Stenting for Intracranial Atherosclerosis

SAMMPRIS (2011) was stopped early for harm and futility: percutaneous transluminal angioplasty and stenting with the Wingspan stent showed 14.7% 30-day stroke or death versus 5.8% with aggressive medical management for symptomatic 70–99% intracranial stenosis. WEAVE (2019), an FDA-mandated post-market registry of on-label Wingspan use, reported a 2.6% 72-hour periprocedural event rate, much lower than SAMMPRIS, supporting that careful patient selection improves safety. Stenting is not first-line for symptomatic intracranial atherosclerosis; aggressive medical management with DAPT and statin remains the standard.

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Clinical Question

Does symptomatic intracranial atherosclerosis benefit from stenting?

Synthesises 4 trialsFrom SAMMPRIS stenting harm through WEAVE on-label safety to CASSISS no-benefit and BASIS positive balloon angioplasty

Clinical Synthesis

For symptomatic intracranial atherosclerotic stenosis of 70% to 99%, aggressive medical management is first-line; stenting as initial therapy is unsupported by two randomized trials (SAMMPRIS harm, CASSISS no benefit), and the first positive endovascular signal (BASIS 2024) is for submaximal balloon angioplasty, not stenting, and is not yet guideline-endorsed.

Bottom line

For symptomatic intracranial atherosclerotic stenosis of 70% to 99%, start aggressive medical management: dual antiplatelet for 90 days then single antiplatelet, high-intensity statin to LDL below 70, SBP below 140, glycemic and lifestyle control. Stenting as initial therapy is not appropriate (SAMMPRIS harm, CASSISS no benefit). Submaximal balloon angioplasty is an emerging, not-yet-guideline-endorsed option at expert centers per BASIS 2024, with real upfront procedural risk; it does not license Wingspan or primary stenting. Reserve any revascularization for narrowly selected refractory patients at experienced high-volume centers.

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