Design of the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis trial

1-Year outcomes of Resolute Onyx Zotarolimus-Eluting Stent for symptomatic intracranial atherosclerotic disease: A multicenter propensity score-matched comparison with stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial

BACKGROUND

Intracranial atherosclerotic disease (ICAD) is one of the most prevalent causes of stroke across the world. Endovascular treatment has gained prominence but remains a challenge with unfavorable results. Recent literature has demonstrated that the Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) is a technically safe option with low complication rates along with 30-day outcomes associated with intracranial stent placement for ICAD with RO-ZES compared to results from the Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Here, we aim to compare outcomes at one year with the SAMMPRIS trial with a multicenter longitudinal study.

MATERIALS AND METHODS

Prospectively maintained databases across seven stroke centers were analyzed for adult patients undergoing RO-ZES placement for ICAD between January 2019 and May 2023. The primary endpoint was composite of one-year stroke, ICH, and/or death. These data were propensity score matched using age, sex, hypertension, diabetes mellitus, smoking status, and impacted vessel for comparison between RO-ZES and the SAMMPRIS percutaneous angioplasty and stenting groups (S-PTAS).

RESULTS

A total of 104 patients were included, mean age ± SD: 64.9 ± 10.9 years, 25.5% female. Propensity score match analysis of the 104 patients with S-PTAS demonstrated one-year stroke, ICH, and/or death rate of 11.5% in the RO-ZES group and 28.1% in the S-PTAS group (odds ratio 4.17, 95% CI 2.06-8.96, p = 0.001).

CONCLUSION

The RO-ZES system demonstrates strong potential to reduce long-term complications at one year compared with the S-PTAS group. Further prospective multicenter studies are needed to corroborate and build upon these findings.

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.

Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis

Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.

Ameliorating Racial Disparities in Vascular Risk Factor Management With Aggressive Medical Management in the SAMMPRIS Trial

BACKGROUND

The WASID trial (Warfarin-Aspirin Symptomatic Intracranial Disease) and the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) evaluated optimal management of symptomatic intracranial atherosclerotic stenosis. The aim of this retrospective, observational study was to determine whether aggressive medical management used in the SAMMPRIS trial ameliorated disparities in risk factor control between Black and non-Black patients.

METHODS

The SAMMPRIS trial was a randomized controlled trial that enrolled patients with symptomatic intracranial atherosclerotic stenosis between November 2008 and April 2011. The frequency of risk factors at study entry (baseline) and mean levels of systolic blood pressure, diastolic blood pressure, LDL (low-density lipoprotein), hemoglobin A1c, and exercise level (quantified by physician-based assessment and counseling for exercise score) at baseline and at 1 year of follow-up were compared between Black (n=104) versus non-Black patients (n=347).

RESULTS

Significant differences at baseline in Black patients (listed first) versus non-Black patients were age (57.5 versus 61.0 years; P=0.004), hypertension (95.2% versus 87.5%; P=0.027), diabetes (52.9% versus 39.7%; P=0.017), mean diastolic blood pressure (82.4 versus 79.5 mm Hg; P=0.035), and mean physician-based assessment and counseling for exercise score (2.7 versus 3.3; P=0.002). The mean diastolic blood pressure and mean physician-based assessment and counseling for exercise scores at 1 year in Black versus non-Black patients were 74.7 versus 75.5 mm Hg (P=0.575) and 4.2 versus 4.1 (P=0.593), respectively. No disparities in other modifiable risk factors emerged at 1 year.

CONCLUSIONS

Significant differences in important risk factors (physical activity and diastolic blood pressure) at baseline between Black and non-Black patients resolved at 1 year, suggesting that aggressive medical management may have an important role in ameliorating disparities in risk factor control between Black and non-Black patients.

Thirty-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity Score-Matched Comparison With Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

BACKGROUND

Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause 10% of strokes annually in the United States. However, treatment remains a challenge with several different stenting options studied in the past with unfavorable results.

OBJECTIVE

To report the 30-day stroke and/or death rate associated with intracranial stent placement for sICAD using Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) and provide a comparison with the results of Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial.

METHODS

Prospectively maintained databases across 8 stroke centers were used to identify adult patients treated with RO-ZES for sICAD between January 2019 and December 2021. Primary end point was composite of 30-day stroke, intracerebral hemorrhage, and/or death. Propensity score matching was performed using age, hypertension, lipid disorder, cigarette smoking, and symptomatic target vessel to create a matched group for comparison between RO-ZES and the SAMMPRIS medical management and treatment groups (SAMMPRIS percutaneous angioplasty and stenting [S-PTAS]).

RESULTS

A total of 132 patients met the inclusion criteria for analysis (mean age: 64.2 years). Mean severity of stenosis was 81.4% (±11.4%). A total of 4 (3.03%) stroke and/or deaths were reported within 30 days of treatment in the RO-ZES group compared with 6.6% in the SAMMPRIS medical management group (OR [odds ratio] 2.26, 95% CI 0.7-9.56, P = .22) and 15.6% in the S-PTAS group (OR 5.9, 95% CI 2.04-23.4, P < .001). Propensity score match analysis of 115 patients in each group demonstrated 30-day stroke and/or death rate of 2.6% in the RO-ZES group and 15.6% in the S-PTAS group (OR 6.88, 95% CI 1.92-37.54, P < .001).

CONCLUSION

Patients treated with RO-ZES had a relatively low 30-day stroke and/or death rate compared with the S-PTAS group. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.

The use of dual antiplatelet therapy for ischemic cerebrovascular events

In the last 10 years, the use of dual antiplatelet therapy (DAPT) in the neurological ambit has been explored in patients with non-cardioembolic ischemic stroke, transient ischemic attack (TIA), and intracranial atherosclerotic disease. Two clinical trials (CHANCE and POINT) showed that in patients with minor non-cardioembolic ischemic stroke or high-risk TIA, the addition of clopidogrel to aspirin reduces the risk of stroke recurrence. Another trial (THALES) evaluated the association of ticagrelor and aspirin in mild-to-moderate non-cardioembolic ischemic stroke or high-risk TIA, showing a reduced risk of subsequent stroke compared to aspirin alone. Finally, the use of DAPT has been assessed in the treatment of stroke associated with atherosclerotic intracranial stenosis in the SAMMPRIS trial, showing a favorable profile compared to percutaneous angioplasty and stenting. The aim of this article is, after a review the major trials evaluating DAPT in patients with ischemic cerebrovascular events and the ways they have been implemented in Italian, European, and USA guidelines, to provide a practical algorithm to help clinicians in their everyday clinical practice and to outline possible caveats in the practical implementation of guidelines. Possible limitations and gaps in knowledge regarding specific conditions (e.g., the use of DAPT after acute phase therapies) are also underlined.

Dual anti-platelet therapy for secondary prevention in intracranial atherosclerotic disease: a network meta-analysis

Background:

Intracranial arterial stenosis (ICAS) is a non-marginal cause of stroke/transient ischemic attacks (TIAs) and is associated with high stroke recurrence rate. Some studies have investigated the best secondary prevention ranging from antithrombotic therapy to endovascular treatment (ET). However, no direct comparison between all the possible treatments is currently available especially between single and dual anti-platelet therapies (SAPT and DAPT).

Aim:

To establish whether DAPT is more effective than SAPT in preventing the recurrence of ICAS-related stroke, by means of a network meta-analysis (NMA).

Design:

Systematic review and NMA in accordance to PRISMA guidelines.

Data sources and methods:

We performed a systematic review of trials investigating secondary prevention (SAPT or DAPT, anticoagulant treatment or ET) in patients with symptomatic ICAS available in MEDLINE, Scopus and Web of Science from January 1989 to May 2021. We defined our primary efficacy outcome as the recurrence of ischemic stroke/TIA. We analysed the extracted data with Bayesian NMA approach.

Results:

We identified 815 studies and included 5 trials in the NMA. Sequence generation was adequate in all the selected studies while the allocation concealment method was described in one study. All the included studies reported the pre-specified primary outcomes, and outcome assessment was blinded in all the studies. We used the fixed-effect approach as the heterogeneity was not significant (p > 0.1) according to the Cochran’s Q statistic. DAPT was superior to SAPT and DAPT + ET in preventing stroke/TIA recurrence [respectively, odds ratio (OR), 0.59; confidence interval (CI), 0.39–0.9; and OR, 0.49, CI, 0.26–0.88], while no difference was found between DAPT and oral anticoagulant therapy (OAC). DAPT was safer than OAC (OR, 0.48; CI, 0.26–0.89) and DAPT + ET (OR, 0.50; CI, 0.35–0.71), while no difference was found between DAPT and SAPT.

Conclusion:

DAPT is more effective than SAPT for secondary stroke prevention in patients with symptomatic ICAS, without increasing the risk of haemorrhage.

Registration:

Prospero/CRD42019140033.

Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies

The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.

Computational Fluid Dynamics in Intracranial Atherosclerosis - Lessons from Cardiology: A Review of CFD in Intracranial Atherosclerosis

BACKGROUND

Intracranial atherosclerosis is a common cause of stroke with a high recurrence rate. Haemodynamically significant lesions are associated with a particularly high risk of recurrence. Computational fluid dynamics (CFD) is a tool that has been investigated to identify haemodynamically significant lesions. CFD in the intracranial vasculature benefits from the precedent set by cardiology, where CFD is an established clinical tool. This precedent is particularly important in CFD as models are very heterogenous. There are many decisions-points in the model-creation process, usually involving a trade-off between computational expense and accuracy.

OBJECTIVES

This study aimed to review published CFD models in intracranial atherosclerosis and compare them to those used in cardiology.

METHODS

A systematic search for all published computational fluid dynamics models applied to intracranial atherosclerosis was performed. Each study was analysed as regards to the different steps in creating a fluid dynamics model and findings were compared with established cardiology CFD models.

RESULTS AND CONCLUSION

38 papers were screened and 12 were included in the final analysis. There were important differences between coronary and intracranial atherosclerosis models in the following areas: area of interest segmented, use of transient models vs steady-state models, boundary conditions, methods for solving the fluid dynamics equations and validation. These differences may be high-yield areas to explore for future research.

A Retrospective Study Comparison Between Stenting and Standardized Medical Treatment for Intracranial Vertebrobasilar Stenosis in a Real-World Chinese Cohort

Background: To date, there has been no consensus regarding the benefits of percutaneous transluminal angioplasty and stenting (PTAS) vs. those of standardized medical treatment (SMT) for patients with symptomatic intracranial vertebrobasilar stenosis (IVBS). The purpose of this retrospective study was to compare the effects of PTAS or SMT on symptomatic IVBS in a real-world Chinese population.

Methods: We included 238 patients with ischemic stroke caused by IVBS stenosis who were admitted to Shandong Provincial Hospital Affiliated to Shandong University between September 2012 and May 2018; 62 of these patients were treated with SMT and 176 underwent PTAS. Ischemic stroke in the territory of the responsible artery, hemorrhage, and death within 1 year were recorded as primary endpoints. Secondary endpoints included assessment of stroke severity and the incidence of re-stenosis. The primary endpoint rates were compared between the PTAS and SMT groups at 7 days, 1, 6 months, and 1 year.

Results: In the PTAS group, the success rate of stent placement was 98.9%. During the entire trial, except for 7 days, the SMT group had a higher frequency of primary endpoint events than did the PTAS group. The primary endpoint was 17.7% (11/62) vs. 8.6% (15/174) at 1 month (p = 0.049), 29% (18/62) vs. 14.4% (25/174) at 6 months (p = 0.01), and 32.2% (20/62) vs. 17.2% (30/174) at 1 year (p = 0.013). The restenosis rate of the target lesion was 13.8%; 60% were symptomatic restenosis and 40% were asymptomatic restenosis. The rate of severe stroke at 1 year after PTAS was 0%, while that in the SMT group was 9.7%.

Conclusions: In a real-world Chinese cohort, PTAS for patients might be superior to SMT, and provide better long-term neurological function recovery and lower disability rate.

Dual Antiplatelet Therapy Beyond 90 days in Symptomatic Intracranial Stenosis in the SAMMPRIS Trial

BACKGROUND

The safety and efficacy of dual antiplatelet use for symptomatic intracranial atherosclerosis beyond 90 days is unknown. Data from SAMMPRIS was used to determine if dual antiplatelet therapy (DAPT) beyond 90 days impacted the risk of ischemic stroke and hemorrhage.

METHODS

This post hoc exploratory analysis from SAMMPRIS included patients who did not have a primary endpoint within 90 days after enrollment (n = 397). Patients in both the aggressive medical management (AMM) and percutaneous transluminal angioplasty and stenting (PTAS) arms were included. Baseline features and outcomes during follow-up were compared between patients who remained on DAPT beyond 90 days (on clopidogrel) and patients who discontinued clopidogrel and remained on aspirin alone at 90 days (off clopidogrel) using Fisher's exact tests.

RESULTS

The stroke rate was numerically lower in the group on clopidogrel vs off clopidogrel among both the AMM alone arm (6.0% versus 10.8%, p = 0.31) and the PTAS arm (8.7% versus 9.8%; p = 0.82), but the difference was not significant. The major hemorrhage rates were numerically higher in the group on clopidogrel vs. off clopidogrel group among both the AMM alone arm (4.0% versus 2.5%; p = 0.67) and the PTAS arm (10.9% versus 3.5%; p = 0.08), but were not significant.

CONCLUSION

This exploratory analysis suggests that prolonged DAPT use may lower the risk of stroke in medically treated patients with intracranial stenosis but may increase the risk of major hemorrhage.

The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis Trial: Reanalysis Using the FDA "On Label" Criteria

BACKGROUND AND PURPOSE

Due to higher rates of 1-month stroke and death with Wingspan intracranial stent placement observed in SAMMPRIS, the Food and Drug Administration (FDA) announced a more limited indication for Wingspan stent.

METHODS

We compared the results of intracranial stent placement with best medical treatment in patients recruited in SAMMPRIS who met the new "on label" criteria with those who were categorized as "off label." The primary endpoint was any stroke or death occurring within 30 days of enrollment, or an ischemic stroke in the territory of the symptomatic intracranial artery from day 31 after study entry to completion of follow-up.

RESULTS

A total of 31 (7%) among 451 recruited patients met the "on label" criteria. The relative risk of primary endpoint was lower in "on label" patients treated with stent placement compared with best medical treatment (relative risk .61, 95% confidence interval .2-1.7) but higher in "off label" patients (relative risk 1.81, 95% confidence interval 1.2-2.6). Primary endpoint was seen in 20% and 23.4% of patients treated with stent placement in "on label" and "off label" patients, respectively. Primary endpoint was seen in 25% and 14.2% of patients treated with best medical treatment in "on label" and "off label" patients, respectively.

CONCLUSION

The new FDA "on label" criteria may identify a small group of people, who may benefit from intracranial stent placement due to higher risk of primary endpoint in those treated with best medical treatment.

Poststroke Montreal Cognitive Assessment and Recurrent Stroke in Patients With Symptomatic Intracranial Atherosclerosis

BACKGROUND AND PURPOSE

Cognitive impairment occurs in 20%-40% of stroke patients and is a predictor of long-term morbidity and mortality. In this study, we aim to determine the association between poststroke cognitive impairment and stroke recurrence risk, in patients with anterior versus posterior circulation intracranial stenosis.

METHODS

This is a post-hoc analysis of the Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. The primary predictor was poststroke cognitive function measured by Montreal Cognitive Assessment (MOCA) at 3-6 months and the primary outcome was recurrent ischemic stroke. We used univariate and multivariable cox-regression models to determine the associations between MOCA at 3-6 months and recurrent stroke.

RESULTS

Of the 451 patients enrolled in SAMMPRIS, 393 patients met the inclusion criteria. The mean age of the sample (in years) was 59.5 ± 11.3, 62.6% (246 of 393) were men. Fifty patients (12.7%) had recurrent ischemic stroke during a mean follow up of 2.7 years. The 3-6 month MOCA score was performed on 351 patients. In prespecified multivariable models, there was an association between 3 and 6 month MOCA and recurrent stroke (hazard ratio [HR] per point increase .93 95% confidence interval [CI] .88-.99, P = .040). This effect was present in anterior circulation stenosis (adjusted HR per point increase .92 95% CI .85-0.99, P = .022) but not in posterior circulation artery stenosis (adjusted HR per point increase 1.00 95% .86-1.16, P = .983).

CONCLUSIONS

Overall, we found weak associations and trends between MoCA at 3-6 months and stroke recurrence but more notable and stronger associations in certain subgroups. Since our study is underpowered, larger studies are needed to validate our findings and determine the mechanism(s) behind this association.

Relationship Between Vascular Risk Factors and Location of Intracranial Atherosclerosis in the SAMMPRIS Trial

BACKGROUND

Previous studies have reported that different locations of intracranial atherosclerosis (ICAS) are associated with different demographic features and vascular risk factors. We aimed to examine this observation in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial population.

METHODS

SAMMPRIS was a randomized controlled trial that enrolled 451 patients with recent transient ischemic attack or stroke-related due to severe (70%-99%) stenosis of a major intracranial artery. We compared the baseline demographic features and vascular risk factors between the symptomatic artery locations. Wilcoxon test was used to compare continuous variables, and chi-square test was used for categorical variables.

RESULTS

Of 449 patients included in the analysis; 289 (64.4%) had ICAS in the anterior circulation and 160 (35.6%) in the posterior circulation. Features that were significantly different between patients with anterior versus posterior ICAS were: median age (58.3 years versus 64.0 years, P < .001), males/females (52.9%/47.1% versus 74.4%/25.6% P < .001), white/black (66.8%/26.6% versus 79.4%/16.9%, P = .02), and history of hyperlipidemia (85.5% versus 92.5%, P = .03).

CONCLUSIONS

The observed differences in the distribution of demographic characteristics and vascular risk factors depending on the location of symptomatic ICAS suggest the possibility of different underlying pathological processes involved in the formation of atherosclerotic plaques in different locations.

Proposed antithrombotic strategy for acute ischemic stroke with large-artery atherosclerosis: focus on patients with high-risk transient ischemic attack and mild-to-moderate stroke

An effective antithrombotic strategy is required to prevent the recurrence and aggravation of large-artery atherosclerosis (LAA) stroke, especially in high-risk transient ischemic attack (TIA) and acute mild ischemic stroke. Based on clinical evidence, atherosclerotic thrombosis theory, antithrombotic treatment guidelines of acute myocardial infarction (AMI), and previous studies, a new antithrombotic strategy "early administration, enhanced therapy, combination therapy, short-term therapy, and sequential therapy" was proposed in this study. Multicenter randomized trials are needed in the future to verify the efficacy of the strategy.

Long-term Outcome of Angioplasty Using a Wingspan Stent, Post-Stent Balloon Dilation and Aggressive Restenosis Management for Intracranial Arterial Stenosis

PURPOSE

To investigate the long-term outcome of stent angioplasty for symptomatic severe intracranial artery stenosis.

METHOD

In this study 95 consecutive patients with intracranial atherosclerotic stenosis (>70%) underwent stent angioplasty using Wingspan stents. The primary endpoints were stroke or death within 30 days of the procedure and subsequent stroke attributed to the stented vessel. Disabling stroke was defined as stroke with a modified Rankin scale > 3. Secondary endpoints included transient ischemic attacks, contralateral stroke, nonstroke death, and other events. Patients underwent prestent balloon dilation with or without poststent balloon dilation, close restenosis follow-up, and selective retreatment, as required.

RESULT

The mean follow-up duration was 34.9 ± 23.3 months. Primary endpoint events occurred in 23% of the patients. The median infarction volume was 2.6 ml, and 11 (68%) of 16 infarctions were <5 ml in volume. Disabling stroke occurred in 3% of patients. The primary endpoint rates were 17.9% within 30 days and 2.1% from 30 days to 1 year. Secondary endpoint events occurred in 27.3% of the patients. Mean stenosis was reduced from 76.8 ± 6.1% to 7.5 ± 13.4%. Of 80 patients who underwent angiographic follow-up, 11 (14%) experienced restenosis (≥50%) and 7 (9%) exhibited restenosis-related symptoms of transient ischemic attack. The rate of symptomatic restenosis was significantly higher in patients who underwent prestent balloon dilation alone than in patients who underwent prestent and poststent balloon dilation (p = 0.016).

CONCLUSION

The postprocedural stroke rate was similar to that observed in the SAMMPRIS study. Symptomatic restenosis may be reduced by poststent dilation, close angiographic follow-up, and retreatment.

Type and Duration of Exercise in the SAMMPRIS Trial

BACKGROUND

Analyses from the Stenting and Aggressive Medical management for prevention of Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial showed that good control of vascular risk factors (systolic blood pressure, low-density lipoprotein, and exercise) was associated with fewer vascular events and exercise had the biggest impact on the outcome. We sought to determine the type and duration of exercise performed by SAMMPRIS patients during the trial.

METHODS

SAMMPRIS aggressive medical management included a telephonic lifestyle modification program, INTERVENT, that was provided free of charge to all subjects during the study. We analyzed self-reported data collected by INTERVENT on the patients' type and duration of exercise from baseline (n=394) to 3 years (n=132). We calculated the mean duration for each exercise type at each time period and then compared the change in exercise duration from baseline using paired t tests and Wilcoxon signed-rank tests.

RESULTS

Walking was the most common form of exercise at all time points, as measured by both the duration of exercise and the number of patients performing the exercise. The mean duration of walking and other aerobic activities increased significantly from baseline to all other time points.

CONCLUSIONS

The type of self-reported exercise performed by SAMMPRIS patients included mostly walking or other aerobic activity and increased significantly during follow-up.

Impact of Baseline Features and Risk Factor Control on Cognitive Function in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

BACKGROUND

Cerebrovascular disease is an important cause of cognitive impairment. The aim of this study is to report the relationship between cognitive function and risk factors at baseline and during follow-up in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial.

METHODS

Subjects in the SAMMPRIS trial were included in this study. In order to have an assessment of cognitive function independent of stroke, patients with a stroke as a qualifying event whose deficits included aphasia or neglect were excluded from these analyses as were those with a cerebrovascular event during follow-up. The Montreal Cognitive Assessment (MoCA) score was used to assess cognitive impairment at baseline, 4 months, 12 months and closeout. Cognitive impairment was defined as MoCA < 26. A multivariate analysis was performed to determine what risk factors were independent predictors of cognitive function at baseline, 12 months and closeout. Among patients randomized to aggressive medical management only, the percentage of patients with cognitive impairment was compared between patients in versus out of target for each risk factor at 12 months and closeout.

RESULTS

Of the 451 patients in SAMMPRIS, 371 patients met the inclusion criteria. MoCA < 26 was present in 55% at baseline. Older age and physical inactivity were associated with cognitive impairment at baseline. Older age, non-white race, lower baseline body mass index, and baseline cognitive impairment were associated with cognitive impairment at 12 months. In the aggressive medical management group, at 12 months, physical inactivity during follow-up was the strongest risk factor associated with cognitive impairment.

CONCLUSION

Cognitive impairment is common in patients with severe symptomatic intracranial atherosclerosis. Physical inactivity at baseline and during follow-up is a strong predictor of cognitive impairment.

Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke

Intracranial stenosis is a common cause of ischaemic strokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23% in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2%) in the medical group had a disabling or fatal stroke beyond 30 days, indicating significant benefit of stenting if periprocedural complications can be reduced. Recently, the results of the Chinese Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial and the Wingspan Stent System Post Market Surveillance Study (WEAVE trial) showed 2%-2.7% periprocedural complications. It is time to evaluate the role of intracranial stenting for the prevention of disabling or fatal stroke.

Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects

Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.

Expression of nerve growth factor carried by pseudotyped lentivirus improves neuron survival and cognitive functional recovery of post-ischemia in rats

AIMS

Nerve growth factor (NGF) has been reported to prevent neuronal damage and contributes to the functional recovery in animal brain injury models and human ischemic disease as well. We aimed to investigate a potential therapeutic effect of NGF gene treatment in ischemic stroke and to estimate the functional recovery both at the cellular and cognitive levels in an ischemia rat model.

METHODS

After microinjection of pseudolentivirus-delivered β-NGF into an established ischemic stroke model in rats (tMCAO), we estimated neuronal cell apoptosis with TUNEL labeling and neurogenesis by cell proliferation marker Ki67 staining in both ischemic core and penumbra of striatum. Furthermore, we used behavioral functional tests, Morris water maze performance, to evaluate cognitive functional recovery in vivo and propose a potential underlying mechanism.

RESULTS

We found that pseudolentivirus-mediated delivery of β-NGF gene into the brain induced high expression in striatum of the infarct core area after ischemia in rats. The β-NGF overexpression in the striatal infarction core after ischemia not only improved neuronal survival by reducing cell apoptosis and increasing cell proliferation, but also rescued cognitive functional impairment through upregulation of GAP-43 protein expression in tMCAO rat model of ischemia.

CONCLUSION

This study demonstrates a potential β-NGF gene therapy by utilization of pseudolentivirus in ischemia and indicates future applications of NGF gene treatment in ischemic patients.

Relationship between Risk Factor Control and Compliance with a Lifestyle Modification Program in the Stenting Aggressive Medical Management for Prevention of Recurrent Stroke in Intracranial Stenosis Trial

BACKGROUND

Lifestyle modification programs have improved the achievement of risk factor targets in a variety of clinical settings, including patients who have previously suffered a stroke or transient ischemic attack and those with multiple risk factors. Stenting Aggressive Medical Management for Prevention of Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) was the first vascular disease prevention trial to provide a commercially available lifestyle modification program to enhance risk factor control. We sought to determine the relationship between compliance with this program and risk factor control in SAMMPRIS.

METHODS

SAMMPRIS aggressive medical management included a telephonic lifestyle modification program provided free of charge to all subjects (n = 451) during their participation in the study. Subjects with fewer than 3 expected lifestyle-coaching calls were excluded from these analyses. Compliant subjects (n = 201) had  greater than or equal to 78.5% of calls (median % of completed/expected calls). Noncompliant subjects (n = 200) had less than 78.5% of calls or refused to participate. Mean risk factor values or % in-target for each risk factor was compared between compliant versus noncompliant subjects, using t tests and chi-square tests. Risk factor changes from baseline to follow-up were compared between the groups to account for baseline differences.

RESULTS

Compliant subjects had better risk factor control throughout follow-up for low-density lipoprotein, systolic blood pressure (SBP), hemoglobin A1c (HgA1c), non-high-density lipoprotein, nonsmoking, and exercise than noncompliant subjects, but there was no difference for body mass index. After adjusting for baseline differences between the groups, compliant subjects had a greater change from baseline than noncompliant subjects for SBP did at 24 months and HgA1c at 6 months.

CONCLUSION

SAMMPRIS subjects who were compliant with the lifestyle modification program had better risk factor control during the study for almost all risk factors.

Seven years' follow-up of comparative study between stenting and medication for treatment of symptomatic vertebrobasilar artery stenosis

Objective Endovascular stent-assistant angioplasty (ESAA) is a valid treatment for symptomatic vertebrobasilar artery stenosis (SVAS), but the long-term effect and the improvement of condition compared with medication treatment are unknown. This study investigated the long-term efficacy of ESAA in patients with moderate and severe SVAS, and compared the efficacy with medication treatment. Materials and methods We conducted a retrospective analysis of clinical data of 43 patients with moderate and severe SVAS hospitalized in our department. According to different treatment methods they were divided into 29 cases in an ESAA group and 14 cases in a medication treatment group. During the follow-up period, the degree of vascular stenosis, vascular blood flow velocity, restenosis rate, recovery of neurological function and the incidence of cerebral ischemic events in the two groups were analyzed. Results The average clinical follow-up period was 89.4 ± 10.2 months. Before treatment, the stenosis rate and average blood flow velocity of the two groups were not statistically significant ( p > 0.05). During the follow-up period, both were significantly lower than the medication treatment group ( p < 0.01). In the ESAA group, three cases of stent stenosis, and three cases in the medication treatment group were completely occluded. The total ischemic events in ESAA group were three cases, compared with nine cases in the medication treatment group; the difference was statistically significant ( p < 0.05). Conclusion ESAA has a long-term effect in the treatment of symptomatic moderate and severe vertebrobasilar artery stenosis. It is superior to medication therapy in preventing posterior circulation ischemia (PCI), but a larger sample size is still needed to confirm the study.

Concomitant Asymptomatic Intracranial Atherosclerotic Stenosis Increase the 30-Day Risk of Stroke in Patients Undergoing Symptomatic Intracranial Atherosclerotic Stenosis Stenting

BACKGROUND

In the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial, 19.1% of ischemic strokes occurred out of the territory of previously symptomatic stenosis during the mean follow-up period of 23.4 months. However, it is unknown how many ischemic strokes were due to a previously asymptomatic intracranial atherosclerotic stenosis (ICAS). The objective of this study was to investigate whether the concomitant asymptomatic ICAS influences the outcome of patients undergoing symptomatic ICAS stenting.

METHODS

We retrospectively reviewed 576 consecutive patients with nondisabling ischemic stroke (modified Rankin scale score of ≤3) who were treated with symptomatic ICAS (≥70% stenosis) stenting with or without concomitant asymptomatic ICAS. The baseline characteristics and the 30-day primary end points (stroke or death after stenting) were compared by bivariate and multivariable logistic analyses.

RESULTS

The 30-day rate of primary end points was 5.2%, which was higher in patients with concomitant asymptomatic ICAS (≥50% stenosis) than in those without asymptomatic ICAS (no stenosis or <50% stenosis) (8.9% versus 3.8%, P = .014). In patients with concomitant asymptomatic ICAS, 25% of ischemic strokes occurred out of the territory of the stented artery, whereas in patients without asymptomatic ICAS, no ischemic stroke occurred out of the territory of the stented artery. Multivariable analysis showed that concomitant asymptomatic ICAS was an independent risk factor for 30-day stroke (odds ratio = 2.37, 95% confidence interval, 1.14-5.63; P = .023).

CONCLUSIONS

Concomitant asymptomatic ICAS (≥50% stenosis) might increase the 30-day risk of stroke in patients undergoing symptomatic ICAS stenting.

Angioplasty, Stenting and Other Potential Treatments of Atherosclerotic Stenosis of the Intracranial Arteries: Past, Present and Future

Although there is an intuitive appeal to treat symptomatic stenotic intracranial arteries with endovascular therapies such as angioplasty and stenting, current data from randomized trials show intensive medical therapy is far superior for preventing stroke. This is in large part due to the high risk of peri-procedural stroke from angioplasty and stenting. If angioplasty and stenting is to emerge as a proven treatment for intracranial stenosis, endovascular techniques will need to become much safer, identification of patients with intracranial stenosis who are at particularly high risk of stroke despite intensive medical therapy will need to be targeted, and well-designed randomized trials will be necessary to show endovascular therapy is superior to medical therapy in these high-risk patients.

Advanced Imaging of Intracranial Atherosclerosis: Lessons from Interventional Cardiology

Intracranial atherosclerosis is a major cause of ischemic stroke. Patients with a high degree of stenosis have a significant rate of stroke despite medical therapy. Two randomized trials of stenting have failed to show benefit. Improving periprocedural complication rates and patient selection may improve stenting outcomes. Fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT) are intravascular imaging techniques employed to improve patient selection and stent placement in interventional cardiology. FFR has been shown to improve cardiovascular outcomes when used in patient selection for intervention. Studies of FFR in intracranial atherosclerosis show that the measure may predict which plaques lead to stroke. IVUS is used in cardiology to quantify stenosis and assist with stent placement. Comparisons with histology show that it can reliably characterize plaques. Several case reports of IVUS in intracranial arteries show the technique to be feasible and indicate it may improve stent placement. Plaque characteristics on IVUS may help identify vulnerable plaques. In interventional cardiology, OCT provides excellent visualization of vessel geometry and is useful periprocedurally. Images reliably identify thin-capped fibroatheromas and other plaque features. Case reports indicate that OCT is safe for use in intracranial arteries. OCT can be used to identify perforator vessels and so may be useful in avoiding perforator strokes, a common complication of stenting. Plaque characteristics on OCT may be useful in patient selection.

Nonprocedural Symptomatic Infarction and In-Stent Restenosis After Intracranial Angioplasty and Stenting in the SAMMPRIS Trial (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis)

BACKGROUND AND PURPOSE

The purpose of this study was to investigate the frequency of symptomatic in-stent restenosis (ISR) and its contribution to nonprocedural symptomatic infarction in the SAMMPRIS trial (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis).

METHODS

Patients without a periprocedural primary end point were followed up to determine the occurrence of any of the following events: ischemic stroke, cerebral infarct with temporary signs, or transient ischemic attack in the territory of the stented artery. Vascular imaging performed after these events was reviewed for ISR. Annual rates for symptomatic ISR were calculated using Kaplan-Meier estimates.

RESULTS

Of 183 patients in the stenting group without a periprocedural primary end point, 27 (14.8%) had a symptomatic infarction (stroke or cerebral infarct with temporary signs) and 16 (8.7%) had transient ischemic attack alone in the territory during a median follow-up of 35.0 months. Of the 27 patients with infarctions, 17 (9.3%) had an ischemic stroke and 10 (5.5%) had a cerebral infarct with temporary signs alone. Adequate vascular imaging to evaluate ISR was available in 24 patients with infarctions (showing ISR in 16 [66.7%]) and in 10 patients with transient ischemic attack alone (showing ISR in 8 [80%]). The 1-, 2-, and 3-year rates (with 95% confidence limits) for symptomatic ISR in the SAMMPRIS stent cohort were 9.6% (6.1%-14.9%), 11.3% (7.5%-17.0%), and 14.0% (9.6%-20.2%), respectively.

CONCLUSIONS

Symptomatic ISR occurred in at least 1 of 7 patients in SAMMPRIS by 3 years of follow-up and was likely responsible for the majority of nonprocedural cerebral infarctions.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT00576693.

Relationship between risk factor control and vascular events in the SAMMPRIS trial

OBJECTIVE

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study is the first stroke prevention trial to include protocol-driven intensive management of multiple risk factors. In this prespecified analysis, we aimed to investigate the relationship between risk factor control during follow-up and outcome of patients in the medical arm of SAMMPRIS.

METHODS

Data from SAMMPRIS participants in the medical arm (n = 227) were analyzed. Risk factors were recorded at baseline, 30 days, 4 months, and then every 4 months for a mean follow-up of 32 months. For each patient, values for all risk factor measures were averaged and dichotomized as in or out of target.

RESULTS

Participants who were out of target for systolic blood pressure and physical activity, as well as those with higher mean low-density lipoprotein cholesterol and non-high-density lipoprotein, were more likely to have a recurrent vascular event (stroke, myocardial infarction, or vascular death) at 3 years compared to those who had good risk factor control. In the multivariable analysis, greater physical activity decreased the likelihood of a recurrent stroke, myocardial infarction, or vascular death (odds ratio 0.6, confidence interval 0.4-0.8).

CONCLUSIONS

Raised blood pressure, cholesterol, and physical inactivity should be aggressively treated in patients with intracranial atherosclerosis to prevent future vascular events. Physical activity, which has not received attention in stroke prevention trials, was the strongest predictor of a good outcome in the medical arm in SAMMPRIS.

CLINICALTRIALSGOV IDENTIFIER

NCT00576693.

Is There Benefit from Stenting on Cognitive Function in Intracranial Atherosclerosis?

BACKGROUND

Revascularization of stenotic cerebral arteries is hypothesized to improve cognition by increasing cerebral perfusion.

AIMS

We compared cognition impairment among patients treated with percutaneous angioplasty and stenting (PTAS) and aggressive medical management (AMM) versus AMM alone in the Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) Trial.

METHODS

In SAMMPRIS, 451 patients with recent transient ischemic attack or stroke attributed to 70-99% intracranial stenosis were randomized to PTAS plus AMM or AMM alone. Patients who had stroke as the qualifying event with National Institutes of Health Stroke Scale indicating aphasia or neglect were excluded from these analyses. Patients with a cerebrovascular event (ischemic stroke, cerebral infarct with temporary signs or intracranial hemorrhage) during follow-up were excluded from follow-up visit analyses. The Montreal Cognitive Assessment (MoCA) score was used to assess cognition impairment at baseline, 4 months, 12 months and closeout. Cognitive impairment was defined as MoCA <26. Mean MoCA scores and the percentage of patients with cognitive impairment were compared between treatment groups at each time point using t tests and chi-square tests. Differences in MoCA mean at baseline and follow-up time points were compared using mixed model repeated measures ANOVA and Tukey-Kramer tests.

RESULTS

There were no significant differences between the treatment groups for mean MoCA at any time point. Mean MoCA scores improved in both groups. The percentage of patients with cognitive impairment in the AMM versus PTAS groups was not significantly different at any time point.

CONCLUSIONS

Revascularization with PTAS showed no improvement in cognitive impairment over AMM alone among patients who did not have recurrent cerebrovascular events during follow-up.

Clopidogrel plus Aspirin for Symptomatic Intracranial Atherosclerotic Stenosis: A Pilot Study

BACKGROUND AND PURPOSE

There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease.

METHODS

Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227).

RESULTS

Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0).

CONCLUSION

A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications.

Taking care of volunteers in a stroke trial: a new assisted-management strategy

BACKGROUND AND PURPOSE

Providing participants with evidence-based care for secondary prevention is an ethical and scientific priority for trials in stroke therapy. The optimal strategy, however, is uncertain. We report the performance of a new approach for delivering preventive care to trial participants.

METHODS

Participants were enrolled in the Insulin Resistance Intervention after Stroke trial, which examined the insulin sensitiser, pioglitazone versus placebo for prevention of stroke and myocardial infarction after ischaemic stroke or transient ischaemic attack. Preventive care was the responsibility of the participants' personal healthcare providers, but investigators monitored care and provided feedback annually. We studied achievement of 8 prevention goals at baseline and 3 annual visits, with a focus on 3 priority goals: blood pressure <140/90 mm Hg, low-density lipoprotein (LDL) cholesterol <2.59 mmol/L and antithrombotic therapy.

RESULTS

The proportion of participants achieving the priority goals was highest for antithrombotic use (96-99% in each year) and similar for blood pressure (66-72% in each year) and LDL (68-70% in each year). All 3 priority goals were achieved by 47-52% of participants in any given year. However, only 22% of participants achieved all 3 goals in each year.

CONCLUSIONS

A strategy of monitoring care and providing feedback was associated with high average yearly achievement of 3 priority secondary prevention goals, but the majority of trial participants did not persist in being at goal over time.

TRIAL REGISTRATION NUMBER

NCT00091949.

Impact of the New American Heart Association/American Stroke Association Definition of Stroke on the Results of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial

BACKGROUND

An American Heart Association/American Stroke Association (AHA/ASA) writing committee has recently recommended that tissue evidence of cerebral infarction associated with temporary symptoms (CITS) lasting <24 hours should be considered a stroke. We analyzed the impact of considering CITS as equivalent to stroke on the results of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial.

METHODS

We compared outcomes in the medical (n = 227) and stenting (n = 224) groups in SAMMPRIS using the following primary end point (new components in bold): any stroke, CITS, or death within 30 days after enrollment or within 30 days after a revascularization procedure for the qualifying lesion during follow-up; or ischemic stroke or CITS in the territory of the qualifying artery beyond 30 days. We also compared the use of brain magnetic resonance imaging (MRI) after transient ischemic attacks (TIAs) in both treatment groups.

RESULTS

By considering CITS as equivalent to stroke, the number of primary end points increased from 34 to 43 in the medical group and from 52 to 66 in the stenting group of SAMMPRIS. The Kaplan-Meier curves for the primary end points in the 2 groups were significantly different (P = .009). The percentage of patients with reported TIAs who underwent brain MRI was 69% in the medical group and 61% in the stenting group (P = .40).

CONCLUSION

Using the AHA/ASA definition of stroke resulted in a substantially higher primary end point rate in both treatment groups and an even higher benefit from medical therapy over stenting than originally shown in SAMMPRIS. The higher rate of CITS in the stenting group was not due to ascertainment bias.

Submaximal angioplasty for symptomatic intracranial atherosclerosis: a prospective Phase I study

OBJECTIVE

Intracranial atherosclerotic disease (ICAD) accounts for approximately 10% of ischemic strokes. The recent Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study demonstrated a high incidence of perioperative complications (15%) for treatment of ICAD with stenting. Although the incidence of stroke was lower in the medical arm, recurrent stroke was found in 12% of patients despite aggressive medical management, suggesting that intervention may remain a viable option for ICAD if perioperative risk is minimized. Angioplasty without stenting represents an alternative and understudied revascularization treatment for ICAD. Submaximal angioplasty limits the risks of thromboembolism, vessel perforation, and reperfusion hemorrhage that were frequently reported with stenting in the SAMMPRIS trial. The authors conducted a prospective Phase I trial designed to assess the safety of submaximal angioplasty in patients with symptomatic ICAD.

METHODS

This study was approved by the local institutional review board. Demographic and clinical data were prospectively collected. Angioplasty was performed with a balloon undersized to approximately 50%–70% of the nondiseased vessel diameter in patients with symptomatic ICAD who had angiographically significant stenosis of ≥ 70%. The primary outcome measure was the incidence of periprocedural complications (combined rate of death, stroke, and hemorrhage occurring within 30 days and at 1 year).

RESULTS

Among the 65 patients with symptomatic ICAD who were screened, 24 had significant angiographic stenosis that met the inclusion criteria of this study. The mean age was 64.08 years (median 65 years; SD ± 11.24 years), most were men (62.5%), and most were white (66.67%). Many patients had concomitants of vascular disease, including hypertension (95.8%), hyperlipidemia (70.83%), smoking history (54.1%), and diabetes mellitus (50.0%). Coronary artery disease (41.66%) and previous stroke or transient ischemic attack (45.83%) were frequently present. Most patients (75%) had anterior circulation stenosis. The mean preprocedure stenosis was 80.16% (median 80%, range 70%–95%). Submaximal angioplasty was performed in patients who met the inclusion criteria, with a mean postangioplasty stenosis rate of 54.62% (median 55.5%, range 31%–78%). Rates of ischemic stroke in the territory of the treated artery were 0% within 30 days and 5.55% (in the only patient who presented with recurrent stroke) at 1 year. The mortality and hemorrhage rates in this series were 0%.

CONCLUSIONS

This study demonstrates the safety of the submaximal angioplasty technique, with no permanent periprocedural complications in 24 treated patients.

Risk factors associated with in-hospital serious adverse events after stenting of severe symptomatic intracranial stenosis

OBJECTIVES

Severe symptomatic intracranial stenosis is an important cause of stroke. Intracranial stenting is alternatively applied to treat intracranial atherosclerotic disease. However, Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis trial (SAMMPRIS) and Vitesse Stent Ischemic Therapy trial (VISSIT) both demonstrated intracranial stenting were inferior to aggressive medical treatment. But careful patient selection probably can improve the outcome of stenting in intracranial artery stenosis. Therefore, the validation of risk factors associated with serious adverse events (SAEs) after intracranial stenting may contribute to identify patients who are at high risk of stenting therapy and benefit patient selection for stenting.

PATIENTS AND METHODS

Patients who underwent intracranial stenting with symptom attributable to severe (>70%) intracranial stenosis were included in our institution. In-hospital SAEs after procedure were reviewed. Risk factors associated with SAEs were analyzed using multivariable logistic regression analysis.

RESULT

Thirty serious adverse events (5.1%) occurred among a total of 583 patients, with a mean age of 58.1±9.7, including 13 ischemic strokes, 12 brain hemorrhages and 5 deaths. Bivariate analysis and multivariable logistic regression analysis showed age (OR=0.94, 95% CI:0.900-0.983), history of DM (OR=2.439, 95% CI:1.107-5.371), preprocedural mRS score (OR=3.076, 95% CI:1.290-7.336) and lesion site in BA (OR=9.056, 95% CI:1.147-71.524) were risk factors associated with SAEs.

CONCLUSION

History of DM and lesion site in BA were risk factors associated with postprocedural in-hospital SAEs after stenting of severe symptomatic intracranial stenosis. But considering of the limitation of this retrospective study, further studies are necessary to confirm our results.

The contemporary management of intracranial atherosclerotic disease

Intracranial atherosclerotic disease is the most common cause of cerebral vasculopathy and an important stroke etiology worldwide, with a higher prevalence in Asian, Hispanic and African ethnicities. Symptomatic intracranial atherosclerotic disease portends a recurrent stroke risk as high as 18% at one year. The key to secondary prevention is an understanding of the underlying stroke mechanism and aggressive control of conventional cardiovascular risks. Contemporary treatment includes antiplatelet therapy, optimal glycemic and blood pressure control, statin therapy and lifestyle modifications. For patients with high-grade (70-99%) symptomatic steno-occlusion, short-term dual antiplatelet therapy with aspirin and clopidogrel followed by life-long single antiplatelet therapy may reduce the recurrent risk. Current evidence does not advocate percutaneous transluminal angioplasty and stenting as an initial treatment. External counterpulsation, encephaloduroarteriosynangiosis and remote limb ischemic preconditioning are treatments under investigation. Future studies should aim at predicting patients prone to recurrence despite of medical therapies and testing the efficacy of emerging therapies.

Factors Associated With Recurrent Ischemic Stroke in the Medical Group of the SAMMPRIS Trial

IMPORTANCE

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial showed that aggressive medical therapy was more effective than stenting for preventing stroke in patients with symptomatic intracranial stenosis. However, 15% of patients in the medical group still experienced a primary end point during a median follow-up of 32.7 months.

OBJECTIVE

To determine baseline features that were associated with a high rate of a primary end point in the medical arm of the SAMMPRIS Trial.

DESIGN, SETTING, AND PARTICIPANTS

A post hoc analysis of patients in the medical arm only of the SAMMPRIS trial. Enrollment occurred between October 2008 and April 2013 and included 227 patients randomized to medical management alone. Baseline demographic features, vascular risk factors, qualifying event, brain imaging, and angiographic features were analyzed. Bivariate and multivariable proportional hazard regression modeling was performed to relate baseline features to the time until a primary end point. The post hoc analysis was conducted from November 2014 to June 2015.

INTERVENTIONS

The SAMMPRIS Trial compared stenting with aggressive medical management in patients with a stroke or transient ischemic attack attributed to 70% to 99% stenosis of a major intracranial artery.

MAIN OUTCOMES AND MEASURES

The primary outcome was any of the following: stroke or death within 30 days of enrollment, ischemic stroke in the territory of the symptomatic intracranial artery beyond 30 days after enrollment, or any stroke or death within 30 days after stenting a patient in the medical group during follow-up.

RESULTS

A total of 227 patients were included in the study, 82 of whom were female, and the mean (SD) age was 59.5 (11.8) years. Being female (hazard ratio [HR], 1.9; 95% CI, 0.96-3.7), having diabetes mellitus (HR, 1.8; 95% CI, 0.9-3.5), not taking a statin at enrollment (HR, 2.6; 95% CI, 1.2-5.7), stroke as the qualifying event (HR, 2.5; 95% CI, 1.03-6.0), Rankin grade of 1 or greater (HR, 2.3; 95% CI, 0.9-5.5), old infarct in the territory of the stenotic artery (HR, 2.6; 95% CI, 1.3-5.1), and greater than 80% stenosis (HR, 1.9; 95% CI, 0.9-3.7) were associated (P < .10) with higher risk on bivariate analysis. Factors that were significantly associated with a primary end point on multivariable analyses were old infarct in the territory (HR, 2.6; 95% CI, 1.3-5.3; P = .006), stroke as the qualifying event (HR, 3.0; 95% CI, 1.1-7.7; P = .03), and no statin use at enrollment (HR, 2.4; 95% CI, 1.1-5.2; P = .03).

CONCLUSIONS AND RELEVANCE

Old infarct in the territory of the stenosis, new stroke presentation, and absence of statin use at enrollment were independently associated with high rates of the primary end point in the medical group in the SAMMPRIS Trial. These features may be useful for selecting high-risk patients for future clinical trials evaluating alternative therapies for intracranial stenosis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00576693.

Enrollment volume effect on risk factor control and outcomes in the SAMMPRIS trial

OBJECTIVE

The role of physician experience and patient volumes on the outcome of surgical or endovascular procedures has been well-studied but there are limited data on how these factors affect the outcome of medical therapy.

METHODS

In the stenting and medical cohorts of the Stenting and Aggressive Medical Management for the Prevention of Recurrent Ischemic Stroke (SAMMPRIS) trial, we compared Kaplan-Meier (K-M) curves for the primary endpoint (any stroke or death within 30 days of enrollment or ischemic stroke in the territory beyond 30 days) using the log-rank test and the percentages of patients achieving target levels for primary and secondary risk factors during the study using Fisher exact test between patients at high-enrolling (≥12 patients) vs low-enrolling (<12 patients) sites.

RESULTS

In the stenting group, the K-M curves for the primary endpoint were similar at high-enrolling sites and low-enrolling sites (p = 0.93) with rates of 13.5% vs 14.7% at 30 days and 19.0% vs 20.6% at 2 years. In the medical group, the K-M curves differed between high-enrolling sites and low-enrolling sites (p = 0.0005) with rates of 1.8% vs 9.8% at 30 days and 7.3% vs 20.9% at 2 years. The percentages of patients who achieved targets for low-density lipoprotein cholesterol and systolic blood pressure at high- vs low-enrolling sites in both treatment groups combined were 64% vs 49% (p = 0.003) and 70% vs 59% (p = 0.026), respectively.

CONCLUSIONS

High-enrolling sites in SAMMPRIS achieved better control of primary risk factors and much lower rates of the primary endpoint than low-enrolling sites in the medical group, suggesting that experience with medical management is an important determinant of patient outcome.

Outcomes of middle cerebral artery angioplasty and stenting with Wingspan at a high-volume center

INTRODUCTION

This study was to investigate the periprocedural stroke rates, safety, and long-term effect of Wingspan stenting for symptomatic severe stenosis of the middle cerebral artery (MCA) at a high-volume center.

METHODS

Between July 2007 and April 2013, 196 consecutive patients with severe MCA atherosclerotic stenosis (≥70%) who were treated with Wingspan stenting were retrospectively studied. All patients had arterial stenosis-related temporary ischemic attack or strokes. The demographic data, cerebral angiography, technical success rate, periprocedural complications, and clinical and imaging follow-up were analyzed.

RESULTS

The successful stenting rate was 98.0%, and the stenosis rate was improved from pre-stenting (80.6 ± 8.3 %) to post-stenting (15.5 ± 6.8%). The 30-day periprocedural stroke or death rate was 7.1%, with a disabling or fatal rate of 2.6%. The perioprocedural stroke rate was significantly (P < 0.01) greater in the early learning stage (16.0%) than in the later technical maturation stage (4.1%). The total periprocedural ischemic and perforator stroke rates were greater in patients with the most stenosis in the distal MCA 1/3 segment (6.8 and 5.7%, respectively) than in the proximal and middle 2/3 segments (0.9 and 0%, respectively). The ipsilateral stroke or death rate beyond 30 days (6-69 months, mean 30 ± 16) was 4.8%, with the 1- and 2-year cumulative stroke rates of 9.6 and 12.1%, respectively. Imaging follow-up 6-69 months (mean 10.9 ± 8.5) revealed restenosis in 21 cases (20.4 %).

CONCLUSION

Intracranial stenting of MCA stenoses may have the potential of better clinical outcomes if patients are properly selected and treated by an experienced operator at a high-volume center.

Wingspan Stenting for Severe Symptomatic Intracranial Atherosclerotic Stenosis in 433 Patients Treated at a Single Medical Center

Purpose

To investigate the safety and outcome of intracranial stenting for intracranial atherosclerotic stenosis (IAS).

Materials and Methods

Between July 2007 and April 2013, 433 consecutive patients with IAS >70% underwent intracranial Wingspan stenting, and the data were prospectively analyzed.

Results

Intracranial stenting was successful in 429 patients (99.1%), and the mean stenosis rate was improved from prestenting (82.3± 7.6)% to poststenting (16.6 ± 6.6)%. During the 30-day perioperative period, 29 patients (6.7%) developed stroke. The total perioperative stroke rate was significantly (P <0.01) higher in the basilar artery area than in others, whereas the hemorrhagic stroke rate was significantly (P <0.05) greater in the middle cerebral artery area than in others. The experience accumulation stage (13%) had a significantly (P <0.05) higher stroke rate than the technical maturation stage (4.8%). Clinical follow-up 6–69 months poststenting revealed ipsilateral stroke in 20 patients (5.5%). The one- and two-year cumulative stroke rates were 9.5% and 11.5%, respectively; the two-year cumulative stroke rate was significantly (P <0.05) greater in the experience accumulation stage (18.8%) than in the technical maturation stage (9.1%).

Conclusion

Wingspan stenting for intracranial atherosclerotic stenosis is safe and the long-term stroke rate after stenting is low in a Chinese subpopulation.

Do Patient Characteristics Explain the Differences in Outcome Between Medically Treated Patients in SAMMPRIS and WASID?

BACKGROUND AND PURPOSE

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) medical group had a much lower primary end point rate than predicted from the preceding Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. This result has been attributed to the aggressive medical therapy used in SAMMPRIS, but an alternative hypothesis is that SAMMPRIS patients were at lower risk. We undertook analyses to evaluate these competing hypotheses.

METHODS

Using proportional hazards regression, we compared the SAMMPRIS primary end point between SAMMPRIS medical patients and WASID patients meeting the same qualifying criteria adjusted for confounding baseline characteristics.

RESULTS

The unadjusted comparison of the SAMMPRIS primary end point showed a significantly higher risk for WASID patients (P=0.009, logrank test) with 12 month Kaplan-Meier estimates of 21.9% in WASID and 12.6% in SAMMPRIS and hazard ratio 1.9 (95% confidence interval =1.2-3.0). The analyses identified the following confounding factors that varied between the studies and that conferred a higher risk: lack of statin use at enrollment (hazard ratio =1.8, 95% confidence interval =1.1-2.9, P=0.027) that was more prevalent among WASID patients (39% versus 14%, P<0.0001) and prior infarcts in the territory of the symptomatic vessel (hazard ratio =1.8, 95% confidence interval =1.1-2.9, P=0.023) that was more prevalent among SAMMPRIS patients (34% versus 22%, P=0.015).The hazard ratio for WASID versus SAMMPRIS adjusted for these 2 characteristics was 1.9 (95% confidence interval =1.1-3.2).

CONCLUSIONS

After adjustment for confounding baseline characteristics, WASID patients had an almost 2-fold higher risk of the SAMMPRIS primary end point, which supports the hypothesis that the lower rate of the primary end point in the medical arm of SAMMPRIS compared with WASID patients was as a result of the aggressive medical management used in SAMMPRIS.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00576693.

Stenting in Intracranial Stenosis: Current Controversies and Future Directions

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.

Percutaneous transluminal angioplasty and stenting for severe stenosis of the intracranial extradural internal carotid artery causing transient ischemic attack or minor stroke

The purpose of this study is to assess the technical feasibility and clinical efficacy of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic stenosis of the intracranial extradural (petrous and cavernous) internal carotid artery (ICA).Review of medical records identified 26 consecutive patients who underwent PTAS using a balloon-expandable coronary stent (n = 15, 57.7%) or a Wingspan self-expandable stent (n = 11, 42.3%) for treatment of severe stenosis (>70%) involving the intracranial extradural ICA. The inclusion criteria were transient ischemic attack with an ABCD(2) score of ≥3 (n = 12, 46.2%) or minor stroke with an NIHSS score of ≤4 (n = 14, 53.8%). Technical success rates, complications, and angiographic and clinical outcomes were analyzed retrospectively.PTAS was technically successful in all patients. The mean stenosis ratio decreased from 77.1% to 10.0% immediately after PTAS. The overall incidence of procedural complications was 23.1%, and the postoperative permanent morbidity/mortality rate was 7.7%. A total of 22 patients were tracked over an average period of 29.9 months. During the observation period, 20 patients (90.9%) had no further cerebrovascular events and stroke recurrence occurred in two patients (9.1%), resulting in an annual stroke risk of 3.7%. Two cases (11.1%) of significant in-stent restenosis (>50%) were found on follow-up angiography (n = 18).PTAS for severe stenosis (>70%) involving the intracranial extradural ICA showed a good technical feasibility and favorable clinical outcome in patients with transient ischemic attack or minor stroke.

Association of thrombelastographic parameters with post-stenting ischemic events

BACKGROUND AND PURPOSE

Thrombelastography (TEG) is widely used for the measurement of platelet function. However, few studies have investigated the TEG parameters in patients receiving extracranial or intracranial artery stenting for ischemic cerebrovascular disease. This study sought to describe the association of TEG parameters before the procedure with post-procedural ischemic events after extracranial or intracranial artery stenting.

METHODS

Patients in whom stenting was performed for extracranial or intracranial artery stenosis (70-99%) were recruited into the study. Blood samples were obtained for TEG to assess platelet function before stenting. The primary endpoint was ischemic stroke or transient ischemic attack in the territory of the stented artery.

RESULTS

A total of 218 patients were included in the study. During a mean follow-up period of 132 days (range 98-226 days), 18 (8.3%) primary endpoint events were recorded. Compared with patients without ischemic events, the ADP-induced platelet-fibrin clot strength (MA_ADP) was significantly higher (41.57±15.10 vs 33.50±13.86, p=0.020) and the ADP inhibition rate (ADP%) was significantly lower in patients with ischemic events (39.54±23.15 vs 55.29±24.43, p=0.009). Multivariate analysis identified MA_ADP and ADP% as significant independent predictors of subsequent ischemic events with HRs of 1.036 and 0.965, respectively. From receiver operating characteristic curve analysis, MA_ADP >49.95 mm had the best predictive value of ischemic events.

CONCLUSIONS

Our study suggests that TEG parameters MA_ADP and ADP% are associated with subsequent ischemic events in patients with extracranial or intracranial stents.

CLINICAL TRIAL NUMBER

NCT01925872.