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Stent plus medical therapy is equal to medical therapy alone for symptomatic severe intracranial stenosis (CASSISS)
Clinical Question
Is stenting plus medical therapy more effective for reducing adverse cardiovascular outcomes than medical therapy alone in adults with symptomatic severe intracranial atherosclerotic stenosis?
Bottom line
This study found no additional benefit of stenting plus medical therapy compared with medical therapy alone for the treatment of adults with symptomatic severe intracranial atherosclerotic stenosis. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
These investigators from China identified 380 adults with a transient ischemic attack (acute onset of neurologic deficit persisting for < 24 hours) or an ischemic stroke (persisting for > 24 hours and confirmed by magnetic resonance imaging or computed tomography) occurring more than 3 weeks prior to study enrollment. Additional eligibility criteria included confirmation of a 70% to 99% stenosis of a major intracranial artery by conventional angiography and procedures performed only in high-volume medical centers demonstrating a low rate of stenting complications. Eligible patients randomly received (concealed allocation assignment) medical therapy alone (100 mg aspirin plus 75 mg clopidogrel daily for 90 days, then either aspirin or clopidogrel alone daily thereafter, and control of stroke risk factors) or the same medical therapy and stenting within 3 to 5 days. Complete follow-up occurred for 95.8% of patients at one year. Using both intention-to-treat and per-protocol analyses, no significant group difference occurred in the primary outcome of stroke or death within 30 days, or stroke in the qualifying artery territory between 30 days and 1 year (stent plus medical treatment vs the medical treatment alone: 8.0% vs 7.2%, respectively, by intention to treat). In addition, no significant group differences occurred after 3 years of additional secondary analysis follow-up.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
No advantage of surgical stunting over medical therapy alo
Intracranial stunting offers no advantage over medical therapy alone.
Stent + medical therapy Vs Medical Therapy alone for severe
Hmmm, if I read this correctly the risk of stroke etc of with stent plus medical treatment was 8% vs 7.2% with medical treatment alone. I am sure this is contrary to expectations and even though said to be not significant it was a study of only 380 pt and therefore likely lacks power. Would be ethically "challenging" to propose a larger study to determine if stenting actually were worse. There must be other literature on this. Would have been useful to the reviewer to mention other contrasting studies if they are out they. Guess I'll have to look for myself!
stenting
similar to the results for coronary stenosis but the cardiologist keep stenting away anyway
Stent plus medical therapy = medical therapy alone in intrac
These results seem hard to believe. It may be that careful selection of which patinets would benefit from stenting could give clearer results. In the meantime, this would make be hesitate to refer for stentint.