Intracranial Angioplasty and Stent Placement After Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial: Present State and Future Considerations

Authors

  • Adnan I Qureshi MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Fahmi M. Al-Senani MBBS,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Shakir Husain MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Nazli A. Janjua MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Giuseppe Lanzino MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Pablo M. Lavados MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Thanh Nguyen MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Jean Raymond MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Qaisar A. Shah MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Jose I. Suarez MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • M. Fareed K. Suri MD,

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • Reha Tolun MD

    1. From the Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (AIQ, MFKS); Department of Neurology, King Fahad Medical City, Riyadh, Saudi Arabia (FMA-S); Department of Interventional Neurology and Stroke, Institute of Neurosciences, Superspeciality Hospital Saket. New Delhi, India (SH); Department of Neurology, Long Island's College of Hospital, Brooklyn, NY, USA (NAJ); Department of Neurosurgery, Mayo Clinic, Minnesota, USA (GL); Department of Neurology Service, Department of Medicine, Clnica Alemana de Santiago, Facultad de Medicina, Clnica Alemana Universidad del Desarrollo and Universidad de Chile, Santiago, Chile (PL); Department of Neurology, Neurosurgery, and Radiology, Boston University School of Medicine (BUSM) Boston, USA (TN); Department of Radiology, Oncology and Nuclear Medicine, University of Montreal and Interventional Neuroradiology Research Laboratory, CRCHUM, Montreal, Canada (JR); Neurosciences Institute, Abington Memorial Hospital, Pennsylvania, USA (QAS); Department of Neurology Baylor University and Baylor College of Medicine, Texas, USA (JIS); Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota (MFKS); and Neuro-angiography Department, Istanbul Science University Florence Nightingale Hospital, Istanbul, Turkey (RT).
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  • A report from the Working Group of International Congress of Interventional Neurology and Practice Committee of American Society of Neuroimaging.

  • J Neuroimaging 2012;22:1-13.

Adnan I. Qureshi, MD, Department of Neurology, University of Minnesota, 420 Delaware St. SE, MMC 295, Minneapolis, MN 55455. E-mail: aiqureshi@hotmail.com.

Abstract

ABSTRACT

OBJECTIVE

The results of prematurely terminated stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) due to excessively high rate of stroke and death in patients randomized to intracranial stent placement is expected to affect the practice of endovascular therapy for intracranial atherosclerotic disease. The purpose of this report is to review the components of the designs and methods SAMMPRIS trial and to describe the influence of those components on the interpretation of trial results.

METHODS

A critical review of the patient population included in SAMMPRIS is conducted with emphasis on “generalizability of results” and “bias due to cherry picking phenomenon.” The technical aspects of endovascular treatment protocol consisting of intracranial angioplasty and stent placement using the Gateway balloon and Wingspan self-expanding nitinol stent and credentialing criteria of trial interventionalists are reviewed. The influence of each component is estimated based on previous literature including multicenter clinical trials reporting on intracranial angioplasty and stent placement.

RESULTS

The inclusion criteria used in the trial ensured that patients with adverse clinical or angiographic characteristics were excluded. Self-expanding stent as the sole stent, technique of prestent angioplasty, periprocedural antiplatelet treatment, and intraprocedural anticoagulation are unlikely to adversely influence the results of intracranial stent placement. A more permissive policy toward primary angioplasty as an acceptable treatment option may have reduced the overall periprocedural complication rates by providing a safer option in technically challenging lesions. The expected impact of a more rigorous credentialing process on periprocedural stroke and/or death rate following intracranial stent placement in SAMMPRIS such as the one used in carotid revascularization endarterectomy versus stenting trial remains unknown.

CONCLUSION

The need for developing new and effective treatments for patients with symptomatic intracranial stenosis cannot be undermined. The data support modification but not discontinuation of our approach to intracranial angioplasty and/or stent placement for intracranial stenosis. There are potential patients in whom angioplasty and/or stent placement might be the best approach, and a new trial with appropriate modifications in patient selection and design may be warranted.

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