Intracranial arterial stenosis causes a significant number of strokes worldwide. While medical management alone has high recurrent stroke risks, several studies show success with intracranial stenting. However, the SAMMPRIS trial found higher 30-day stroke/death rates for stenting versus medical management alone. Critics argue SAMMPRIS design flaws like enrolling small vessels and long lesions made stenting higher risk. Additionally, ideal medical management in SAMMPRIS may be difficult to replicate in reality. Overall stenting remains valuable for patients not controlled on medical therapy alone, though SAMMPRIS supports modifying but not abandoning the approach.

1. STENTING VS MEDICAL MANAGEMENT
IN INTRACRANIAL ARTERIAL STENOSIS
FOR- STENTING
Dr Prashant Makhija

2. EVIDENCE
 8–10% of all ischemic strokes in America, 30% to 50% of
strokes in the Asian population1
 With medical therapy alone risk of recurrent stroke
unacceptably high, approximately 23% at 1 year1
 Several studies demonstrate success with intracranial stenting
 SSYLVIA Trial- 61 pts(70.5% intracranial stenosis), 95% success
rate, 1 mth 6.6% strokes & 0% mortality, 7.3% strokes later
than 1 mth, FDA granted a humanitarian device exemption2
1.
J NeuroIntervent Surg 2012 4: 397-406
2.
AJNR: 26, October 2005

3. Study
n
Technical
success rate
(%)
30 day ipsilat
stroke /death
rate
Wingspan
study(2007)
45
100
4.5
Fiorella et
al(2007)
78
98.8
6.1
NIH
registry(2008)
129
96.7
9.6
 Anand Alurkar et al (2013)- 182 patients, 97.44% success
rate, 1mth stroke incidence 11 (5.64%), of which 2 (1.02%) were
major, 2 deaths(mortality=1.09%)
 Simon Chun Ho Yu et al (2013)- 65 pts, 93.8% success rate, 66
stenotic lesions, ISR 16.7%, periprocedural stroke or death rate
was 6.1%, no interval strokes 1-year follow-up

4. THE OPPOSITION- SAMMPRIS
 SAMMPRIS- RCT 451 pts, 30-day rate of stroke or death was
14.7% in the PTAS group and 5.8% in the medicalmanagement group
 Why so ?
 Experience - higher rate in the current study does not reflect
inexperience of the operators (NIH registry data- 9% at high
enrolling sites versus 23% at low enrolling sites)
 inherently high risk to the procedures with the device used in the
trial, which does not decline with user experience
 Design - 2-step procedure with a long exchange wire
 difficulty with wire control, can cause perforations and
subarachnoid hemorrhage or wire injury of small perforating
arteries

5.  Vessel size & lesion- trial mandated that lesions had to be 14 mm
long and arteries had to have a normal diameter of 2.0 to 4.5 mm
 treatment of small vessels(2.5 to 2.75 mm)is problematic, more
likely to have restenosis, acute thrombosis, more prone to injury
with PTAS
 >10 mm (Mori C) lesions, higher rates of death, ipsilateral stroke,
in stent restenosis after angioplasty
 Medical therapy- team (neurologist, study coordinator, lifestyle
coach), study coordinator counted pts’ antiplatelet medications,
lifestyle coach developed personal action plans, contacted pts every
2 wks for the first 3 months & then monthly thereafter
 Idealistic , difficult to achieve in “real-world” situations
1.
2.
Michael P. Marks. Stroke. 2012;43:580-584
Alex Abou-Chebl and Helmuth Steinmetz. Stroke. 2012;43:616-620

6. CONCLUSION
 SAMMPRIS trial, set a higher bar for the investigation of
endovascular therapy for symptomatic intracranial stenosis
 Supports modification but not discontinuation of our approach to
intracranial angioplasty and/or stent placement for intracranial
stenosis
 PTAS remains a valuable tool for patients refractory to medical
therapy
 Do Not Throw the Baby Out with the Bathwater…
(T. KRINGS )