COMMENTARY

Stenting vs Medical Therapy in Intracranial Stenosis

Mark J. Alberts, MD

Disclosures

October 12, 2011

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Hello. Welcome to this Medscape Stroke Update. I am Dr. Mark Alberts, Professor of Neurology and Director of the Stroke Program at Northwestern University in Chicago.

Today I would like to update you about the recently published results of the SAMMPRIS trial, published in the September 15, 2011, issue of The New England Journal of Medicine.[1] As some of you may know, SAMMPRIS was a National Institutes of Health-sponsored prospective, randomized study of intracranial carotid stenting plus medical therapy vs best medical therapy in people with high-grade symptomatic stenosis of the intracranial vasculature.

The SAMMPRIS trial was discontinued early by the Data Safety Monitoring Board because of a higher number of strokes and deaths in the stent group compared with the medical therapy-only group. The actual numbers were about 15% in the stent group and about 6% in the best medical therapy group. Furthermore, after these patients were followed beyond 30 days, for up to about 11 or 12 months, this difference continued, with about 20% of patients in the stent group having stroke or death compared with about 12% in the best medical therapy group. As noted in an editorial [in the same issue of The New England Journal of Medicine], this is not the first study to show that many of the procedures that we thought would be beneficial for patients with high-grade intracranial stenosis, such as extracranial-intracranial bypass and the like, really do not have good outcomes.

Where do we stand in terms of understanding SAMMPRIS and putting it in context? Based on this study of over 470 patients, we know that, in general, intracranial stenting is probably harmful and not as effective as best medical therapy in these patients with high-grade symptomatic intracranial disease. Perhaps we need to do a better job of stenting in terms of better devices, more gentle techniques, and the like, or perhaps we just need to improve our medical therapy. Certainly these patients are at high risk for subsequent medical events but they did pretty well with medical therapy alone, which typically consisted of aspirin combined with clopidogrel in both arms of the study.

There you have it. Intracranial stenting is, in fact, not as safe as best medical therapy for these patients. Stay tuned as further results are forthcoming.

Thank you very much.

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