After 4 years! "Symptomatic intracranial atherosclerotic stenosis intravascular treatment of Chinese expert consensus 2022" released

Intracranial atherosclerotic stenosis (ICAS), also known as intracranial atherosclerotic disease (ICAD), is a common cause
of ischemic stroke.
"Chinese Expert Consensus on Symptomatic Intracranial Atherosclerotic Stenosis Intravascular Treatment 2022" is a partial update of the 2018 version of the consensus, which mainly puts forward the following recommendations
.

Medical treatment

(1) For patients with symptomatic ICAS (sICAS), aspirin-based antiplatelet therapy and intensive medical therapy (B-R level evidence, strongly recommended)
should be initiated as soon as possible after the onset of illness.
(2) In the early stage of ICAS onset, dual antiplatelet therapy is recommended to reduce the risk
of early stroke recurrence caused by thromboembolism.
Recommended dual antiplatelet therapy with aspirin and clopidogrel for 90 days (B-NR level evidence, moderately recommended); For clopidogrel-resistant patients (eg, carrying the CYP2C19 functional deletion allele), ticagrelor plus aspirin therapy is justified (B-NR level evidence, weak recommendation) and silotazole (200 mg/day) therapy is reasonable (B-NR level evidence, moderately recommended).


(3) ICAS patients with hypertension should actively control blood pressure, and the initiation time and blood pressure target value of antihypertensive therapy should be individualized
.
If there is no special, the long-term blood pressure control target should < 140/90mmHg, and the principle is gradual and stable blood pressure reduction (B-NR level evidence, strongly recommended); The selection of antihypertensive drugs should fully consider the patient's systemic target organ damage and drug tolerance, and long-acting antihypertensive drugs (C-EO level evidence, moderately recommended)<b15> may be preferred.

(4) It is recommended to start intensive lipid-lowering therapy early for ICAS patients (B-R level evidence, strongly recommended); Statins are recommended to reduce LDL-C to <1.
8 mmol/L (70 mg/dL) (B-NR level evidence, moderately recommended); If necessary, the addition of ezemabra and/or PCSK9 inhibitors (C-EO evidence, weakly recommended)<b17> may be considered.

(5) For ICAS patients with diabetes mellitus, it may be reasonable to target glycosylated hemoglobin ≤7% (B-NR level evidence, moderately recommended).


(6) Promote a healthy lifestyle, exercise moderate-intensity 3 to 5 times a week, and control other risk factors to reduce the risk of stroke recurrence (B-NR level evidence, moderately recommended).

Intravascular therapy

(1) Intensive medical therapy is the basic treatment of sICAS patients, and sICAS patients should receive intensive medical therapy (including antiplatelet therapy and control of risk factors) regardless of whether they choose endovascular therapy (B-R level evidence, strongly recommended).



(2) Stent placement treatment sICAS is safe for trained physicians in experienced medical centers where the patient meets the screening criteria, and can be considered as an effective, safe complementary treatment other than intensive medical treatment (B-R level evidence, weak recommendation).


(3) For people at high risk of sICAS (ineffective after intensive medical treatment, severe stenosis, hypoperfusion of the responsible vascular blood supply area, and poor collateral circulation), it may be reasonable to choose stent placement for the treatment of sICAS (C-LD level evidence, weak recommendation).

Ultra instructions for applications using stents

Based on current clinical experience and reports, microcatheter-released self-expanding stents reduce the difficulty of operation in treatment, help to improve technical success and reduce the incidence of surgical complications, ultra-manual use of stents in the treatment of sICAS selective application may be reasonable (C-EO level evidence, medium recommended).

Treatment of balloon dilation alone

(1) Simple balloon dilation treatment sICAS may be safe and effective, and intracranial dedicated balloons and low-pressure, semi-compliant balloons can be preferentially selected in treatment to improve the safety of surgery (C-LD level evidence, moderately recommended).


(2) Simple balloon dilation and prototyping technology is recommended for slow filling and slow pressure relief, and a long period of blood flow observation after expansion, and remedial stent placement should be carried out in the presence of flow restriction dissection or elastic retraction
.
It is recommended that the balloon choose a diameter of 50% to 80% of the reference diameter of the responsible blood vessel (sub-satisfactory dilation) (C-EO level evidence, weakly recommended).

Drug-coated balloon/stent therapy

(1) Drug-coated stent therapy for sICAS may be a new treatment to
solve the problem of sICAS restenosis and stroke recurrence.
Selection can be based on the patient's specific lesion and pathway characteristics (B-R level evidence, moderately recommended).



(2) Drug-coated balloon therapy for sICAS may be a new treatment to
solve the problem of sICAS restenosis and stroke recurrence.
It can be selected according to the specific lesion and pathway characteristics of the patient, and a higher level of evidence is required to confirm it (C-EO level evidence, weak recommendation).


(3) For patients with symptomatic restenosis, it is recommended to give priority to drug-coated stents for intracranial specific treatment of sICAS (C-EO level evidence, weak recommendation).

Restenosis and prevention

The risk of asymptomatic restenosis recurrent stroke is relatively low, and follow-up under drug therapy is recommended in principle; Patients with symptomatic severe restenosis who do not respond to pharmacotherapy may be considered for treatment by vascular intervention (C-EO level evidence, moderately recommended).

Preoperative evaluation of intravascular therapy

(1) Timing of surgery: Patients with ICAS may be safe for intravascular therapy (except for progressive stroke) after at least 2 weeks of acute ischemic stroke (C-LD level evidence, moderately recommended).


(2) Lateral circulation: for patients with ICAS, preoperative evaluation of collateral circulation is beneficial for screening patients with suitable surgery, and patients with poor lateral branch circulation in preoperative imaging assessment may be more suitable for intravascular therapy (C-LD level evidence, moderately recommended).


(3) Individualized endovascular therapy is better benefited from the morphological analysis of the etiology and stenosis of ICAS patients (C-EO level evidence, moderately recommended).

Perioperative management

(1) Perioperative blood pressure management and antiplatelet and anticoagulant therapy applications have not been updated, the same as the 2018 edition
.


(2) The perioperative anesthesia method and complication management have not been updated, the same as the 2018 edition
.

(3) The perioperative application of platelet membrane glycoprotein II.
b/III.
a receptor antagonists may benefit from reducing thrombotic complications, especially in preventing intraoperative acute intrastent thrombosis, but still requires high-level clinical research evidence to confirm (C-LD level evidence, weak recommendation).

Medical pulse from the Neurointerventional Branch of the Chinese Stroke Society.
Chinese Expert Consensus on Intravascular Treatment of Symptomatic Intracranial Atherosclerotic Stenosis 2022[J].
Chinese Journal of Stroke,2022,17(08):863-888.