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Research ArticleORIGINAL RESEARCH

Impact of Stenosis Degree on Outcomes of Stenting versus Medical Treatment Alone for Symptomatic Intracranial Stenosis: A Pooled Individual Patient Data Analysis

Zixuan Xing, Tianhua Li, Eyad Almallouhi, Peng Gao, Jichang Luo, Haozhi Gong, Xuesong Bai, Colin P. Derdeyn, Tao Wang and Liqun Jiao On behalf of the 6S Collaborators
American Journal of Neuroradiology February 2025, ajnr.A8701; DOI: https://doi.org/10.3174/ajnr.A8701
Zixuan Xing
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Tianhua Li
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Eyad Almallouhi
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Peng Gao
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Jichang Luo
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Haozhi Gong
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Xuesong Bai
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Colin P. Derdeyn
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Tao Wang
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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Liqun Jiao
From the Department of Neurosurgery (Z.X., T.L., P.G., J.L., H.G., X.B., T.W., L.J.), and Neurosurgery and Interventional Neuroradiology (L.J.), Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, 45 Changchun Street, Beijing 100053, China; Health Science Center (Z.X.), Xi’an Jiaotong University, Shaanxi, China; Department of Neurosurgery (T.L.), The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China; Neuro Interventional Surgery (E.A.), Sarasota Memorial Hospital, Sarasota, Florida, USA; and Department of Radiology and Medical Imaging (C.P.D.), University of Virginia, Charlottesville VA, USA.
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ABSTRACT

BACKGROUND AND PURPOSE: This study explores the impact of stenosis degree on outcomes of stenting compared with medical therapy alone in patients with symptomatic intracranial artery stenosis.

MATERIALS AND METHODS: Patients with a transient ischemic attack or nondisabling ischemic stroke, attributed to 70 to 99% stenosis of a major intracranial artery, were included. The patient cohort was drawn from the China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) and the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS). The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year.

RESULTS: Out of 806 patients, 92 patients (11%) met the primary outcome. As the degree of stenosis increased, the risk of the primary endpoint was significantly lower in the stenting group (R = -0.886, P = .03). For stenosis below or equal to 85%, stenting is worse than medical therapy given the high perioperative risk [13% vs. 8.0%, HR, 1.67, (95% CI, 1.04-2.67); P = .04]; at stenosis degree above 85%, stenting was preferred over medical therapy given the potential for better long-term prevention [14% vs. 21%, HR, 0.67, (95% CI, 0.29-1.56); P = .36].

CONCLUSIONS: Patients with higher degrees of stenosis are more likely to benefit from stenting. Patients with intracranial artery stenosis exceeding 85% may be the focus of future studies. If innovations in interventional techniques significantly reduce perioperative risk, the critical threshold of 85% as the degree of stenosis might be reconsidered.

ABBREVIATIONS: CASSISS = China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis; SAMMPRIS = Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis; ICAS = Intracranial atherosclerotic arterial stenosis; WASID = Warfarin versus Aspirin for Symptomatic Intracranial Disease; VISSIT = Vitesse Intracranial Stent Study for Ischemic Stroke Therapy; PH = proportional hazards; HR = Hazard ratio

Footnotes

  • The authors declare no conflicts of interest related to the content of this article.

  • Zixuan Xing, Tianhua Li, and Eyad Almallouhi contributed equally to this article.

  • © 2025 by American Journal of Neuroradiology

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Cite this article
Accepted Manuscript
Zixuan Xing, Tianhua Li, Eyad Almallouhi, Peng Gao, Jichang Luo, Haozhi Gong, Xuesong Bai, Colin P. Derdeyn, Tao Wang, Liqun Jiao
Impact of Stenosis Degree on Outcomes of Stenting versus Medical Treatment Alone for Symptomatic Intracranial Stenosis: A Pooled Individual Patient Data Analysis
American Journal of Neuroradiology Feb 2025, ajnr.A8701; DOI: 10.3174/ajnr.A8701

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Accepted Manuscript
Impact of Stenosis Degree on Outcomes of Stenting versus Medical Treatment Alone for Symptomatic Intracranial Stenosis: A Pooled Individual Patient Data Analysis
Zixuan Xing, Tianhua Li, Eyad Almallouhi, Peng Gao, Jichang Luo, Haozhi Gong, Xuesong Bai, Colin P. Derdeyn, Tao Wang, Liqun Jiao
American Journal of Neuroradiology Feb 2025, ajnr.A8701; DOI: 10.3174/ajnr.A8701
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