Failure of Intracranial Stenting for Stroke Prevention

Seemant Chaturvedi, MD, reviewing Gao P et al. JAMA 2022 Aug 9

In previous clinical trials such as SAMMPRIS (NEJM JW Neurol Nov 2011 and N Engl J Med 2011; 365:993), angioplasty and stenting for severe intracranial arterial disease (ICAD) was not effective compared with intensive medical therapy. However, some clinicians have wondered whether more experienced interventionists and refined patient selection would provide evidence of benefit. This randomized trial from China enrolled patients with transient ischemic attack or nondisabling ischemic stroke and severe ICAD (70% to 99% stenosis). Patients were assigned to angioplasty with stenting plus medical therapy or medical therapy alone. Procedures were performed by centers with at least 30 such cases annually. To avoid the hyperacute period, when interventional complications are higher, patients were required to be at least 3 weeks out from the most recent transient ischemic attack or stroke. The primary endpoint was stroke or death within 30 days or stroke ipsilateral to the stenosis between 30 days and 1 year.

Over a 2.5-year period, 380 patients were enrolled, of whom 358 (mean age, 56 years; 73% men) were confirmed as eligible. Patients were enrolled at a median of 35 days after their last ischemic event. About two thirds of patients had hypertension and about one third had diabetes. The primary endpoint occurred in 8.0% of the stenting plus medical therapy group versus 7.2% of the medical therapy alone group. The periprocedural stroke-or-death rate was 5.1% in the stenting group. No benefit was seen for stroke prevention with stenting for up to 3 years after enrollment.