Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients.

BACKGROUND

Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.'

METHODS

A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.

RESULTS

Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO).

CONCLUSIONS

The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.

Informations de copyright

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Déclaration de conflit d'intérêts

Competing interests: The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health (NIH). JJH is a consultant for Medtronic and MicroVention, and a member of the medical and scientific advisory board for iSchemaView. JJH’s research is supported by the NIH (R01 NS121720-01, R01 NS075209, R01 NS11351704, R01 NS130172-01, and R01 EB032417-01A1). JRM is a consultant for Stryker. CMS has contract or research support from Penumbra, Medtronic, MIVI, Cerenovus, Stryker, and Balt, and ownership interest in NTI. JKB serves as a consultant for Stryker, Microvention, Cerenovus, Balt, Medtronic, Q’Apel Medical, Longeviti Neuro Solutions, and Siemens Healthineers. DR consults for Q’Apel, Penumbra, and Phenox. SWH is an ex officio member of the Society of NeuroInterventional Surgery Board of Directors. SWH’s research is supported by NIH (R01CA194533, R42CA265316, and R01EB012031). SWH has consulting agreements with Medtronic, Imperative, and Cerenovus and an ownership interest in Filtro. SWH’s institution has contract and grant support from Siemens, Stryker Neurovascular, and Route 92.