Medical Management Superior to Intracranial Angioplasty and Stenting in Preventing Subsequent Stroke Due to Intracranial Atherosclerosis S. Andrew Josephson Intracranial atherosclerosis is an important cause of ischemic stroke worldwide. Atherosclerotic plaque accumulation in the major intracerebral arteries can lead to stroke or transient ischemic attack (TIA), and when the accompanying stenosis is severe (70”“99%), these patients are at high risk for recurrent stroke (nearly 25% at 1 year). Two strategies used to treat this disorder are aggressive medical management, and percutaneous transluminal angioplasty and stenting (PTAS), a practice gaining favor in many countries. A recent large trial (Chimowitz et al., 2011) compared these two strategies in an attempt to guide future therapeutic treatment decisions in those with intracranial atherosclerosis. The authors conducted a large, randomized, National Institutes of Health-sponsored trial at 50 sites in the United States using the FDA-approved self-expanding Wingspan stenting system. Enrolled patients had experienced a TIA or nondisabling stroke within 30 days caused by 70”“99% stenosis of a major intracranial artery. Patients were randomized to either PTAS and aggressive medical management, or aggressive medical management alone, consisting of combination antiplatelet therapy with 325 mg of aspirin and 75 mg of clopidogrel daily, as well as targeted vascular risk factor reduction including a low-density lipoprotein goal of <70 mg/dL (achieved with rosuvastatin) and systolic blood pressure <140 mmHg (<130 mmHg in those with diabetes). Those in the PTAS group were treated by experienced neurointerventionalists who were certified to participate in the study. Aggressive medical management was identical in the two groups. A total of 451 patients were randomized in the trial, 227 to medical management alone and 224 to PTAS plus medical management, with around 5% crossover in each group. The primary endpoint examined was stroke or death within 30 days of enrollment or stroke in the territory of the affected artery after 30 days. The trial was stopped early after the data safety and monitoring board expressed safety concerns regarding periprocedural stroke in the PTAS group. The 30-day rate of stroke or death was found to be 14.7% in the PTAS group and 5.8% in the medical management group (p = .002). Of the 33 strokes in the PTAS group, 25 occurred within 1 day of the procedure; the other 8 occurred within 6 days. The risk of periprocedural stroke did not diminish over the course of the enrollment period, and there was no significant difference between rates at high-enrolling and other centers. After 30 days, there were 13 additional strokes in the territory of the affected artery in each group. The 1-year rates of the primary endpoint were 20% in the PTAS group and 12.2% in the medical management group (p = .009). Secondary endpoints including the rate of any stroke and that of any major hemorrhage were significantly higher in the PTAS group. This important secondary prevention stroke study demonstrated that aggressive medical management was superior to PTAS plus aggressive medical management in patients with recent TIA or stroke referable to large artery intracranial atherosclerosis. The study had unexpectedly high rates of periprocedural stroke compared with previous observational studies, and unexpectedly low rates of recurrent stroke in the group receiving medical management only. For clinicians, this trial should lead to recommendations against intracranial PTAS in patients with stroke and TIA. Furthermore, the aggressive medical management strategy described here should be considered for these high-risk patients; the combination of aspirin and clopidogrel has typically not been used in secondary stroke prevention due to bleeding concerns, but perhaps in this particular high-risk group it may play an important role moving forward. [TABLE] [TR] [TD="class: contentReference"] Reference [/TD] [/TR] [TR] [TD="class: contentBody"]Chimowitz MB et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011;365:993. [PMID: 21899409] [Full Text][/TD] [/TR] [/TABLE]
