Prevention Practice in Primary Care by Sheinfeld Gorin Sherri;

Author:Sheinfeld Gorin, Sherri;
Language: eng
Format: epub
Publisher: Oxford University Press, Incorporated
Published: 2014-08-15T00:00:00+00:00

Intra-cranial Atherosclerotic Artery Disease

Patients with symptomatic intracranial atherosclerosis have a high relative risk of recurrent stroke of about 20–25%. In the Extra-Cranial/Intra-Cranial (EC/IC) bypass study, patients with middle cerebral artery stenosis were randomized to surgical intervention and medical treatment with aspirin; no benefit was found for the surgical group (EC/IC, 1985). A newer clinical trial using more specific techniques to select patients with perfusion failure due to hemodynamic compromise was also negative (Powers et al., 2011).

In the recent Warfarin Aspirin Symptomatic Intracranial Disease (WASID) study, 569 patients with symptomatic intracranial stenosis were prospectively randomized to aspirin or warfarin, but the study was halted prematurely because of increased bleeding in the Warfarin arm and no difference between groups was detected for the end point of recurrent ischemic stroke. Importantly, this study demonstrated that patients with intracranial stenosis who fail anti-platelet therapy may be at higher risk of recurrent stroke (Chimowitz et al., 2005). However, it is unclear if warfarin and aspirin are equivalent in those who have “failed” anti-platelet therapy.

Endovascular management of intracranial stenosis by either angioplasty or stent, or both, provides an opportunity to rapidly improve cerebral blood flow in affected patients. Nevertheless, only a few large randomized prospective controlled trials have addressed this issue. Results from single-center studies suggest that these procedures can be achieved with a high level of technical success in those patients with recurrent symptoms despite optimal medical therapy. The Guidant-sponsored multicenter Stenting of Symptomatic Atherosclerotic lesions in the Vertebral or Intracranial Arteries (SSYLVIA) study was a prospective non-randomized feasibility study of stenting for the treatment of intracranial artery stenosis (SSYLVIA, 2004). In this study, 43 intracranial vessels and 18 extracranial vertebral arteries were treated. Successful stent deployment occurred in 95% of the cases. The 30-day stroke incidence was 6.6% with no deaths. Late (more than 30-day) stroke incidence was 7.3%. Recurrent stenosis occurred in 32% of intracranial vessels treated and 43% of those extracranial vessels treated.

In the recent Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial (Chimowitz et al., 2011), the investigators indicated that medical therapy was superior than stenting, which was associated with a higher risk of peri-procedural stroke or death. Moreover, the essential elements of the medical regimen used in this trial can readily be adopted in clinical practice.(Chimowitz et al., 2011).

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