Intracranial stenosis: Impact of randomized trials on treatment preferences of us neurologists and neurointerventionists

• Type of Material: Article
• Authors: Tanya N. Turan, Medical University of South; George Cotsonis, Emory University; Michael Lynn, Emory University; Rahim H. Wooley, Medical University of South; Seegar Swanson, Emory University; Janice E. Williams, University of North Carolina Chapel Hill; Barney J. Stern, University of Maryland, Baltimore; Colin P. Derdeyn, Washington University, St. Louis; David Fiorella, Washington University, St. Louis; Marc I. Chimowitz, Medical University of South
• Language: English
• Date: 2014-01-01
• Publisher: Karger Publishers
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2014 S. Karger AG, Basel.
• Final Published Version (URL): http://dx.doi.org/10.1159/000358120
• Title of Journal or Parent Work: Cerebrovascular Diseases
• ISSN: 1015-9770
• Volume: 37
• Issue: 3
• Start Page: 203
• End Page: 211
• Grant/Funding Information: TNT, MJL, GC, SS, BJS, and MIC currently receive funding from the research grant (U01NS058728) from NINDS for the Stenting and Aggressive Medical Management for Prevention of Recurrent stroke in Intracranial Stenosis Trial (SAMMPRIS).; Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) was supported by the National Institute of Neurological Disorders and Stroke (NINDS) (R01NS36643).; The use of the REDCap survey tool was supported by NIH (NCATS UL1TR000062).
• Keywords: Clopidogrel; Ticlopidine; Angioplasty; Drug Therapy, Combination; Stroke; Surveys and Questionnaires; Aspirin; Humans; Warfarin; Cerebral Arteries; Health Care Surveys; Practice Patterns, Physicians'; Intracranial Arteriosclerosis; Risk Reduction Behavior; Stents; Drug Utilization; Radiology, Interventional; Constriction, Pathologic; Neurology; Randomized Controlled Trials as Topic; Fibrinolytic Agents; Secondary Prevention; United States
• Research Categories: Health Sciences, Medicine and Surgery; Biology, Biostatistics; Biology, Neuroscience

Abstract

Background and Purpose: Medical and endovascular treatment options for stroke prevention in patients with symptomatic intracranial stenosis have evolved over the past several decades, but the impact of 2 major multicenter randomized stroke prevention trials on physician practices has not been studied. We sought to determine changes in US physician treatment choices for patients with intracranial atherosclerotic stenosis (ICAS) following 2 NIH-funded clinical trials that studied medical therapies (antithrombotic agents and risk factor control) and percutaneous transluminal angioplasty and stenting (PTAS). Methods: Anonymous surveys on treatment practices in patients with ICAS were sent to physicians at 3 time points: before publication of the NIH-funded Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial (pre-WASID survey, 2004), 1 year after WASID publication (post-WASID survey, 2006) and 1 year after the publication of the NIH-funded Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial (post-SAMMPRIS survey, 2012). Neurologists were invited to participate in the pre-WASID survey (n = 525). Neurologists and neurointerventionists were invited to participate in the post-WASID (n = 598) and post-SAMMPRIS (n = 2,080) surveys. The 3 surveys were conducted using web-based survey tools delivered by E-mail, and a fax-based response form delivered by E-mail and conventional mail. Data were analyzed using the χ2 test. Results: Before WASID, there was equipoise between warfarin and aspirin for stroke prevention in patients with ICAS. The number of respondents who recommended antiplatelet treatment for ICAS increased across all 3 surveys for both anterior circulation (pre-WASID = 44%, post-WASID = 85%, post-SAMMPRIS = 94%) and posterior circulation (pre-WASID = 36%, post-WASID = 74%, post-SAMMPRIS = 83%). The antiplatelet agent most commonly recommended after WASID was aspirin, but after SAMMPRIS it was the combination of aspirin and clopidogrel. The percentage of neurologists who recommended PTAS in >25% of ICAS patients increased slightly from pre-WASID (8%) to post-WASID surveys (12%), but then decreased again after SAMMPRIS (6%). The percentage of neurointerventionists who recommended PTAS in >25% of ICAS patients decreased from post-WASID (49%) to post-SAMMPRIS surveys (17%). Conclusions: The surveyed US physicians' recommended treatments for ICAS differed over the 3 survey periods, reflecting the results of the 2 NIH-funded clinical trials of ICAS and suggesting that these clinical trials changed practice in the USA.