Combination of Rescue Stenting and Antiplatelet Infusion Improved Outcomes for Acute Intracranial Atherosclerosis-Related Large-Vessel Occlusion

Baek, Jang Hyun; Jung, Cheolkyu; Kim, Byung Moon; Heo, Ji Hoe; Kim, Dong Joon; Nam, Hyo Suk; Lim, Eun Hyun; Kim, Jun Hwee; Kim, Jun Yup; Kim, Jae Hyoung

doi:10.3389/fneur.2021.608270

Cited by 17 publications

(41 citation statements)

References 27 publications

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“…Despite the high incidence of ICAD-related intracranial arterial occlusions (especially in Asian populations in which they are the underlying cause for up to 40% of all large vessel occlusions) 30–33 and that ICAD-related intracranial arterial occlusions might pose an independent risk factor for mechanical thrombectomy failure and early reocclusion, 34,35 no randomized-controlled clinical trial has evaluated the effects of hyperacute management approaches for these challenging situations. 36,37 The authors of these guidelines acknowledge that there is a need for well-designed randomized-controlled clinical trials to answer this clinically important question.…”

Section: Results: Pico Questionsmentioning

confidence: 99%

“…Our systematic review identified four retrospective studies of very low quality comparing the effects of angioplasty and/or stenting plus BMT after initial mechanical thrombectomy to BMT alone on functional outcome in ICAD-related intracranial arterial occlusions (see Table 3 for the GRADEpro ratings of the included studies). 37,[43][44][45] One out of the four studies compared LVO patients related to ICAD undergoing angioplasty and/or stenting to non-ICAD LVO patients with similar characteristics. 45 This study suggested that functional outcome did not differ between both groups, which would suggest that rescue therapy in the form of angioplasty and/or stenting appears to be safe.…”

Section: Picomentioning

confidence: 99%

“…In two out of three studies 43,44 angioplasty and/or stenting was associated with a positive effect on the rate of good functional outcome, while in one study 37 only the combination of angioplasty and/or stenting and infusion of OR reported for the studies are crude OR calculated by authors based on the raw numbers reported in the articles.…”

Section: Picomentioning

confidence: 99%

“…Patients were enrolled between 2015 and 2018 in multiple Chinese centers. 43 The second largest study 37 distinguished between patients receiving only additional angioplasty and/or stenting and receiving additional angioplasty and/or stenting plus infusion of glycoprotein IIb/IIIa inhibitors. Patients were enrolled between 2010 and 2018 in three South Korean centers.…”

Section: Expert Consensus Statementmentioning

confidence: 99%

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European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

Psychogios

López‐Cancio

Marchis

et al. 2022

European Stroke Journal

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The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified eleven relevant clinical problems affecting ICAD patients and formulated the corresponding Patient Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.

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Section: Results: Pico Questionsmentioning

confidence: 99%

Section: Picomentioning

confidence: 99%

Section: Picomentioning

confidence: 99%

Section: Expert Consensus Statementmentioning

confidence: 99%

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European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

Psychogios

López‐Cancio

Marchis

et al. 2022

European Stroke Journal

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“…However, preprocedural or earlier determination of an occlusion pathomechanism can be helpful for setting up an optimal endovascular strategy. As mechanical thrombectomy modalities are not so effective for an ICAS-related occlusion, rescue modalities, including glycoprotein IIb/IIIa inhibitors, percutaneous balloon angioplasty, and intracranial stenting, are frequently needed 23. Importantly, achieving a successful recanalization and elapsed time to recanalization are critical to patients' outcomes 7 24.…”

Section: Discussionmentioning

confidence: 99%

Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision

Baek

Kim

et al. 2022

J NeuroIntervent Surg

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ObjectiveTo evaluate whether an occlusion pathomechanism can be accurately determined by common preprocedural findings through a machine learning-based prediction model (ML-PM).MethodsA total of 476 patients with acute stroke who underwent endovascular treatment were retrospectively included to derive an ML-PM. For external validation, 152 patients from another tertiary stroke center were additionally included. An ML algorithm was trained to classify an occlusion pathomechanism into embolic or intracranial atherosclerosis. Various common preprocedural findings were entered into the model. Model performance was evaluated based on accuracy and area under the receiver operating characteristic curve (AUC). For practical utility, a decision flowchart was devised from an ML-PM with a few key preprocedural findings. Accuracy of the decision flowchart was validated internally and externally.ResultsAn ML-PM could determine an occlusion pathomechanism with an accuracy of 96.9% (AUC=0.95). In the model, CT angiography-determined occlusion type, atrial fibrillation, hyperdense artery sign, and occlusion location were top-ranked contributors. With these four findings only, an ML-PM had an accuracy of 93.8% (AUC=0.92). With a decision flowchart, an occlusion pathomechanism could be determined with an accuracy of 91.2% for the study cohort and 94.7% for the external validation cohort. The decision flowchart was more accurate than single preprocedural findings for determining an occlusion pathomechanism.ConclusionsAn ML-PM could accurately determine an occlusion pathomechanism with common preprocedural findings. A decision flowchart consisting of the four most influential findings was clinically applicable and superior to single common preprocedural findings for determining an occlusion pathomechanism.

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Intracranial Atheromatous Stenosis

Holay,

Boisseau,

Walker

et al. 2024

Mastering Endovascular Techniques

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Combination of Rescue Stenting and Antiplatelet Infusion Improved Outcomes for Acute Intracranial Atherosclerosis-Related Large-Vessel Occlusion

Cited by 17 publications

References 27 publications

European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease

Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision

Intracranial Atheromatous Stenosis

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