Aaron Tansy, MD

The advent of intracranial stenting offered the stroke community new hope for the improved treatment of severe intracranial atherosclerosis. Thus, the early termination of the SAMMPRIS trial due to stenting’s inferiority in comparison to medical therapy was for many, at best, a bittersweet result and, at worst, another dashed possibility. However, Anand Alurkar and colleagues’ study that will appear in the upcoming issue of Stroke suggests that we should not abandon all hope for intracranial stenting just yet.

The group evaluated stroke prevention efficacy of balloon expandable intracranial stents in severe, medically refractive intracranial stenosis. Eligibility included >70% stenotic lesions and symptomatic events attributable to the lesion despite maximal medical therapy. Both non- and drug-eluting stents were used. Maximal medical therapy included aspirin, clopidogrel, and atorvastatin. Post-stenting clinical monitoring occurred every two weeks during the first month and at increasingly longer intervals thereafter for 1 year. Follow up diagnostic cerebral angiogram was performed at 1 year in 121 patients. Over 97% of 198 lesions in 182 patients were successfully stented. Of these, stroke incidence during the post-procedure first month was roughly 6% (1% were major) and at 1 year 10%. DSA at 1 year revealed >20% luminal loss in over 50% of patients who had suffered a stroke during the year of monitoring. Mortality at 1 month was roughly 1%.

Although this small single-center analysis was notably different (e.g. patient population, device type, trial type) from and cannot be directly compared with SAMMPRIS, its results remain encouraging. Not only did this group show that intracranial stenting is readily feasible, but also efficacious with better outcomes and long-term complication rates than those seen in SAMMPRIS. Hence, the stroke community must continue to investigate intracranial stenting including identifying the specific devices by which and stroke populations for which it may yield the greatest clinical impact and stroke protection.