Stroke. 2006;37:2858-2859
Published online before print September 28, 2006,
doi: 10.1161/01.STR.0000244823.59463.1f
(Stroke. 2006;37:2858.)
© 2006 American Heart Association, Inc.
Angioplasty With or Without Stenting for Intracranial Artery Stenosis
Graeme J. Hankey, MD, FRCP, Section Editor:;
Salvador Cruz-Flores, MD
Alan L. Diamond, DO
From the Department of Neurology (S.C.-F.), Souers Stroke Institute, St. Louis University School of Medicine, St. Louis, Mo, and the Colorado Neurologic Institute (A.L.D.), Englewood, Colo.
Correspondence to Salvador Cruz-Flores, MD, Department of Neurology, St. Louis University Hospital, 3635 Vista Ave, St. Louis, MO. E-mail cruzfls{at}slu.edu
Key Words: angioplasty • intracranial artery stenosis • stent placement
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Introduction
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Intracranial artery stenosis causes 10% of all ischemic strokes.
The annual rate of recurrent vascular ischemic events is very
high (20%).
1,2 Angioplasty with or without stent placement is
feasible; however, its safety and efficacy have not been systematically
studied.
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Objectives
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We sought to determine the efficacy and safety of angioplasty
combined with best medical treatment compared with best medical
treatment alone for preventing recurrent ischemic strokes, death,
and vascular events in patients with ischemic stroke or transient
ischemic attack resulting from intracranial artery stenosis.
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Search Strategy
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We searched the Cochrane Stroke Group Trials Register (last
searched March 2006), the Cochrane Central Register of Controlled
Trials (CENTRAL; The Cochrane Library Issue 1, 2006), MEDLINE
(1966 to March 2006), EMBASE (1980 to February 2006), and Science
Citation Index (1945 to March 2006). We searched reference lists
of relevant articles and contacted authors and experts in the
field.
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Selection Criteria
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Randomized or otherwise-controlled studies comparing best medical
care plus angioplasty of the intracranial cerebral arteries,
with or without stent placement, with best medical care alone
were included. Studies were included only if data for clinically
significant end points such as recurrent ischemic stroke, hemorrhagic
stroke, and death were available.
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Data Collection and Analysis
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Two review authors selected trials for inclusion, independently
assessed trial quality, and extracted the data. Calculation
of relative treatment effects with subgroup analysis was done
when possible.
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Main Results
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No randomized controlled trials were found. There were 79 articles
of interest, consisting of open-label series with 3 or more
cases. The overall perioperative rate of stroke was 7.9% (95%
CI, 5.5% to 10.4%), the perioperative death rate was 3.4% (95%
CI, 2.0% to 4.8%), and the perioperative stroke or death rate
was 9.5% (95% CI, 7.0% to 12.0%). No comments can be made on
the effectiveness of the procedure.
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Reviewers’ Conclusions
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Angioplasty with or without stent placement for the prevention
of stroke in patients with intracranial artery stenosis is feasible,
although this procedure carries a significant morbidity and
mortality risk. Evidence from randomized, controlled trials
is needed to assess its safety and effectiveness in preventing
recurrent territorial stroke before it is recommended for routine
clinical practice.
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Implications for Practice
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There is insufficient evidence to recommend angioplasty of the
intracranial arteries, with or without stent placement, for
secondary stroke prevention in clinical practice.
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Implications for Research
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A controlled, clinical trial comparing angioplasty, with or
without stent placement, with best medical treatment must target
the population at highest risk of recurrent stroke.
2 Assuming
a stroke rate of 20% per year and considering the procedural
complication rates from this review, a trial with an
of 0.05,
power of 80%, and an expected relative risk reduction of 25%
would require 950 participants per treatment arm and a perioperative
rate of stroke or death of <7%. A similar trial with an expected
relative risk reduction of 50% would require 220 participants
per treatment arm and a perioperative rate of stroke or death
<3%.
Note: The full text of this review is available in the Cochrane Library. It should be cited as follows: Cruz-Flores S, Diamond AL. Angioplasty for intracranial artery stenosis (Cochrane Review). In: The Cochrane Library, Issue 3, July 19, 2006. Oxford: Update Software. Copyright Cochrane Library, reproduced with permission.
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Acknowledgments
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We would like to acknowledge and thank Hazel Fraser and Brenda
Thomas for their help with searching for trials and their comments.
Disclosures
None.
Received July 22, 2006;
accepted August 14, 2006.
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References
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- Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005; 352: 1305–1316.[Abstract/Free Full Text]
- Kasner SE, Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, Levine SR, Chaturvedi S, Benesch CG, Sila CA, Jovin TG, Romano JG, Cloft HJ; Wafarin Aspirin Symptomatic Intracranial Disease Trial Investigators. Predictors of ischemic stroke in the territory of a symptomatic intracranial arterial stenosis. Circulation. 2006; 113: 555–563.[Abstract/Free Full Text]
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Introduction
Objectives