Dedicated Guidelines for Arterial Dissections: More Specifics Amid Uncertainty
2021; Lippincott Williams & Wilkins; Volume: 53; Issue: 2 Linguagem: Inglês
10.1161/strokeaha.121.037324
ISSN1524-4628
Autores Tópico(s)Acute Ischemic Stroke Management
ResumoHomeStrokeVol. 53, No. 2Dedicated Guidelines for Arterial Dissections: More Specifics Amid Uncertainty Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBDedicated Guidelines for Arterial Dissections: More Specifics Amid Uncertainty Enrique C. Leira Enrique C. LeiraEnrique C. Leira Correspondence to: Enrique C. Leira, MD, MS, 2 RCP; 200 Hawkins Drive, Iowa City, IA 52242. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3695-2946 Department of Neurology, Department of Neurosurgery, Carver College of Medicine and Department of Epidemiology, College of Public Health, University of Iowa, Iowa City. Originally published23 Dec 2021https://doi.org/10.1161/STROKEAHA.121.037324Stroke. 2022;53:e53–e55Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 23, 2021: Ahead of Print The European Stroke Organization (ESO) has recently released a specific guideline for the management of dissections.1 Cervicocephalic dissections are arteriopathies defined by the presence of a hematoma in the arterial wall.2 Dissection is less common than atherosclerosis in the general population, but a main mechanism of stroke in younger patients.2 The widespread use of noninvasive arterial imaging studies contributes to its growing relevance.3,4 Arterial dissections are classified as extracranial and intracranial.1 Both can lead to secondary arterial thrombosis and cerebral ischemia, or compressive local symptoms.5 In addition, intracranial dissections can result in subarachnoid hemorrhage.6 This is the first attempt at a comprehensive guideline dedicated to arterial dissections in stroke. Until now, the recommendations for the management of arterial dissections have been scattered in different documents, including the acute stroke treatment7 and secondary prevention American Stroke Association (ASA) guidelines.8 The ESO guideline by Debette et al used a rigorous methodology that included the GRADE system.9 The format includes a series of 6 management scenarios using the PICO approach (population, intervention, comparator, and outcome) where they provide specific recommendations, as well as a consensus statement from an expert panel (Table).Table 1. Comparison Between the ESO Dissection Guidelines and ASA GuidelinesPICO ESO guidelinesASA acute guidelinesASA secondary prevention guidelinesSafety of r-tPAGeneral agreement: yes for extracranial, uncertainty intracranialN/ASafety thrombectomyN/AN/AEndovascular/surgery of ruptured dissecting aneurysmsN/AN/AIntracranial dissecting aneurysm with isolated headacheN/AN/AAntiplatelets versus anticoagulantsN/AGeneral agreement: both treatments reasonableEndovascular/surgery for ischemic symptomsN/AESO: no evidence-based recommendation, but expert panel could consider intervention. ASA: can be considered if recurrent or progressive symptomsASA indicates American Stroke Association; ESO, European Stroke Organization; PICO, population, intervention, comparison and outcome; and r-tPA, recombinant tissue-type plasminogen activator.The first question addressed pertains to the efficacy and safety of the use of r-tPA (recombinant tissue-type plasminogen activator) for both extracranial and intracranial dissection. Traditionally, this may have not been a relevant question since the diagnosis of a dissection was typically done after initiating r-tPA. But this has changed in the era of thrombectomy where the trend is to have emergent arterial studies at the time of the initial evaluation.10 Theoretically, the concern is that the r-tPA would extend the intramural hematoma and induce a ruptured vessel in these patients. In the case of intracranial dissections, this could result in subarachnoid hemorrhage. In the heat of the emergency setting providers might draw parallels with aortic dissection, which is an established contraindication for r-tPA.11 Despite all these fears, it makes more sense to tackle the actual symptomatic thrombotic process causing cerebral ischemia rather than deferring treatment based on theoretical concerns for vessel rupture. The authors reviewed the limited evidence available regarding this issue and suggest using r-tPA in patients with extracranial dissection. This recommendation is in line with the ASA acute stroke guidelines which states that it is reasonably safe and probably recommended to administer thrombolytics in extracranial dissection (COR IIa, LOE C-LD).7 On the contrary, they did not make a recommendation for patients with intracranial dissection citing a lack of evidence. This also aligns with the ASA acute stroke guidelines which state that the benefit is unknown (COR IIb, LOE C-LD).7 However, the ESO panel made an expert consensus statement suggesting r-tPA should still be considered in these patients.1 This seems reasonable in a scenario where there are theoretical risks that are not necessarily backed by supportive evidence.The second question pertains to the efficacy and safety of mechanical thrombectomy in patients with dissection. Here they contribute a recommendation not directly addressed by the existing ASA guidelines, which only focuses on obtaining proximal neck imaging to screen for dissection to better plan the thrombectomy.7 Since there are not any randomized trials dedicated to this question, most of the evidence stems from single-center retrospective series. Given the overall strong benefit of mechanical thrombectomy on functional outcomes,12 they recommend the use of this intervention for patients with extracranial dissection despite the very low quality of the evidence in this particular population.1The third question addressed is whether an intracranial dissecting aneurysm causing subarachnoid hemorrhage should be addressed with either endovascular or surgical interventions. The recent ASA guidelines for managing subarachnoid hemorrhage did not have enough granularity to address such a specific issue.13 Again, and given that the quality of evidence is very low, the guideline recommends early intervention with either technique, but concludes that there is insufficient data to provide a recommendation on the type of intervention, or its precise timing. The expert consensus suggests a multidisciplinary team assess the choice of intervention.The fourth question addresses the scenario of an intracranial dissecting aneurysm presenting with isolated headache but no cerebrovascular symptoms. This is also a very specific scenario that has not been covered by the ASA guidelines. They concluded that the very low quality of the data suggests uncertainty of whether an endovascular intervention is better than medical treatment. The expert consensus statement was even more conservative, advising against endovascular intervention unless the dissecting aneurysm increases in size or shows signs of compression.1The fifth is the classical dilemma of whether antiplatelets or anticoagulants are more appropriate for symptomatic dissections. As a notable exception in the dissection literature, 2 randomized trials have been done to answer this question. The first one CADISS,14,15 was recognized by the ASA secondary prevention guidelines.8 The recent TREAT-CAD, a trial that did not find aspirin to be noninferior to vitamin K antagonists using a combination of imaging and clinical outcomes, was included for the first time in a guideline.16 Based on these 2 trials, the guideline suggests as a strong recommendation that physicians can prescribe either anticoagulants or antiplatelet therapy. This is also aligned with the ASA secondary prevention guidelines, which beside recommending some form of antithrombotic therapy in these patients,8 state that aspirin or warfarin are both reasonable (COR IIa, LOE B-R) for the first 3 months.8 This recommendation basically endorses the 2 different schools of practice for this issue, which will presumably remain unpersuaded by these trials. It is sad that the only management issue addressed by randomized clinical trials, albeit with limitations, did not result in more definitive recommendations. Perhaps the lack of demonstrated superiority of anticoagulants could have perhaps been an argument to default to the presumably safer antiplatelets agents. Instead, the expert consensus endorses aspects of clinical preventive practice for which there are limited data, such as favoring direct oral anticoagulants over vitamin K antagonists, and the temporary use of double antiplatelets agents.1The sixth and last question was whether endovascular or surgical treatment is indicated over medical treatment alone to address a stenotic vessel or a dissecting aneurysm in the absence of subarachnoid hemorrhage. This is another topic for which no solid evidence exists. Clinical trials are challenging since the overall recurrence rate in these patients is very low.14,16 Still, there are a subset of patients in clinical practice who continue to get worse despite best medical therapy and may benefit from rescue endovascular approaches.17,18 Given the low quality of the evidence, the ESO guideline acknowledges the uncertainty over the risks and benefits of endovascular or surgical treatment, and concludes that is not possible to make a recommendation.1 This is slightly more conservative than the ASA secondary prevention guidelines which weakly (COR 2b C-LD) recommended rescue endovascular intervention in case of recurrent or progressive symptoms.8 The expert consensus is that such interventions could be carefully considered by a multidisciplinary team.Debette at al should be commended for the rigor and thoroughness of this guideline that included international experts from three continents. The data reviewed was extensive for a topic relevant to stroke care that is still plagued with small series and retrospective reviews. One can question the need for having dedicated guidelines for such specific stroke mechanisms. It could be argued that such specialized guidelines could result in duplicity with the main ones. Or worse, in direct contradiction which could lead to confusion. Fortunately, this is not the case. This ESO guideline is well aligned with the general guidelines while addressing new questions not previously covered. Furthermore, integrating all the aspects of stroke management for arterial dissection in one document could result in an easier, single point of information for medical providers who manage all aspects of care of a patient. In summary, this is a valuable addition to the guideline armamentarium. It endorses the growing importance of arterial dissections in stroke management in young adults.4 But also shows the amount of uncertainty regarding this topic, highlighting some knowledge gaps to be targeted by future research.Article InformationSources of FundingNone.DisclosuresDr Leira is a co-author in the American Stroke Association secondary stroke prevention guidelines.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page e55.Correspondence to: Enrique C. Leira, MD, MS, 2 RCP; 200 Hawkins Drive, Iowa City, IA 52242. Email [email protected].eduReferences1. Debette S, mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, et al. Express: eso guideline for the management of extracranial and intracranial artery dissection.Eur Stroke J. 2021; 6:XXXIX–LXXXVIII. doi: 10.1177/23969873211046475Google Scholar2. 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Stroke prevention by endovascular treatment of carotid and vertebral artery dissections.J Neurointerv Surg. 2017; 9:952–957. doi: 10.1136/neurintsurg-2016-012565Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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