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Clinical Question

Does symptomatic intracranial atherosclerosis benefit from stenting?

Synthesises 2 trialsWingspan stent: RCT harm, post-market on-label safety signal

Clinical Synthesis

For symptomatic intracranial atherosclerotic stenosis of 70 to 99 percent, aggressive medical management is the standard of care; intracranial stenting with the Wingspan stent caused excess periprocedural stroke and death in SAMMPRIS (2011) and is reserved for narrowly selected patients at experienced centers under restricted FDA labeling.

Bottom line

For symptomatic intracranial atherosclerotic stenosis of 70 to 99 percent, start aggressive medical management: dual antiplatelet for 90 days then single antiplatelet, high-intensity statin to LDL <70, SBP <140, glycemic and lifestyle control. Reserve intracranial stenting for narrowly selected patients (recurrent stroke despite optimal medical therapy, no perforator-stroke index lesion, ≥7 days from qualifying event, on-label per the WEAVE indication) at experienced high-volume centers. SAMMPRIS-era routine stenting is not appropriate.

Sources

§5.5 Intracranial Atherosclerosis· 2021SAMMPRIS· 2011SAMMPRIS long-term· 2014WEAVE· 2019CASSISS· 2022

Trials in this question· 2

SAMMPRIS2011
Wingspan stenting as initial therapy for symptomatic ICAS 70–99% causes harm vs aggressive medical therapy.
Harm14.7% vs 5.8% 30-d
WEAVE2019
Wingspan stenting met FDA safety threshold (2.6% periprocedural stroke/death) in highly selected ICAS failures.
Safety met2.6% (target <4%)

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