Indications for Intracranial Endovascular Procedures

Eskey CJ, Meyers PM, Nguyen TN, et al., on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention and Stroke Council.
Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association. Circulation 2018;Apr 19:[Epub ahead of print].

The following are key points to remember about this American Heart Association Scientific Statement on indications for the performance of intracranial endovascular neurointerventional procedures:

  1. Acute ischemic stroke patients with National Institutes of Health Stroke Scale (NIHSS) ≥6, anterior circulation (first branch of the middle cerebral artery or internal carotid artery) occlusion, and reassuring noncontrast head computed tomography should undergo mechanical thrombectomy with a stent retriever if treatment can be initiated within 6 hours of symptom onset or last known normal. More recent trials have suggested a benefit of thrombectomy for select patients out to 24 hours from last known normal.
  2. Acute ischemic stroke patients who are eligible for intravenous (IV) tissue plasminogen activator (tPA) should receive IV tPA, regardless of whether mechanical thrombectomy is being considered. Treatment with IV tPA and/or mechanical thrombectomy should be delivered as quickly as possible.
  3. Stroke/transient ischemic attack (TIA) patients with intracranial artery narrowing should receive aggressive medical management, not intracranial angioplasty or stenting. Angioplasty or stenting should only be considered in patients with severe (70-99%) intracranial stenosis who have progressing or recurrent symptoms despite optimal medical therapy.
  4. The population prevalence of unruptured intracranial aneurysms is estimated to be as high as 2%. The risk of aneurysm rupture is higher in patients with a history of prior subarachnoid hemorrhage (SAH).
  5. In the prospective ISUIA aneurysm study, the 5-year rupture rate was 0% for patients without a history of SAH and anterior circulation aneurysm <7 mm. For posterior circulation aneurysms <7 mm, the 5-year rupture rate was 2.5%.
  6. In the prospective UCAS Japanese aneurysm study, the 5-year rupture rate of anterior or posterior aneurysms <5 mm was 1.7% for patients without a history of SAH.
  7. In 2012, approximately 60% of ruptured aneurysms and approximately 70% of unruptured aneurysms were treated with endovascular coiling (as opposed to surgical clipping) in the United States. The ongoing CURES and ISAT II trials seek to compare 1-year outcomes of patients who undergo coiling versus clipping.
  8. Arteriovenous malformations (AVMs) are rare vascular anomalies that carry a high risk of rupture. The yearly rupture risk is estimated at 1-3% per year in patients without a prior history of rupture and at about 5% per year in patients with a prior history of rupture.
  9. The ARUBA AVM trial showed a lower incidence of stroke or death in patients with AVM who received conservative management as compared to those who received intervention. The results of ARUBA have been called into question because: 1) the treatment strategy (embolization, surgery, radiation, or a combination) was left up to the treating provider, and 2) the follow-up was relatively short at a mean of 33.3 months.
  10. When intervention, as opposed to conservative management, is selected for a patient’s AVM, it is reasonable to pursue embolization alone or presurgical embolization.
  11. Dural arteriovenous fistulas are rare, acquired shunts within the dura mater. For patients with asymptomatic dural arteriovenous fistulas without cortical venous reflux or other aggressive angiographic features, conservative management is recommended.
  12. For patients with dural arteriovenous fistulas with: 1) cortical venous reflux, 2) hemorrhage on presentation, or 3) debilitating tinnitus, treatment (endovascular therapy, surgical therapy, radiosurgery, or a combination) is generally recommended.
  13. Patients with cerebral venous thrombosis (thrombus within the dural venous sinuses) should receive systemic anticoagulation as first-line therapy. Endovascular thrombectomy or thrombolysis may be considered for select patients, such as those who deteriorate despite systemic anticoagulation, or those with coma at presentation.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Lipid Metabolism, Interventions and Imaging, Interventions and Vascular Medicine

Keywords: Aneurysm, Ruptured, Angioplasty, Anticoagulants, Arteriovenous Malformations, Brain Ischemia, Cardiac Surgical Procedures, Central Nervous System Vascular Malformations, Constriction, Pathologic, Embolization, Therapeutic, Endovascular Procedures, Intracranial Aneurysm, Ischemic Attack, Transient, Radiosurgery, Secondary Prevention, Stents, Stroke, Subarachnoid Hemorrhage, Thrombectomy, Thrombosis, Tinnitus, Tissue Plasminogen Activator, Tomography, Vascular Diseases, Venous Thrombosis

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