Large Vessel Ischemic Stroke Treatment
By Matthew E. Fink, MD, Editor
Feil Professor and Chairman, Department of Neurology, and Assistant Dean of Clinical Affairs, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a consultant for Procter & Gamble.
Dual Antiplatelet Therapy
Yilong Wang, from Beijing, presented a subgroup analysis of the CHANCE study, looking at the benefits of dual antiplatelet therapy in patients with multiple acute infarcts. Previous studies have shown that dual antiplatelet therapy with clopidogrel and aspirin may be more effective than aspirin alone in reducing artery-to-artery micro-embolism in patients with TIA and ischemic stroke. Data from this trial were analyzed with a focus on patients who had multiple acute infarcts and the risk of recurrence on dual antiplatelet therapy vs. aspirin alone. The CHANCE trial included 1,089 patients with non-cardioembolic TIA or minor stroke. In the entire CHANCE population, 553 patients had single acute infarctions and 281 had multiple acute infarctions. Patients who presented with multiple acute infarctions had a higher three-month rate of recurrent stroke — 14.2% compared to 8.7% in patients who had a single acute infarction. Patients treated with dual antiplatelet therapy (aspirin plus clopidogrel) had a significantly lower rate of recurrent stroke at three months compared to patients treated with aspirin alone — 10.14% of patients on dual antiplatelet therapy compared to 18.8% of patients on aspirin alone. The bleeding risk was no different between the two groups. The major limitation was that the study was performed in a single ethnic group (Chinese) and needs to be generalized to a more diverse population before dual antiplatelet therapy can be recommended as standard therapy.
Stent Placement for Symptomatic Intracranial Stenosis
Emrah Ishfaq, from the University of Minnesota, presented a meta-analysis of both randomized and non-randomized studies comparing stent placement vs. best medical therapy for symptomatic intracranial stenosis. So far, individual trials comparing intracranial stenting with medical therapy have been inconclusive or have shown no significant benefits for one therapy over another. The authors reviewed studies that included patients who had intracranial stenosis and compared stent placement with medical therapies. They recorded outcomes such as intracranial hemorrhage, ischemic stroke, mortality, and transient ischemic attack, and had a mean follow-up of at least one month following intervention. Three selective studies were randomized, and three were non-randomized. The primary endpoints studied were symptomatic intracranial hemorrhage, mortality, ischemic stroke rate, and TIA in the qualifying artery territory. Symptomatic intracranial hemorrhage was significantly higher in all of the studies in the groups that were treated with intracranial stenting compared to medical therapy. The rate of recurrent stroke in the qualifying artery also was significantly higher in the patients who underwent intracranial stenting. There were no significant differences between the groups in terms of mortality or rate of subsequent transient ischemic attacks. In conclusion, current techniques of intracranial stenting were inferior compared to the best medical therapy in terms of recurrent stroke risk, as well as rates of intracranial hemorrhage.
Intracranial Stenting
Michael Alexander, from Cedars-Sinai, presented an interim analysis of the WEAVE trial, reporting on the first 116 consecutive on-label patients treated with intracranial stenting using the Wingspan device from Stryker. This postmarket surveillance study was approved by Stryker and the FDA. The use of intracranial stenting generally was stopped after the results of the SAMMPRIS trial indicated > 15% rate of periprocedural complications (stroke and death) in patients with acute stroke or TIA from intracranial stenosis, much higher than medical therapy. Therefore, no further investigation was undertaken. However, since the periprocedural rate of on-label patients was considerably lower (4.5% to 6%) in previous registries, the WEAVE trial was undertaken as a postmarket surveillance of patients who were treated under IDE on-label indications, including intracranial atherosclerosis with > 70% stenosis, a history of two strokes in the same vascular territory, failure of best medical therapy, stenting performed eight days or longer following the last stroke, age between 22 and 80 years, and a modified Rankin score of 0-3 at baseline prior to stenting. In the first 116 patients reported in this trial, patients treated with on-label indications had a 3.4% rate of stroke or death within 72 hours of the procedure, but those treated off-label had a 20.6% rate of periprocedural stroke or death. The difference in complications between on-label and off-label patients was highly significant, and indicates that selection of patients should adhere to labeling requirements.
These articles are based on the editor's personal interactions as a participant at the International Stroke Conference in Houston, Feb. 22-24, 2017. All interpretations and opinions are exclusively those of the editor.
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