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. 2022 Sep;7(3):III-IV.
doi: 10.1177/23969873221099715. Epub 2022 Jun 3.

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

Marios Psychogios  1 , Alex Brehm  1 , Elena López-Cancio  2 , Gian Marco De Marchis  3 , Elena Meseguer  4 , Aristeidis H Katsanos  5 , Christine Kremer  6 , Peter Sporns  1   7 , Marialuisa Zedde  8   9 , Adam Kobayashi  10   11 , Jildaz Caroff  12 , Daniel Bos  13   14 , Sabrina Lémeret  15 , Avtar Lal  15 , Juan F Arenillas  16   17
Affiliations

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

Marios Psychogios et al. Eur Stroke J. 2022 Sep.

Abstract

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 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population 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.

Keywords: Intracranial atherosclerotic disease; guideline; intracranial artherosclerosis; stroke.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in the Supplemental material.

Figures

Figure 1.1.
Figure 1.1.
PICO 1 – Association between asymptomatic ICAD and risk of future stroke. *Data from Wang 2016 missing from totals.
Figure 3.1.
Figure 3.1.
PICO 3 – Association between infusion of glycoprotein IIb/IIIa inhibitors after mechanical thrombectomy, compared to standard of care, and good functional outcome (mRS 0–2) at 90 days, in observational studies. OR reported for the studies are crude OR calculated by authors based on the raw numbers reported in the articles.
Figure 5.1.
Figure 5.1.
PICO 5 - Risk of bias assessment.
Figure 6.1.
Figure 6.1.
PICO 6 - Risk of bias assessment.
Figure 6.2.
Figure 6.2.
PICO 6 – Association between anticoagulation therapy compared to antiplatelet therapy and risk of long term recurrence of IS in RCT.
Figure 6.3.
Figure 6.3.
PICO 6 – Association between anticoagulation therapy compared to antiplatelet therapy and risk of MACE in RCT.
Figure 6.4.
Figure 6.4.
PICO 6 – Association between anticoagulation therapy compared to antiplatelet therapy and risk of major bleeding in RCT.
Figure 6.5.
Figure 6.5.
PICO 6 – Association between anticoagulation therapy compared to antiplatelet therapy and mortality in RCT.
Figure 7.1.
Figure 7.1.
PICO 7 - Risk of bias assessment.
Figure 7.2.
Figure 7.2.
PICO 7 – Association between aspirin + cilostazol intake, compared to aspirin intake alone, and risk of recurrent IS in RCT.
Figure 7.3.
Figure 7.3.
PICO 7 – Association between aspirin + P2Y12 inhibitor intake, compared to aspirin intake alone, and risk of recurrent IS or death in RCT.
Figure 7.4.
Figure 7.4.
PICO 7 – Association between aspirin + cilostazol intake, compared to aspirin intake alone, and risk of MACE in RCT.
Figure 7.5.
Figure 7.5.
PICO 7 – Association between aspirin + cilostazol intake, compared to aspirin intake alone, and risk of major bleeding in RCT.
Figure 7.6.
Figure 7.6.
PICO 7 – Association between aspirin + cilostazol intake, compared to aspirin intake alone, and risk of hemorrhagic stroke in RCT.
Figure 7.7.
Figure 7.7.
PICD 7 – Association between aspirin + cilostazol intake, compared to aspirin intake alone, and death in RCT.
Figure 8.1.
Figure 8.1.
PICO 8 - Risk of bias assessment.
Figure 8.2.
Figure 8.2.
Pico 8 – Association between angioplasty and/or stenting + BMT compared to BMT and risk of recurrent IS at 30 days in RCT.
Figure 8.3.
Figure 8.3.
PICO 8 – Association between angioplasty and/or stenting + BMT compared to BMT and risk of major bleeding in RCT.
Figure 8.4.
Figure 8.4.
PICO 8 – Association between angioplasty and/or stenting + BMT compared to BMT and overall mortality in RCT.
Figure 8.5.
Figure 8.5.
Pico 8 – Association between angioplasty and/or stenting + BMT compared to BMT and risk of long term recurrence of IS in RCT.
Figure 8.6.
Figure 8.6.
Pico 8 – Association between angioplasty and/or stenting + BMT compared to BMT and risk of MACE in RCT.
Figure 8.7.
Figure 8.7.
PICO 8 – Restenosis rate in the angioplasty and/or stenting + BMT group of RCT.
Figure 9.1.
Figure 9.1.
PICO 9 - Risk of bias assessment.
Figure 10.1.
Figure 10.1.
PICO 10 - Risk of bias assessment.
Figure 10.2.
Figure 10.2.
PICO 10 – Association between remote ischemic conditioning plus BMT compared to BMT alone and the risk of long term recurrence of IS in RCTs.
Figure 11.1.
Figure 11.1.
PICO 11 - Risk of bias assessment.
See this image and copyright information in PMC

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