Editors' ChoiceStroke

Stenting for Stroke

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Science Translational Medicine  27 Nov 2013:
Vol. 5, Issue 213, pp. 213ec195
DOI: 10.1126/scitranslmed.3008067

Stenting blood vessels open prevents heart attacks, so couldn’t it also be effective for preventing stroke? Derdeyn and colleagues sought to answer this very question in a randomized trial called SAMMPRIS: Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis.

The authors conducted a multicenter, randomized trial that recruited 451 patients with recent stroke or transient ischemic attack related to stenosis of an artery in the brain. These patients received aggressive medical management with or without intracranial stenting with the Wingspan system. During a nearly 3-year follow-up, 15% of patients in the medical group and 23% of patients in the stenting group met one of the following clinical end points: stroke or death within 30 days after enrollment, ischemic stroke in the territory of the affected artery beyond 30 days of enrollment, or stroke or death within 30 days of the stenting procedure. Intention-to-treat analysis was used, with patient outcomes analyzed according to assigned treatment group, regardless of what treatment (or treatments) each individual ultimately received. At the end of each of the first 3 years of follow-up, a significantly lower percentage of patients suffered from stroke in the aggressive medical treatment group, suggesting that stenting is not beneficial in this context.

These findings are unexpected but compelling. What is not completely clear is whether patients in the medical therapy cohort would fare as well in a real-world setting—in other words, without the benefit of a comprehensive lifestyle modification regimen and aggressive management of secondary risk factors. Further, the study does not examine other methods of increasing vessel caliber. It remains possible that symptomatic patients with severe narrowing of blood vessels in the brain could benefit from other treatments, such as balloon vessel dilation in the absence of a stent. Additional randomized trials are needed to assess the utility of such catheter-based treatments for stroke prevention

C. P. Derdeyn et al., Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): The final results of a randomised trial. Lancet, published online 25 October 2013 [10.1016/S0140-6736(13)62038-3]. [Full Text]

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