Can interventions for Intracranial vascular disease prevent stroke better than medical therapies?
Carotid artery disease is recognized as a predisposing factor for the stroke in the diabetic or elderly hypertensive patients. The stroke in such patients is prevented by medical therapies and interventions. Segmental extra cranial carotid artery disease is amenable for endarterectomy or angioplasty stenting. But the intracranial vascular disease is not easily amenable for the operations or interventions. After succeeding with angioplasty and stenting of the extra cranial vessels the attention is now focused on the intracranial vascular repairs with angioplasty and stenting. The intracranial vessels are small and delicate. They can need much more careful handling and softer devices to pass through them and at the same time hard enough to dilate stenotic lesions.The 30-day rate of stroke or death associated with stenting in the SAMMPRIS trial (14.7%) is nearly 2.5 times as high as the 6% rate associated with stenting of symptomatic extracranial carotid-artery stenoses in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST, NCT00004732).
One surprising finding was that symptomatic intracranial hemorrhage, a relatively rare complication after revascularization of extracranial carotid-artery stenosis, represented almost a third of all perioperative strokes in the SAMMPRIS trial. The intracranial hemorrhages were thought to be due to reperfusion hemorrhage or subarachnoid hemorrhage from wire manipulations during the procedure. This makes it clear that interventional therapies for the intracranial disease needs to face more challenges to prove that they are superior to the best medical therapies in the coming trials or studies. It is generally felt that the intracranial disease more common in Indian and Asian population. Among the Asians, the number who died from stroke was more than three times that for CHD. In one report, the age standardized, gender-specific stroke mortality rate was 44 to 102.6/100,000 for Asian males, compared with only 19.3 for Australian white males. In the early 1980s the prevalence rates of stroke were around 500-700 per 100,000 in the western countries and 900 per 100,000 in Asia. The disparity between the stroke and CHD incidence rates is usually attributed to high prevalence of hypertension and low levels of blood lipids among the Orientals.
Carotid artery disease is recognized as a predisposing factor for the stroke in the diabetic or elderly hypertensive patients. The stroke in such patients is prevented by medical therapies and interventions. Segmental extra cranial carotid artery disease is amenable for endarterectomy or angioplasty stenting. But the intracranial vascular disease is not easily amenable for the operations or interventions. After succeeding with angioplasty and stenting of the extra cranial vessels the attention is now focused on the intracranial vascular repairs with angioplasty and stenting. The intracranial vessels are small and delicate. They can need much more careful handling and softer devices to pass through them and at the same time hard enough to dilate stenotic lesions.The 30-day rate of stroke or death associated with stenting in the SAMMPRIS trial (14.7%) is nearly 2.5 times as high as the 6% rate associated with stenting of symptomatic extracranial carotid-artery stenoses in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST, NCT00004732). One surprising finding was that symptomatic intracranial hemorrhage, a relatively rare complication after revascularization of extracranial carotid-artery stenosis, represented almost a third of all perioperative strokes in the SAMMPRIS trial. The intracranial hemorrhages were thought to be due to reperfusion hemorrhage or subarachnoid hemorrhage from wire manipulations during the procedure. This makes it clear that interventional therapies for the intracranial disease needs to face more challenges to prove that they are superior to the best medical therapies in the coming trials or studies. It is generally felt that the intracranial disease more common in Indian and Asian population. Among the Asians, the number who died from stroke was more than three times that for CHD. In one report, the age standardized, gender-specific stroke mortality rate was 44 to 102.6/100,000 for Asian males, compared with only 19.3 for Australian white males. In the early 1980s the prevalence rates of stroke were around 500-700 per 100,000 in the western countries and 900 per 100,000 in Asia. The disparity between the stroke and CHD incidence rates is usually attributed to high prevalence of hypertension and low levels of blood lipids among the Orientals.
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