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A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy

  • Interventional Neuroradiology
  • Published:
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A Correction to this article was published on 14 June 2021

This article has been updated

Abstract

Purpose

There is little data and lack of consensus regarding antiplatelet management for intracranial stenting due to underlying intracranial atherosclerosis in the setting of endovascular treatment (EVT). In this DELPHI study, we aimed to assess whether consensus on antiplatelet management in this situation among experienced experts can be achieved, and what this consensus would be.

Methods

We used a modified DELPHI approach to address unanswered questions in antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. An expert-panel (19 neurointerventionalists from 8 countries) answered structured, anonymized on-line questionnaires with iterative feedback-loops. Panel-consensus was defined as agreement ≥ 70% for binary closed-ended questions/≥ 50% for closed-ended questions with > 2 response options.

Results

Panel members answered a total of 5 survey rounds. They acknowledged that there is insufficient data for evidence-based recommendations in many aspects of antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. They believed that antiplatelet management should follow a standardized regimen, irrespective of imaging findings and reperfusion quality. There was no consensus on the timing of antiplatelet-therapy initiation. Aspirin was the preferred antiplatelet agent for the peri-procedural period, and oral Aspirin in combination with a P2Y12 inhibitor was the favored postprocedural regimen.

Conclusion

Data on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT are limited. Panel-members in this study achieved consensus on postprocedural antiplatelet management but did not agree upon a preprocedural and intraprocedural antiplatelet regimen. Further prospective studies to optimize antiplatelet regimens are needed.

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References

  1. C D (2018) How to train your oracle: the Delphi method and its turbulent youth in operations research and the policy sciences. Soc Stud Sci 48:846–868. https://doi.org/10.1177/0306312718798497

    Article  Google Scholar 

  2. Filippi M, Rocca MA, Ciccarelli O, De Stefano N, Evangelou N, Kappos L, Rovira A, Sastre-Garriga J, Tintore M, Frederiksen JL, Gasperini C, Palace J, Reich DS, Banwell B, Montalban X, Barkhof F, Group MS (2016) MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines. Lancet Neurol 15(3):292–303. https://doi.org/10.1016/S1474-4422(15)00393-2

    Article  PubMed  PubMed Central  Google Scholar 

  3. Meves SH, Neubauer H, Overbeck U, Endres HG (2011) Is there an ideal way to initiate antiplatelet therapy with aspirin? A crossover study on healthy volunteers evaluating different dosing schemes with whole blood aggregometry. BMC Res Notes 4:106. https://doi.org/10.1186/1756-0500-4-106

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Baek JH, Kim BM, Heo JH, Kim DJ, Nam HS, Kim YD (2018) Outcomes of endovascular treatment for acute intracranial atherosclerosis-related large vessel occlusion. Stroke 49(11):2699–2705. https://doi.org/10.1161/STROKEAHA.118.022327

    Article  PubMed  Google Scholar 

  5. Chang Y, Kim BM, Bang OY, Baek JH, Heo JH, Nam HS, Kim YD, Yoo J, Kim DJ, Jeon P, Baik SK, Suh SH, Lee KY, Kwak HS, Roh HG, Lee YJ, Kim SH, Ryu CW, Ihn YK, Kim B, Jeon HJ, Kim JW, Byun JS, Suh S, Park JJ, Lee WJ, Roh J, Shin BS, Kim JM (2018) Rescue stenting for failed mechanical thrombectomy in acute ischemic stroke: a multicenter experience. Stroke 49(4):958–964. https://doi.org/10.1161/STROKEAHA.117.020072

    Article  PubMed  Google Scholar 

  6. Nappini S, Limbucci N, Leone G, Rosi A, Renieri L, Consoli A, Laiso A, Valente I, Rosella F, Rosati R, Mangiafico S (2019) Bail-out intracranial stenting with Solitaire AB device after unsuccessful thrombectomy in acute ischemic stroke of anterior circulation. J Neuroradiol 46(2):141–147. https://doi.org/10.1016/j.neurad.2018.05.004

    Article  PubMed  Google Scholar 

  7. Woo HG, Sunwoo L, Jung C, Kim BJ, Han MK, Bae HJ, Bae YJ, Choi BS, Kim JH (2018) Feasibility of permanent stenting with solitaire FR as a rescue treatment for the reperfusion of acute intracranial artery occlusion. AJNR Am J Neuroradiol 39(2):331–336. https://doi.org/10.3174/ajnr.A5477

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Kim KS, Fraser JF, Grupke S, Cook AM (2018) Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg 129(4):890–905. https://doi.org/10.3171/2017.5.JNS162307

    Article  CAS  PubMed  Google Scholar 

  9. Thompson BG, Brown RD Jr, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES Jr, Duckwiler GR, Harris CC, Howard VJ, Johnston SC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J, American Heart Association Stroke Council CoC, Stroke N, Council on E, Prevention, American Heart A, American Stroke A (2015) Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 46(8):2368–2400. https://doi.org/10.1161/STR.0000000000000070

    Article  PubMed  Google Scholar 

  10. Adeeb N, Griessenauer CJ, Foreman PM, Moore JM, Shallwani H, Motiei-Langroudi R, Alturki A, Siddiqui AH, Levy EI, Harrigan MR, Ogilvy CS, Thomas AJ (2017) Use of platelet function testing before pipeline embolization device placement: a multicenter cohort study. Stroke 48(5):1322–1330. https://doi.org/10.1161/STROKEAHA.116.015308

    Article  PubMed  Google Scholar 

  11. Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Hanel RA, Kallmes DF (2015) Platelet testing is associated with worse clinical outcomes for patients treated with the pipeline embolization device. AJNR Am J Neuroradiol 36(11):2090–2095. https://doi.org/10.3174/ajnr.A4411

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgments

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Funding

There was no funding for this manuscript.

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Authors and Affiliations

  1. Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, Calgary, AB, T2N2T9, Canada

    Mayank Goyal

  2. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation

    Kirill Orlov

  3. Departments of Neurological Surgery, Radiology and Medical Imaging, UVA Health, Charlottesville, VA, USA

    Mary E. Jensen

  4. Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

    Allan Taylor

  5. Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands

    Charles Majoie

  6. Departments of Diagnostic Imaging, Neurology and Neurosurgery Warren Alpert School of Medicine at Brown University, Providence, RI, USA

    Mahesh Jayaraman

  7. Department of Neurosurgery, Changhai Hospital Naval Medical University, Shanghai, China

    Jianmin Liu & Pengfei Yang

  8. Department of Neurosurgery, CHU de Québec, Quebec City, Canada

    Geneviève Milot

  9. Department of Interventional Neuroradiology, Karolinksa Hospital, Stockholm, Sweden

    Patrick Brouwer

  10. University NeuroVascular Center ‘UNVC’, Leiden University Medical Center, Haaglanden Medical Center, Leiden, Netherlands

    Patrick Brouwer

  11. Department of Neurosurgery, Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya, Hyogo, Japan

    Shinichi Yoshimura

  12. Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA

    Felipe Albuquerque

  13. Department of Neurosurgery, Semmes-Murphey Clinic/ University of TN, Memphis, TN, USA

    Adam Arthur

  14. Department of Radiology, Mayo Clinic, Rochester, USA

    David Kallmes

  15. Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan

    Nobuyuki Sakai

  16. Departments of Neurosurgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington, KY, USA

    Justin F. Fraser

  17. Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA

    Raul Nogueira

  18. Department of Neuroradiology, University Hospital Bonn, Bonn, Germany

    Franziska Dorn

  19. WFITN, Paris, France

    Lucie Thibault

  20. Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Jens Fiehler

  21. Department of Neuroradiology, Alfred Krupp Krankenhaus Essen, Essen, Germany

    René Chapot

  22. Department of Clinical Neurosciences, University of Calgary, Calgary, Canada

    Johanna Maria Ospel

  23. Department of Neuroradiology, University Hospital of Basel, Basel, Switzerland

    Johanna Maria Ospel

Authors
  1. Mayank Goyal
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  2. Kirill Orlov
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  3. Mary E. Jensen
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  4. Allan Taylor
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  5. Charles Majoie
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  6. Mahesh Jayaraman
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  7. Jianmin Liu
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  8. Geneviève Milot
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  9. Patrick Brouwer
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  10. Shinichi Yoshimura
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  11. Felipe Albuquerque
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  12. Adam Arthur
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  13. David Kallmes
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  14. Nobuyuki Sakai
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  15. Justin F. Fraser
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  16. Raul Nogueira
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  17. Pengfei Yang
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  18. Franziska Dorn
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  19. Lucie Thibault
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  20. Jens Fiehler
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  21. René Chapot
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  22. Johanna Maria Ospel
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Corresponding author

Correspondence to Mayank Goyal.

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Conflict of interest

Johanna Ospel is supported by the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation and Freiwillige Akademische Gesellschaft Basel. Mayank Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, Mentice. The remaining authors have nothing to disclose.

Ethical approval

For this type of study, approval from an ethics board is not required since no patient data were used. All participants gave their consent prior to answering the survey questions.

Informed consent

Since the study did not involve patients, formal consent from patients is not required.

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Goyal, M., Orlov, K., Jensen, M.E. et al. A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy. Neuroradiology 63, 627–632 (2021). https://doi.org/10.1007/s00234-020-02556-z

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  • DOI: https://doi.org/10.1007/s00234-020-02556-z

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