Randomized Controlled Trial of Symptomatic Middle Cerebral Artery Stenosis

Stenting versus medical treatment alone for symptomatic intracranial artery stenosis: a preplanned pooled individual patient data analysis

BACKGROUND

Whether the safety and efficacy of percutaneous transluminal angioplasty and stenting (PTAS) is significantly different from that of medical treatment alone for symptomatic intracranial arterial stenosis (ICAS) is debatable. A study was undertaken to determine the safety and efficacy of both treatments for symptomatic ICAS.

METHODS

This preplanned pooled individual patient data analysis included 400 participants treated with PTAS and 409 treated with medical treatment alone in two large multicenter randomized clinical trials (SAMMPRIS and CASSISS). Patients were treated with PTAS using a self-expanding stent or medical treatment alone. The primary outcome was stroke or death within 30 days, or ischemic stroke in the territory of the qualifying artery more than 30 days after enrollment.

RESULTS

Individual data were obtained for 809 patients, 451 from SAMMPRIS and 358 from CASSISS. 400 participants were randomly assigned to the PTAS group and 409 to the medical group. The risk of the primary outcome was not significant between the PTAS and medical groups (17.5% vs 13.2%; HR 1.37 (95% CI 0.96 to 1.95), P=0.08). However, the risk of stroke or death within 30 days was higher in the PTAS group (10.5% vs 4.2%; HR 2.62 (95% CI 1.49 to 4.61), P<0.001). Patients of white ethnicity (HR 1.97, 95% CI 1.17 to 3.31) and those with hyperlipidemia (HR 2.04, 95% CI 1.27 to 3.26) or a transient ischemic attack (TIA) (HR 2.19, 95% CI 1.08 to 4.45) were at higher risk for PTAS.

CONCLUSIONS

PTAS poses an increased risk of short-term stroke/death and therefore is not advised as primary treatment for symptomatic ICAS. A balance exists between stroke risks and revascularization benefits. For patients with asymptomatic ICAS of white ethnicity and those with hyperlipidemia or a history of TIA, a thorough assessment is warranted before considering PTAS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00576693, NCT01763320.

Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis : A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials

PURPOSE

In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death.

METHODS

Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies,  letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines.

RESULTS

7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28-3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41-66.45], I² = 0%) and death (RR = 5.41 [1.20-24.28], I² = 0%).Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25-2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(-0.83 months; 95% CI: -1.30-0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11-2.32).

CONCLUSIONS AND RELEVANCE

There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks.

Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS): protocol of a prospective, multicentre, randomised, controlled trial

BACKGROUND

The superiority of balloon angioplasty plus aggressive medical management (AMM) to AMM alone for symptomatic intracranial artery stenosis (sICAS) on efficacy and safety profiles still lacks evidence from randomised controlled trials (RCTs).

AIM

To demonstrate the design of an RCT on balloon angioplasty plus AMM for sICAS.

DESIGN

Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS) trial is a multicentre, prospective, randomised, open-label, blinded end-point trial to investigate whether balloon angioplasty plus AMM could improve clinical outcome compared with AMM alone in patients with sICAS. Patients eligible in BASIS were 35-80 years old, with a recent transient ischaemic attack within the past 90 days or ischaemic stroke between 14 days and 90 days prior to enrolment due to severe atherosclerotic stenosis (70%-99%) of a major intracranial artery. The eligible patients were randomly assigned to receive balloon angioplasty plus AMM or AMM alone at a 1:1 ratio. Both groups will receive identical AMM, including standard dual antiplatelet therapy for 90 days followed by long-term single antiplatelet therapy, intensive risk factor management and life-style modification. All participants will be followed up for 3 years.

STUDY OUTCOMES

Stroke or death in the next 30 days after enrolment or after balloon angioplasty procedure of the qualifying lesion during follow-up, or any ischaemic stroke or revascularisation from the qualifying artery after 30 days but before 12 months of enrolment, is the primary outcome.

DISCUSSION

BASIS trail is the first RCT to compare the efficacy and safety of balloon angioplasty plus AMM to AMM alone in sICAS patients, which may provide an alternative perspective for treating sICAS.

TRIAL REGISTRATION NUMBER

NCT03703635; https://www.

CLINICALTRIALS

gov.

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.

The Necessity or Not of Additional Endovascular Therapy to Medical Therapy for Symptomatic Intracranial Artery Stenosis: Insights from 30-Day and 1-Year Results

BACKGROUND

The optimal treatment between endovascular therapy and medical treatment for symptomatic intracranial artery stenosis is still unclear. This study aimed to compare the safety and efficacy of 2 treatments based on the results from currently published randomized controlled trials (RCTs).

METHODS

PubMed, Cochrane Library, EMBASE, and Web of Science were used for searching the RCTs evaluating the addition of endovascular therapy to medical therapy for treating symptomatic intracranial artery stenosis from the inception of these databases to September 30, 2022. P < 0.05 was considered statistically significant. All analyses were performed using STATA version 12.0.

RESULTS

A total of 4 RCTs were involved in the current study, including 989 participants. In the 30-day results, the data showed that compared with the medical therapy alone group, the additional endovascular therapy group was associated with a higher risk of death or stroke (relative risk (RR): 2.857; 95% confidence interval (CI): 1.756-4.648; P < 0.001), ipsilateral stroke (RR: 3.525; 95% CI: 1.969-6.310; P < 0.001), death (risk differences (RD): 0.01; 95% CI: 0.004-0.03; P = 0.015), hemorrhagic stroke (RD: 0.03; 95% CI: 0.01-0.06; P < 0.001), and ischemic stroke (RR: 2.221; 95% CI: 1.279-3.858; P = 0.005). In the 1-year results, the additional endovascular therapy group was related to a greater incidence of ipsilateral stroke (RR, 2.247; 95% CI, 1.492-3.383; P < 0.001) and ischemic stroke (RR: 2.092; 95% CI: 1.270-3.445; P = 0.004).

CONCLUSIONS

Given that the medical treatment alone was related to a lower risk of stroke and death in the short-term and long-term compared with endovascular therapy combined with medical therapy. Based on this evidence, these findings do not support the addition of endovascular therapy to medical therapy for treating patients with symptomatic intracranial stenosis.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Safety and efficacy of stenting for symptomatic intracranial artery stenosis: a systematic reveiw and meta-analysis

Background: Stroke is currently the second-leading cause of death just behind ischaemic heart disease. Drug therapy is currently the standard of care for patients with symptomatic intracranial artery stenosis (sICAS). Stenting is an important treatment for the prevention and treatment of ischemic stroke. It has been suggested that vertebral artery stenting might reduce this risk, but operation-related complications limit the application of stenting in the treatment of ischemic stroke. The differences in the safety and efficacy of stenting combined with drugs and drugs alone in the treatment of sICAS are unclear. The aim of this study was to assess the impact of both treatment modalities on the prognosis of patients with sICAS through a systematic review and meta-analysis. Methods: The Chinese databases (CNKI, Wanfang, VIP, CBM, DUXIU) and English databases (Pubmed, Embase, Ovid_medline, Cochrane library, Web of science)were searched to identify all studies describing sICAS. The "Risk of Bias Assessment" tool and the "Jadad Scale" provided by the Cochrane Collaboration were used to evaluate the risk of bias and quality of the collected literature. The risk ratio (RR) and its 95% confidence interval (CI) were determined using Stata statistical software version 14.0. Results: A total of 11 studies were included, comprising a total of 1,915 patients. The combined results of the study showed no significant difference between the incidence of transient cerebral ischemia (TIA)and stroke in patients with sICAS treated with drugs in combination with stents versus drugs alone. The incidence of death or stroke, cerebral haemorrhage, disabling stroke or death was significantly higher in patients receiving stent-combined drug therapy versus drug therapy alone for sICAS. Conclusion: Studies suggest that stenting combined with medication for patients with sICAS may increase the incidence of death or stroke, cerebral haemorrhage, stroke or death, but has no significant effect on the incidence of TIA and stroke. The studies report inadequate and conflicting data and therefore the safety and efficacy of stenting for sICAS should be interpreted with caution. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022377090, identifier CRD42022377090.

Antiplatelet Therapy in Neurointervention

The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.

Percutaneous transluminal angioplasty and stenting vs aggressive medical management on stroke or intracranial atherosclerotic stenosis: a systematic review and meta-analysis

There are currently two main treatment strategies mainly for high-risk patients: percutaneous transluminal angioplasty and stenting (PTAS) and aggressive medical management (AMM). However, the choice between PTAS or AMM remains controversial for patients with stroke or intracranial atherosclerotic stenosis (ICAS). The investigators searched the PubMed, Web of Science, Embase, Scopus, and Cochrane library databases. Randomized controlled trial (RCT) comparing PTAS and AMM for patients with stroke or ICAS were selected. RevMan 5.3 was used to analyze the results and assess risk of bias. The primary endpoints are stroke and death within 30 days after enrollment, or ischemic stroke in the territory of the qualifying artery beyond 30 days, and entire follow-up endpoints. The secondary outcomes were the disabling or fatal stroke, and incidence of death within 3 years. Four studies, 989 patients were included in this article. The AMM group was superior in the entire follow-up endpoint (OR 0.56; 95% CI 0.40, 0.79). The AMM also better in primary endpoint within 30 days (OR 0.32; 95% CI 0.17, 0.61). There was no significant difference beyond 30 days (OR 1.08; 95% CI 0.63, 1.86). The remaining outcomes, such as stroke and death, were not significantly different (P > 0.05). This meta-analysis shows AMM is significantly more effective than PTAS in subjects with ICAS due to the high rate of periprocedural stroke (OR 0.32; 95% CI 0.17, 0.61) and stroke during the entire follow-up (OR 0.56; 95% CI 0.40, 0.79) associated with PTAS. Furthermore, PTAS offers no additional benefits over AMM beyond 30 days (OR 1.08; 95% CI 0.63, 1.86).

Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis

BACKGROUND

Intracranial artery stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy (ET) and conventional medical treatment (CMT) may prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS.

OBJECTIVES

To evaluate the safety and efficacy of endovascular therapy plus conventional medical treatment compared with conventional medical treatment alone for the management of symptomatic intracranial artery stenosis.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registries on 16 August 2022. We contacted study authors and researchers when we required additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the records to select eligible RCTs, then extracted data from them. We resolved any disagreements through discussion, reaching consensus decisions among the full team. We assessed risk of bias and applied the GRADE approach to assess the certainty of the evidence. The primary outcome was death by any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included all-cause death or non-fatal stroke of any type occurring more than three months after randomisation, ipsilateral stroke, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, death, restenosis, dependency, and health-related quality of life.

MAIN RESULTS

We included four RCTs with 989 participants who had symptomatic ICAS, with an age range of 18 to 85 years. We identified two ongoing RTCs. All trials had high risk of performance bias, as it was impossible to blind participants and personnel to the intervention. Three trials were terminated early. One trial was at high risk of attrition bias because of substantial loss to follow-up after one year and a high proportion of participants transferring from ET to CMT. The certainty of evidence ranged from low to moderate; we downgraded for imprecision. Compared to CMT alone, ET plus CMT probably increases the risk of short-term death or stroke (risk ratio (RR) 2.93, 95% confidence interval (CI) 1.81 to 4.75; 4 RCTs, 989 participants; moderate certainty), short-term ipsilateral stroke (RR 3.26, 95% CI 1.94 to 5.48; 4 RCTs, 989 participants; moderate certainty), short-term ischaemic stroke (RR 2.24, 95% CI 1.30 to 3.87; 4 RCTs, 989 participants; moderate certainty), and long-term death or stroke (RR 1.49, 95% CI 1.12 to 1.99; 4 RCTs, 970 participants; moderate certainty). Compared to CMT alone, ET plus CMT may increase the risk of short-term haemorrhagic stroke (RR 13.49, 95% CI 2.59 to 70.15; 4 RCTs, 989 participants; low certainty), short-term death (RR 5.43, 95% CI 1.21 to 24.40; 4 RCTs, 989 participants; low certainty), and long-term haemorrhagic stroke (RR 7.81, 95% CI 1.43 to 42.59; 3 RCTs, 879 participants; low certainty). It is unclear if ET plus CMT compared with CMT alone has an effect on the risk of short-term transient ischaemic attack (RR 0.79, 95% CI 0.30 to 2.07; 3 RCTs, 344 participants; moderate certainty), long-term transient ischaemic attack (RR 1.05, 95% CI 0.50 to 2.19; 3 RCTs, 335 participants; moderate certainty), long-term ipsilateral stroke (RR 1.78, 95% CI 1.00 to 3.17; 4 RCTs, 970 participants; moderate certainty), long-term ischaemic stroke (RR 1.56, 95% CI 0.77 to 3.16; 4 RCTs, 970 participants; moderate certainty), long-term death (RR 1.61, 95% CI 0.77 to 3.38; 4 RCTs, 951 participants; moderate certainty), and long-term dependency (RR 1.51, 95% CI 0.93 to 2.45; 4 RCTs, 947 participants; moderate certainty). No subgroup analyses significantly modified the effect of ET plus CMT versus CMT alone. The trials included no data on restenosis or health-related quality of life.

AUTHORS' CONCLUSIONS

This review provides moderate-certainty evidence that ET plus CMT compared with CMT alone increases the risk of short-term stroke and death in people with recent symptomatic severe ICAS. This effect was still apparent at long-term follow-up but appeared to be due to the early risks of ET; therefore, there may be no clear difference between the interventions in terms of their effects on long-term stroke and death. The impact of delayed ET intervention (more than three weeks after a qualifying event) warrants further study.

Advanced age is associated with increased adverse outcomes in patients undergoing middle cerebral artery stenting

Purpose

This study tried to evaluate whether advanced age has an increased incidence of major complications in patients undergoing MCA stenting.

Methods

A total of 348 patients who underwent MCA stenting were reviewed from a prospectively maintained database. Ninety-day ischemic stroke, intracerebral hemorrhage, and death outcomes were compared among the young (≤40 years old), middle (41-60 years old) and old (≥61 years old) groups. Univariate analysis and multivariable logistic regression analysis were used to investigate different variables associated with 90-day major adverse events. Kaplan-Meier analysis was performed to determine long-term outcomes during follow-up.

Results

The incidence of 90-day ischemic stroke was 9.26% in the old group, 2.86% in the middle group, and 0% in the young group (P = 0.024). The incidence of all 90-day major adverse events was 3.33% in patients ≤40 years old, 19.90% in patients 41-60 years old, and 24.07% in patients ≥61 years old, with statistical significance (P = 0.04). Advanced age was associated with increased 90-day ischemic stroke (OR = 1.074, 95% CI: 1.019-1.132, P = 0.007; adjusted OR: 1.071, 95% CI: 1.008-1.138, P = 0.026) and 90-day death (OR = 1.072, 95% CI: 1.012-1.135, P = 0.018; adjusted OR: 1.095, 95% CI: 1.015-1.182, P = 0.018). Meanwhile, advanced age was also associated with decreased long-term survival and ischemic stroke-free survival during follow-up.

Conclusion

Our data indicated that MCA stenting in elderly patients is associated with a high risk of adverse events and should be cautiously considered.

Intracranial angioplasty with a self-expandable stent for intracranial atherosclerotic stenosis: Systematic review and meta-analysis

Background

Intracranial angioplasty with a self-expandable stent (SES) is an important endovascular therapy for symptomatic intracranial arterial stenosis. We sought to update the evaluation of the perioperative safety and long-term outcomes of self-expandable stent for the treatment of symptomatic intracranial arterial stenosis.

Methods

We comprehensively searched the published literature from each database through Sept 16, 2022, for the PubMed, EMBASE, Web of Science, Cochrane, and Clinical Trials databases. The characteristics of the studies and patients, perioperative complications, and long-term outcomes were extracted. The pooled outcomes and 95% confidence intervals (CIs) were estimated by Stata Statistical Software 14.0.

Results

A total of 4,632 patients from 58 studies were included. The pooled rate of perioperative stroke or death was 6.32% (95% CI 5.04-7.72%); ischemic stroke beyond 30 days through 1 year was 2.72% (95% CI 1.41-4.38%). Perioperative complications differed between the 2014-2022 and 2005-2013 subgroups, as did long-term outcomes between the off-label SES and Wingspan subgroups.

Conclusion

The perioperative complications of intracranial angioplasty with SES have been reduced, but the risk of perioperative stroke or death is still higher than that of aggressive medical therapy, and additional studies are needed to determine whether it has better long-term outcomes than aggressive medical therapy. Perioperative complications varied between the 2014-2022 and 2005-2013 subgroups, as did long-term outcomes between the off-label SES and Wingspan subgroups. Given the high level of heterogeneity observed between the included studies, these results should be interpreted with caution and additional studies are needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022316066.

The CASSISS Randomized Clinical Trial

The CASSISS trial (China Angioplasty & Stenting for Symptomatic Intracranial Severe Stenosis), recently published in JAMA, is the most recent of several randomized controlled trials that have failed to show a benefit of percutaneous angioplasty and stenting over medical therapy for the prevention of stroke due to intracranial atherosclerotic stenosis. Current practice guidelines recommended that percutaneous angioplasty and stenting should not be performed routinely as a treatment for stroke prevention in patients with intracranial atherosclerotic stenosis. The CASSISS trial reinforces those recommendations and will not change practice, but it may provide some important lessons for future trial design.

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.

Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial

Importance

Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes.

Objective

To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis.

Design, Setting, and Participants

Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019).

Interventions

Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control.

Main Outcomes and Measures

The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years.

Results

Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08).

Conclusions and Relevance

Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT01763320.

Intracranial Atherosclerotic Disease: Current Concepts in Medical and Surgical Management

PURPOSE OF THE REVIEW

This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery.

RECENT FINDINGS

Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT.

SUMMARY

ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.

Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective

OBJECTIVES/BACKGROUND

Medical therapy is the first line of treatment for intracranial atherosclerotic disease (ICAD). Percutaneous transluminal angioplasty and stenting (PTAS) are mainly considered for those patients with severe stenosis and recurrent events despite aggressive medical therapy. In this review, we discuss the application of PTAS as a treatment option for ICAD and its future prospect.

MATERIALS AND METHODS

We did the literature review of the key articles and guidelines to elaborate on the role of PTAS in the management of ICAD based on the current data and expert opinion. We searched PubMed, Google Scholar, and Scopus up to August 2020, and included articles published only in the English language.

RESULTS

Since the publication of the results from SAMMPRIS and VISSIT trials, stenting is no longer recommended for secondary stroke prevention in patients with symptomatic ICAD. However, recent clinical studies on intracranial stenting for a subgroup of ICAD patients have shown promising results, likely due to better patient selection and continued advancement of endovascular techniques.

CONCLUSION

There exists a lack of consensus regarding the best endovascular treatment approach (e.g., angioplasty alone or balloon mounted stent vs. self-expanding stent with or without prior angioplasty) or management of in-stent restenosis. Another area of clinical controversy relates to the ideal use and duration of antiplatelet therapy.

Initial Experience With the Next-Generation Resolute Onyx Zotarolimus-Eluting Stent in Symptomatic Intracranial Atherosclerotic Disease

Background and Purpose: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke worldwide. Although there are different endovascular options for the treatment of symptomatic ICAD (sICAD), it is still controversial. Herein, we aim to study the safety and efficacy of a new generation of drug-eluting balloon-mounted stent (DES); Resolute (R) onyx DES in the treatment of sICAD.

Methods: A prospectively maintained neuroendovascular procedures database in a high-volume comprehensive stroke center was reviewed from October 2019 through January 2020. Patients were included if they had sICAD (≥70% stenosis), failed medical management, and underwent intracranial stenting with R-onyx DES. Technical success was defined as the ability to deploy the device at the desired location and achievement of <30% residual stenosis. The primary outcome was the occurrence of complications within 72 h of the procedure (strokes, ischemic or hemorrhagic; and mortality). Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure.

Results: A total of 18 consecutive patients (mean age, 66.6 years; 44.4% were females and 94.4% were Hispanic) were eligible for the analysis. Indication for treatment was recurrent strokes in 13 and recurrent transient ischemic attack (TIA) in 5. A total of 22 symptomatic lesions with a mean baseline stenosis percent (84.9 ± 9.6) were treated using 23 R-onyx DES in 19 procedures. All procedures were done under general anesthesia with 100% technical success, and no reported periprocedural strokes or death. Among 13 patients who had clinical follow-up, 1 (7.7%) patient had TIA. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for 9 (50%) patients showed no in-stent restenosis.

Conclusion: The use of R-onyx DES in the treatment of sICAD is safe with high technical success rates. Large prospective multicenter trials with long-term follow-up are warranted.

Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy and medical management may be used to prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS.

OBJECTIVES

To compare the safety and efficacy of endovascular therapy (ET) plus conventional medical treatment (CMT) with CMT alone for the management of symptomatic ICAS.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (30 August 2019), Cochrane Central Register of Controlled Trials (CENTRAL: to 30 August 2019), MEDLINE Ovid (1946 to 30 August 2019), Embase Ovid (1974 to 30 August 2019), Scopus (1960 to 30 August 2019), Science Citation Index Web of Science (1900 to 30 July 2019), Academic Source Complete EBSCO (ASC: 1982 to 30 July 2019), and China Biological Medicine Database (CBM: 1978 to 30 July 2019). We also searched the following trial registers: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Stroke Trials Registry. We also contacted trialists and researchers where additional information was required.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials to select potentially eligible RCTs and extracted data. Any disagreements were resolved by discussing and reaching consensus decisions with the full team. We assessed risk of bias and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death of any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included any-cause death or non-fatal stroke of any type more than three months of randomisation, ipsilateral stroke, type of recurrent event, death, restenosis, dependency, and health-related quality of life.

MAIN RESULTS

We included three RCTs with 632 participants who had symptomatic ICAS with an age range of 18 to 85 years. The included trials had high risks of performance bias and other potential sources of bias due to the impossibility of blinding of the endovascular intervention and early termination of the trials. Moreover, one trial had a high risk of attrition bias because of the high rate of loss of one-year follow-up and the high proportion of participants transferred from endovascular therapy to medical management. The quality of evidence ranged from low to moderate, downgraded for imprecision. Compared to CMT, ET probably results in a higher rate of 30-day death or stroke (risk ratio (RR) 3.07, 95% confidence interval (CI) 1.80 to 5.24; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ipsilateral stroke (RR 3.54, 95% CI 1.98 to 6.33; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ischaemic stroke (RR 2.52, 95% CI 1.37 to 4.62; 3 RCTs, 632 participants, moderate-quality evidence), and 30-day haemorrhagic stroke (RR 15.53, 95% CI 2.10 to 115.16; 3 RCTs, 632 participants, low-quality evidence). ET was also likely associated with a worse outcome in one-year death or stroke (RR 1.69, 95% CI 1.21 to 2.36; 3 RCTs, 632 participants, moderate-quality evidence), one-year ipsilateral stroke (RR 2.28, 95% CI 1.52 to 3.42; 3 RCTs, 632 participants, moderate-quality evidence), one-year ischaemic stroke (RR 2.07, 95% CI 1.37 to 3.13; 3 RCTs, 632 participants, moderate-quality evidence), and one-year haemorrhagic stroke (RR 10.13, 95% CI 1.31 to 78.51; 2 RCTs, 521 participants, low-quality evidence). There were no significant differences between ET and CMT in 30-day transient ischaemic attacks (TIA) (RR 0.52, 95% CI 0.11 to 2.35, P = 0.39; 2 RCTs, 181 participants, moderate-quality evidence), 30-day death (RR 5.53, 95% CI 0.98 to 31.17, P = 0.05; 3 RCTs, 632 participants, low-quality evidence), one-year TIA (RR 0.82, 95% CI 0.32 to 2.12; 2 RCTs, 181 participants, moderate-quality evidence), one-year death (RR 1.20, 95% CI 0.50 to 2.86, P = 0.68; 3 RCTs, 632 participants, moderate-quality evidence), and one-year dependency (RR 1.90, 95% CI 0.91 to 3.97, P = 0.09; 3 RCTs, 613 participants, moderate-quality evidence). No data on restenosis and health-related quality of life for meta-analysis were available from the included trials. Two RCTs are ongoing.

AUTHORS' CONCLUSIONS

This systematic review provides moderate-quality evidence showing that ET, compared with CMT, in people with recent symptomatic severe intracranial atherosclerotic stenosis probably does not prevent recurrent stroke and appears to carry an increased hazard. The impact of delayed ET intervention (more than three weeks after a qualifying event) is unclear and may warrant further study.

Stenting with Acclino (flex) for symptomatic intracranial stenosis as secondary stroke prevention

BACKGROUND AND PURPOSE

Stroke recurrence is high in patients with symptomatic intracranial stenosis despite best medical treatment. Based on evidence from past studies using previous stent generations, elective intracranial stenting (eICS) is considered in a minority of patients. This study aims to report on experience performing eICS with a novel device combination.

METHODS

We retrospectively reviewed data from three high volume stroke centers and analyzed patients that were treated with eICS for symptomatic intracranial stenosis using the Acclino (flex) stent and the NeuroSpeed balloon catheter (Acandis GmbH, Pforzheim, Germany). Study endpoints were periprocedural rates of stroke regardless of territory or death at discharge and at the time of follow-up after eICS. Safety evaluation included asymptomatic and symptomatic intracranial hemorrhage, serious adverse events related to the intervention, and evaluation of stent patency at the time of follow-up.

RESULTS

The median age of patients that met the inclusion criteria (n=76) was 69 years. Target vessels were located in the anterior circulation in 55.3% (42/76) of patients. The periprocedural stroke rate was 6.5% (fatal stroke 2.6%; non-fatal stroke 3.9%) at discharge after eICS. Asymptomatic intracranial hemorrhage was observed in 5.2% (4/76) of patients. Follow-up DSA revealed in-stent restenosis of 25% (15/60), and percutaneous transluminal angioplasty was performed again in 11.6% (7/60) of patients.

CONCLUSION

Stenting for symptomatic intracranial stenosis with the Acclino (flex)/NeuroSpeed balloon catheter seemed to be safe and reinforces eICS as an endovascular therapy option for secondary stroke prevention. Future studies are warranted to confirm these findings and investigate antithrombotic strategies and in-stent restenosis to minimize periprocedural complications and guarantee long term stent patency.

Intracranial Stenting: Is It Still an Option for Treatment of Patients With Intracranial Atherosclerosis?

Intracranial atherosclerotic disease (ICAD) is considered a major cause of recurrent cerebrovascular events. ICAD continues to be a disease without an effective method of reducing the risk of recurrent stroke and death, even with aggressive, highly monitored medical treatment. We reviewed data from three randomized controlled studies that published data comparing intracranial stenting vs. medical treatment for symptomatic severe-ICAD. Ethnic, demographic, clinical, and procedural differences were observed among the data from these trials that might influence their results. Future research should aim at establishing refined selection criteria that can identify high-risk ICAD patients who may benefit from intracranial stenting.

Early versus delayed stenting for intracranial atherosclerotic artery stenosis with ischemic stroke

OBJECTIVE

To evaluate the clinical outcomes of early stenting (≤14 days) or late stenting (>14 days) in patients who underwent intracranial stent placement.

METHODS

Patients with ischemic stroke caused by 70-99% intracranial atherosclerotic stenosis combined with poor collaterals were enrolled. The early stenting group, who underwent stenting within 14 days of last ischemic symptoms, were compared with the late stenting group who underwent stenting >14 days from last ischemic symptom. The patients were treated either with a balloon-mounted stent or a self-expanding stent as determined by the operators following a guideline. The baseline characteristics and clinical outcomes were evaluated and compared.

RESULTS

One hundred and fifteen stroke patients were recruited into the study. Four patients (4/41) in the early stenting group and two patients (2/74) in the late stenting group were diagnosed with a cerebral vascular event associated with stenting within 3 days (p=0.184). In the long-term follow-up, eight patients in the early stenting group had restenosis ≥50%, which was higher than patients in the late stenting group (8/41 vs 4/74, p=0.018). The total rates of any ischemic stroke, transient ischemic attack, hemorrhagic stroke, and death in the early stenting group were higher than in the late stenting group (9/41 vs 6/74, p=0.035). The recurrence rate of ischemic stroke in the early stenting group was higher than in the late stenting group (5/41 vs 2/74, p=0.041).

CONCLUSIONS

Stent placement in the setting of ischemic stroke caused by intracranial artery stenosis within 14 days may confer a higher risk of long-time cerebral vascular events and lead to a higher risk of restenosis.

CLINICAL TRIAL REGISTRATION

NCT01968122.

Cognitive Decline in Asymptomatic Middle Cerebral Artery Stenosis Patients with Moderate and Poor Collaterals: A 2-Year Follow-Up Study

Background

The aim of this study was to determine whether poor collaterals contribute to the occurrence of certain types of cognitive disorders in asymptomatic middle cerebral artery stenosis (MCAS).

Material/Methods

Patients aged ≥45 years with asymptomatic MCAS confirmed by computed tomography angiography were included in a single-center retrospective study. They did not have prior stroke or dementia. Within 7 days of admission, MRI and comprehensive neuropsychological assessment were performed. Cognitive assessment was conducted after 2 years. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff scale. Demographic date and Fazekas scores were collected.

Results

A total of 173 patients with asymptomatic MCAS (66% men, mean age 59.4 years) and 42 controls (45% men, mean age 61.4 years) were enrolled. Executive function, attention, and information-processing speed in poor collateral circulation patients were more frequently and more often impaired than those in good collateral circulation patients. Throughout the study period, patients with poor collateral circulation had worse executive function, attention, and information-processing speed than those with moderate collateral circulation. Over time, MCAS patients with good collateral circulation did not show an association with cognitive function.

Conclusions

MCAS patients with moderate and poor collateral circulation have impairment of ≥1 cognitive domain over time. The affected domains are consistent with the profile of vascular cognitive impairment. Good collateral circulation is more important in patients with MCAS, and is associated with less risk of cognitive disorders.

Intracranial artery stenosis: Current status of evaluation and treatment in China

Intracranial artery stenosis (ICAS), a common cause of ischemic stroke, is a growing cause of concern in China. Recently, many epidemiological, etiological, pathophysiological, therapy, and diagnostic imaging studies have focused on ICAS, and guidelines and consensus on the diagnosis and treatment of ICAS have been published and updated by domestic experts. Such work is pivotal to our enhanced comprehension, diagnosis, and treatment of ICAS. In this review, we summarize the latest progress in the evaluation and treatment of ICAS in China.

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

Angioplasty and stenting for patients with symptomatic intracranial atherosclerosis: study protocol of a randomised controlled trial

INTRODUCTION

Whether adding percutaneous transluminal angioplasty and stenting (PTAS) to background medical treatment is effective for decreasing the incidence of stroke or death in patients with symptomatic intracranial atherosclerosis (ICAS) is still controversial. We perform a randomised controlled trial to examine the effectiveness and safety of an improved PTAS procedure for patients with ICAS.

METHODS AND ANALYSIS

A randomised controlled trial will be conducted in three hospitals in China. Eligible patients with ICAS will be randomly assigned to receive medication treatment (MT) plus PTAS or MT alone. The MT will be initiated immediately after randomisation, while the PTAS will be performed when patients report relief of alarm symptoms defined as sudden weakness or numbness. All patients will be followed up at 30 days, 3 and 12 months after randomisation. The primary end point will be the incidence of stroke or death at 30 days after randomisation. Secondary outcomes will be the incidence of ischaemic stroke in the territory of stenosis arteries, the incidence of in-stent restenosis, the Chinese version of the modified Rankin Scale and the Chinese version of the Stroke-Specific Quality of Life (CSQoL).

ETHICS AND DISSEMINATION

The study protocol is approved by institutional review boards in participating hospitals (reference number FZ20160003, 180PLA20160101 and 476PLA2016007). The results of this study will be disseminated to patients, physicians and policymakers through publication in a peer-reviewed journal or presentations in conferences. It is anticipated that the results of this study will improve the quality of the current PTAS procedure and guide clinical decision-making for patients with ICAS.

TRIAL REGISTRATION NUMBER

NCT02689037.

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.

Relationship between visible branch arteries distal to the stenosis on magnetic resonance angiography and stroke recurrence in patients with severe middle cerebral artery trunk stenosis: a one-year follow up study

Background

To evaluate the relationship between the flow signal intensity of branch arteries distal to the stenosis on 3-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) and the risk of stroke recurrence in patients with severe middle cerebral artery (MCA) trunk stenosis.

Methods

We prospectively recruited 153 patients (mean age 62.9 ± 13.0 years, 106 males) with a first ischemic stroke or transient ischemic attack caused by a severe MCA trunk stenosis (70 % to 99 %) confirmed by 3D TOF MRA and followed them for one year to determine the stroke recurrence. The MCA branch signal intensity distal to the site of stenosis on 3D TOF MRA was classified as either good (grade A) or poor [mild reduction (grade B) or severe reduction (grade C)] according to the extent to which the MCA could be visualized. The patients were divided into groups A (35), B (58), or C (60) based on the MRA grading of the MCA branch signal intensity distal to the site of stenosis.

Results

Poor MCA branch signal intensity was associated with internal border-zone infarction (p < 0.05). The risk of stroke recurrence in the ipsilateral MCA in the first year was 18.3 %. The 1-year cumulative incidence of recurrence was higher in the patients in group C (30 %) than in groups B (12.1 %) or A (8.6 %) (Log rank, p = 0.007). Multivariate analyses via Cox proportional hazard regression demonstrated that only a grade C classification of the signal intensity of the MCA branches was an independent predictor of stroke recurrence in the ipsilateral MCA (hazard ratio = 3.0, 95 % confidence interval = 1.3-7.4, p = 0.014).

Conclusions

This study demonstrated that MCA branch signal intensity as assessed via 3D TOF MRA may be a useful and simple tool to stratify the risk of stroke recurrence in patients with severe MCA trunk stenosis.

What's new in stroke? Phase III randomized clinical trials of 2012-2014

BACKGROUND

Randomized clinical trials provide the most reliable evidence to guide the management of stroke and threatened stroke and reflect the interests of the stroke research community. The spectrum of phase III randomized clinical trials in stroke has not been previously characterized.

METHODS

Phase III stroke randomized clinical trials published between 2012 and 2014 were identified by search of the Cochrane Central Register of Controlled Trials supplemented by recent publications known to the co-authors.

RESULTS

Thirty-four randomized clinical trials were included involving 85 770 participants: 20 acute stroke randomized clinical trials (32 590 patients), 11 stroke prevention randomized clinical trials (28 964 patients), and three randomized clinical trials in which stroke was a major component of a composite primary outcome involving nonstroke patients (24 216 patients). Twenty-two (65%) trials were international, and eight (24%) were industry sponsored. Drugs were tested in 21 (62%) randomized clinical trials, with devices (n = 9), surgery (n = 3), and diet (n = 1) in the remainder. Thirteen (38%) randomized clinical trials were stopped early: seven for futility, three for efficacy, two for harm, and one for budget/administrative reasons. Overall, the results of seven (21%) randomized clinical trials were positive, five (15%) equivocal, 18 (53%) negative, and four (12%) inconclusive. Considering positive and definitively negative randomized clinical trials testing currently used interventions, 11 (32%) randomized clinical trials have direct implications for clinical management.

CONCLUSIONS

The diversity of interventions, high-quality, and worldwide origins of recently published phase III randomized clinical trials reflects a vibrant international stroke research community. The current generation of stroke randomized clinical trials provides important guidance for stroke prevention and acute stroke care.

Improved clinical outcome 3 months after endovascular treatment, including thrombectomy, in patients with acute ischemic stroke: a meta-analysis

Background and purpose

Intravenous thrombolysis with tissue plasminogen activator is standard treatment in acute stroke today. The benefit of endovascular treatment has been questioned. Recently, studies evaluating endovascular treatment and intravenous thrombolysis compared with intravenous thrombolysis alone, have reported improved outcome for the intervention group. The aim of this study was to perform a meta-analysis of randomized controlled trials comparing endovascular treatment in addition to intravenous thrombolysis with intravenous thrombolysis alone.

Methods

Databases were searched for eligible randomized controlled trials. The primary outcome was a functional neurological outcome after 90 days. A secondary outcome was severe disability and death. Data were pooled in the control and intervention groups, and OR was calculated on an intention to treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I² (significance cut-off value >50%) with the Mantel–Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.

Results

Six studies met the eligibility criteria, and data from 1569 patients were analyzed. A higher probability of a functional neurological outcome after 90 days was found for the intervention group (OR 2, 95% CI 2 to 3). There was a significantly higher probability of death and severe disability in the control group compared with the intervention group.

Conclusions

Endovascular treatment in addition to intravenous thrombolysis for acute ischemic stroke leads to an improved clinical outcome after 3 months, compared with patients receiving intravenous thrombolysis alone.

Intracranial Angioplasty and Stenting before and after SAMMPRIS: "From Simple to Complex Strategy - The Chinese Experience"

Intracranial atherosclerotic disease (ICAD) accounts for 33–50% of all ischemic strokes in the Asian population (1) and represents an important public health issue in China. The results of the SAMMPRIS trial alarmed most experienced interventionalists in China for two reasons. Firstly, the high complication rate in the stenting arm (20% the first year) was higher than expected. Secondly, the recurrent stroke rate in the aggressive medical treatment arm at 12.2% during the first year was unacceptably high, not to mention the fact that such tight vascular risk factor control is difficult to achieve for many patients in real life clinical experience, at least in China. The experience of treating ICAD in China, gained over the last two decades, is very rich and promising. We intend to highlight these past experiences and address future trials and trends in China. We will also address our criticism of the SAMMPRIS trial design in order to better design a future trial.

Natural history of intracranial atherosclerotic disease

Intracranial atherosclerotic disease was very common among stroke patients of Asians, Blacks, and Hispanics ancestry. Furthermore, stroke patients with intracranial atherosclerosis (ICAS) have higher recurrence rate of cerebral ischemia and death than those without ICAS. However, the natural history of intracranial atherosclerotic disease is still in controversy. Most of the studies were retrospective and randomized controlled trial of drugs. This review summarized the prognosis of symptomatic and asymptomatic intracranial atherosclerotic disease in order to guide clinical decision-making and further clinical research.

Intracranial atherosclerosis

Atherosclerotic disease often involves the intracranial arteries including those encased by cranial bones and dura, and those located in the subarachnoid space. Age, hypertension, and diabetes mellitus are independent risk factors for intracranial atherosclerosis. Intracranial atherosclerosis can result in thromboembolism with or without hypoperfusion leading to transient or permanent cerebral ischaemic events. High rates of recurrent ischaemic stroke and other cardiovascular events mandate early diagnosis and treatment. Present treatment is based on a combination of antiplatelet drugs, optimisation of blood pressure and LDL cholesterol values, and intracranial angioplasty or stent placement, or both, in selected patients.