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. 2021 Sep;6(3):XXXIX-LXXXVIII.
doi: 10.1177/23969873211046475. Epub 2021 Oct 13.

ESO guideline for the management of extracranial and intracranial artery dissection

Stephanie Debette  1   2 , Mikael Mazighi  3   4   5   6   7 , Philippe Bijlenga  8 , Alessandro Pezzini  9 , Masatoshi Koga  10 , Anna Bersano  11 , Janika Kõrv  12   13 , Julien Haemmerli  8 , Isabella Canavero  11 , Piotr Tekiela  14 , Kaori Miwa  10 , David J Seiffge  15 , Sabrina Schilling  16 , Avtar Lal  16 , Marcel Arnold  15 , Hugh S Markus  17 , Stefan T Engelter  18   19 , Jennifer J Majersik  14
Affiliations

ESO guideline for the management of extracranial and intracranial artery dissection

Stephanie Debette et al. Eur Stroke J. 2021 Sep.

Erratum in

Abstract

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.

Keywords: Extracranial artery dissection; anticoagulants; aspirin; cervical artery dissection; endovascular treatment; intracranial artery dissection; mechanical thrombectomy; stroke; subarachnoid hemorrhage; thrombolysis.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
PRISMA flow chart of study selection for PICO1. “Wrong study design, patient population, intervention, comparator, and control group” in COVIDENCE corresponds to studies that do not match criteria for this PICO.
Figure 2.
Figure 2.
(a) Meta-analysis of effects of intravenous thrombolysis in observational studies on mortality at 3 months. (b) Meta-analysis of effects of intravenous thrombolysis in observational studies on mortality at 7 days.
Figure 3.
Figure 3.
(a) Meta-analysis of effects of intravenous thrombolysis in observational studies on excellent functional outcome (mRS 0–1 vs. mRS 2–6) at 3–6 months. Functional outcome was assessed after a maximum of 6 months in Dziewas et al, and at 3 months in Engelter et al.. (b) Meta-analysis of effects of intravenous thrombolysis in observational studies on good functional outcome (mRS 0–2 vs. mRS 3–6) at 3 months.
Figure 4.
Figure 4.
(a) Meta-analysis of effects of intravenous thrombolysis in observational studies on the risk of intracranial hemorrhage. (b) Meta-analysis of effects of intravenous thrombolysis in observational studies on the risk of intracranial hemorrhage, without the NIS study.
Figure 5.
Figure 5.
Meta-analysis of effects of intravenous thrombolysis in observational studies on the risk of major bleedings.
Figure 6.
Figure 6.
PRISMA flow chart of study selection for PICO2. “Wrong study design, setting, intervention, outcomes, and (patient) population” in COVIDENCE corresponds to studies that do not match criteria for this PICO
Figure 7.
Figure 7.
Meta-analysis of effects of endovascular treatment in observational studies on good functional outcome (mRS 0–2 vs. 3–6) at 3 months.
Figure 8.
Figure 8.
Meta-analysis of effects of endovascular treatment in observational studies on risk of symptomatic ICH at 3 months.
Figure 9.
Figure 9.
(a) Meta-analysis of effects of endovascular treatment in observational studies on mortality, at 3 months. (b) Meta-analysis of effects of endovascular treatment in observational studies on mortality at 7 days.
Figure 10.
Figure 10.
PRISMA flow chart of study selection for PICO3.
Figure 11.
Figure 11.
Meta-analysis of effects of endovascular or surgical treatment in observational studies on the risk of rebleeding (SAH recurrence).
Figure 12.
Figure 12.
Meta-analysis of effects of endovascular or surgical treatment in observational studies on mortality. Anxionnat 2003: deaths occurred in the acute or subacute phase; Mizutani 1995: deaths occurred in the acute or subacute phase, the latest death occurred within a month; Rabinov 2003: four of five deaths occurred in the initial hospital course, the last death occurred in a delayed fashion due to an unknown cause; Zhao 2007: most deaths occurred in the acute or subacute phase, except one death that occurred at 16 months due to the rupture of another IAD.
Figure 13.
Figure 13.
Meta-analysis of effects of endovascular or surgical treatment in observational studies on good functional outcome (mRS 0–2 vs. 3–6 or equivalent).
Figure 14.
Figure 14.
Mortality rate in IAD patients with SAH under medical treatment only.
Figure 15.
Figure 15.
Rebleeding rate (SAH recurrence) in IAD patients with SAH under medical treatment only.
Figure 16.
Figure 16.
Rebleeding rate (SAH recurrence) in IAD patients with SAH undergoing endovascular or surgical treatment.
Figure 17.
Figure 17.
Rebleeding rate (SAH recurrence) in IAD patients with SAH undergoing endovascular or surgical treatment, prior to intervention.
Figure 18.
Figure 18.
Rebleeding rate (SAH recurrence) in IAD patients with SAH undergoing endovascular or surgical treatment, after intervention.
Figure 19.
Figure 19.
Mortality rate in IAD patients with SAH undergoing endovascular or surgical treatment.
Figure 20.
Figure 20.
Rate of good functional outcome in IAD patients with SAH undergoing endovascular or surgical treatment.
Figure 21.
Figure 21.
Rate of good functional outcome in IAD patients with SAH under medical treatment only.
Figure 22.
Figure 22.
PRISMA flow chart of study selection for PICO4. “Wrong patient population” in COVIDENCE corresponds to studies that do not match criteria for this PICO.
Figure 23.
Figure 23.
PRISMA flow chart of study selection for PICO5. *these included 2 consecutive publications on the same trial (3 months and 1 year follow-up), and 4 observational studies on partly overlapping samples.,,,; “wrong population” in COVIDENCE corresponds to studies that do not match criteria for this PICO.
Figure 24.
Figure 24.
Meta-analysis of effects on risk of ischemic stroke of anticoagulant versus antiplatelet treatment at the acute phase of EAD in RCTs (at 3 months).
Figure 25.
Figure 25.
Meta-analysis of effects on risk of major bleeding of anticoagulant versus antiplatelet treatment at the acute phase of EAD in RCTs (at 3 months).
Figure 26.
Figure 26.
Meta-analysis of effects on risk of ischemic stroke, major bleeding or death of anticoagulant versus antiplatelet treatment at the acute phase of EAD in RCTs (at 3 months).
Figure 27.
Figure 27.
Risk of bias of RCTs for PICO5.
Figure 28.
Figure 28.
Meta-analysis of effects on mortality of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 29.
Figure 29.
Meta-analysis of effects on good functional outcome (mRS 0–2) of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 30.
Figure 30.
Meta-analysis of effects on excellent functional outcome (mRS 0–1) of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 31.
Figure 31.
Meta-analysis of effects on ischemic stroke of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 32.
Figure 32.
Meta-analysis of effects on intracranial hemorrhage of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 33.
Figure 33.
Meta-analysis of effects on major bleedings of anticoagulant versus antiplatelet treatment at the acute phase of EAD in observational studies.
Figure 34.
Figure 34.
PRISMA flow chart of study selection for PICO6 “Wrong study design, language, setting, intervention, outcomes, and (patient) population” in COVIDENCE corresponds to studies that do not match criteria for this PICO.
See this image and copyright information in PMC

Comment in

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