Department of Neurosurgery, Xuanwu Hospital 2024-05-18 18:02 Beijing

The 10th European Stroke Organisation Conference 2024 (ESOC 2024) was held on May 15-17 in Basel, Switzerland.

Dr. Gao Peng, Director of the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, delivered a lecture at the main session of the closing ceremony, entitled: Stenting Plus Medical Therapy vs. Medical Therapy Alone for Symptomatic Intracranial Atherosclerotic Stenosis: 7-Year Results of a Randomized Controlled Trial (CASSISS-FU).

Dr. Lu Xia and Dr. Liu Delin of our department were present at the same time to present the academic poster, sending first-time, first-person perspective panoramic academic reports as "frontline reporters".

Theme of the report

Stenting Plus Medical Therapy vs. Medical Therapy Alone for Symptomatic Intracranial Stenosis (CASSISS-FU): 7-Year Results of the CASSISS Trial.

Stenting Plus Medical Therapy VS Medical Therapy Alone for Symptomatic Intracranial Stenosis: 7-Year Results of the CASSISS Trial

Speaker

Gao Peng

Xuanwu Hospital, Capital Medical University

Dr. Gao Peng was speaking at the closing plenary session of ESOC 2024 in Basel, Switzerland.

Study Background

Symptomatic intracranial atherosclerotic stenosis (ICAS) poses a significant risk of ischemic stroke globally, accounting for 10% of all ischemic strokes in the United States and up to 50% in China. Previous randomized trials (SAMMPRIS, VISSIT, and CASSISS) have shown no significant benefit in patients with symptomatic, severe intracranial stenosis treated with stents in combination with medications. However, it remains unclear whether ICAS would benefit from stenting in terms of long-term follow-up.

Study Objectives

Previously, the CASSISS trial showed results of a 3-year analysis and has been published in 2022. The CASSISS-FU trial extended the follow-up window with the aim of clarifying whether the benefits gained in long-term prevention of stroke using stenting in combination with medication offset the perioperative risks of stenting compared with medication alone during a median of 7 years of follow-up.

Study Design

CASSISS was a multicenter, open-label, randomized trial conducted in 8 centers in China. We recruited patients with transient ischemic attack (TIA) or ischemic stroke (mRS score 0-2) due to severe intracranial atherosclerotic stenosis (ICAS) (stenosis of 70%-99%). Eligible patients were randomly assigned in a 1:1 ratio to either the stent combined with medication group or the medication alone group. The primary outcome was stroke or death within 30 days or ipsilateral ischemic stroke occurring beyond 30 days. Secondary outcomes included ipsilateral stroke, disabling or fatal stroke, and death after enrollment.

Inclusion and Exclusion Criteria

1. Exclusion of patients who had a TIA or ischemic stroke in the past 3 weeks (lasting more than 24 hours; confirmed by DWI)

Exclusion of patients who had experienced only brainstem or basal ganglia penetrating infarcts;

No loading doses of DAPT medications allowed.

Results of the Study

From March 2014 to November 2016, a total of 380 patients were enrolled and randomly assigned to the stenting group (188) and the medication group (192). Of these 380 patients, 358 (176: stent implantation group, 182: medication group) were identified as eligible and included in the FAS for final analysis (Figure 1). Of the 358 patients, 237 (66.2% completed) 7 years of follow-up.

The median follow-up was 7.4 years (IQR 6.0-8.0).

Figure 1 Flow chart of the study

The primary outcome (composite event of stroke or death within 30 days or ipsilateral ischemic stroke after 30 days) showed no difference between the two groups during the 7-year follow-up period (HR, 1.02 [95% CI, 0.58-1.77]; P=0.97) (Figure 2).

Figure 2 Primary outcome (composite event of stroke or death within 30 days or ipsilateral ischemic stroke after 30 days)

Study Conclusions

Over a follow-up period of up to 7 years, stenting combined with pharmacologic therapy in symptomatic patients with severe ICAS still fails to demonstrate long-term benefit under current patient selection criteria.

Potential Effects

Pharmacotherapy remains an important treatment for long-term stroke prevention in patients with symptomatic severe intracranial atherosclerotic stenosis.

Reviewer

Wang Tao

Xuanwu Hospital, Capital Medical University

Author      

He Xiaoxin

Xuanwu Hospital, Capital Medical University

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