke with Intracranial Artery Stenosis (CATHARSIS)

Purpose

To compare the effect of cilostazol plus aspirin versus aspirin alone on the progression of intracranial arterial stenosis (IAS), and to compare ischemic and hemorrhagic events in patients with symptomatic IAS, an investigator-driven, nationwide multicenter cooperative randomized controlled trial (CATHARSIS; ClinicalTrials.gov Identifier 00333164) was conducted.

Methods

165 noncardioembolic ischemic stroke patients with >50% stenosis in the responsible intracranial artery after 2 weeks to 6 months from the onset were randomly allocated to receive either cilostazol 200 mg/day plus aspirin 100 mg/day (n = 83, CA group) or aspirin 100 mg/day alone (n = 82, A group). The primary endpoint was the progression of IAS on magnetic resonance angiography at 2 years after randomization. Secondary endpoints were any vascular events, any cause of death, serious adverse events, new silent brain infarcts, and worsening of the modified Rankin Scale score.

Results

Progression of IAS was observed in 9.6% of the CA group patients and in 5.6% of the A group patients, with no significant intergroup difference (p = 0.53). The incidence of the secondary endpoints tended to be lower in the CA group compared with the A group, although the differences were not significant. By using exploratory logistic regression analysis adjusted for patient background characteristics, it was shown that the risk for certain combinations of secondary endpoints was lower in the CA group than in the A group [all vascular events and silent brain infarcts: odds ratio (OR) = 0.37, p = 0.04; stroke and silent brain infarcts: OR = 0.34, p = 0.04; all vascular events, worsening of modified Rankin Scale scores and silent brain infracts: OR = 0.41, p = 0.03]. Major hemorrhage was observed in 4 patients of the CA group and in 3 of the A group.

Conclusion

Progression of IAS during the 2-year observation period appears to be less frequent than previously reported in stroke patients on antiplatelet agents after the acute phase, which could be due to the adequate control of risk factors, and because patients with stroke within 2 weeks after the onset were excluded. The results of the CATHARSIS trial suggest a potential utility of pharmacotherapies with cilostazol plus aspirin as well as of strict control of risk factors for the management of symptomatic IAS. Larger studies with higher statistical power are required to obtain conclusive results.

Intracranial atheromatous disease treatment with the Wingspan stent system: evaluation of clinical, procedural outcome and restenosis rate in a single-center series of 21 consecutive patients with acute and mid-term results

BACKGROUND

Intracranial atherosclerosis may be the underlying pathology in up to 15% of ischemic strokes, but may account for about 40% of strokes in some populations. After an ischemic event determined by intracranial atherosclerosis, patients have a 12% annual risk of stroke recurrence, mostly during the first year.

OBJECTIVE

To evaluate procedural safety, clinical outcome and restenosis rate of Wingspan stent placement.

METHODS

Twenty-one caucasoid patients were enrolled. Target patients were affected by high-grade, symptomatic, intracranial atherosclerotic lesions, were on antithrombotic therapy and at high stroke risk. All patients were treated with the Wingspan stent system.

RESULTS

Technical success resulted 100%, with all target lesions being reduced to <50%. No stroke or death were observed at 30. The mean percent of stenosis was reduced from a middle value of 84% to a middle value of 17% after stent placement. Medium follow-up was 19.5months (range 6-36months). No stroke or death occurred in any patient. None of the patients presented a <50% stent patency rate at follow-up.

CONCLUSIONS

The short-term results and follow up analysis provide evidence demonstrating the safety of the Wingspan system when used in high-risk patient population. Due to concerns regarding long-term stent patency and ischemic events occurrence emerged from clinical trials such as the SAMMPRIS, intracranial angioplasty and stent with the Wingspan system should be considered only for high risk patients in which it may be considered the only viable therapeutic option.