Aggressive Medical Treatment More Effective in Preventing Strokes

Schematic of a stent in a bloodstream

An intracranial artery compromised by plaque at left; at right, a stent keeps blood flowing freely through the artery. Note the difficult pathway leading to the stent. Illustrations by Martha Headworth / Mayfield Clinic.

For years patients who survived a minor stroke caused by a narrowed artery in the brain have had reason to feel both grateful and uneasy. They have dodged a bullet, true, but now what? They are clearly at risk of a major stroke, which could cause brain damage or death. And a narrowed artery in the brain – a condition called intracranial stenosis – is difficult to treat.

Until recently, physicians were uneasy as well. They did not know the best way to treat narrowed intracranial arteries. Did they prescribe intensive management with medications and behavioral modification? Or did they recommend medications, behavior modification and a stent that props open the artery?

The national, multi-site clinical trial known as SAMMPRIS (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) found the answer quickly enough that the trial was halted last spring. Results were published in September in the New England Journal of Medicine, with an accompanying editorial by Joseph Broderick, MD, Research Director of UCNI and the Albert Barnes Voorheis Professor and Chair of UC’s Department of Neurology.

Researchers found that aggressive medical therapy alone was preferable, as 14.7 percent of the 451 patients enrolled died within 30 days of treatment with aggressive medical therapy and a stent, compared to 5.8 percent of those treated with aggressive medical therapy alone. Dr. Broderick identified the “tortuous course” a stent must travel to reach its proper place inside the brain and the small diameter of the intracranial arteries as factors in stenting’s difficulty.

The study’s results provided a wealth of information for UC Cerebrovascular Disease and Stroke Center specialists, including the local principal investigators of the SAMMPRIS study at UC Health / University Hospital: Pooja Khatri, MD, MSc, a UC Health neurologist and Associate Professor of Neurology, and Andrew Ringer, MD, a Mayfield Clinic neurosurgeon and Professor of Neurosurgery.

The cerebrovascular team is establishing a uniform approach for treating patients who show symptoms of intracranial stenosis. Initial treatment will begin with optimal medical management (including antiplatelet medications) and strong encouragement for patients to control risk factors, including blood pressure, cholesterol, blood glucose levels, body mass index, and tobacco use.

“We will pursue aggressive medical therapy with every patient who comes to us with intracranial stenosis before even considering a stent,” Dr. Ringer said. “But if a patient’s symptoms are not controlled by this approach, we should then evaluate the stenting option. Patients who continue to have symptoms despite aggressive medical therapy should not be denied consideration for this potentially life-prolonging treatment.”

Meanwhile, the six patients originally enrolled in UC’s portion of the SAMMPRIS study continue to be followed and cared for by Dr. Khatri and Dr. Ringer.

— Cindy Starr

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