Periprocedural management of patients with endovascular treatment of intracranial atherosclerotic disease.
Clinical outcome in endovascular therapy of intracranial atherosclerosis with stenting and angioplasty or angioplasty alone is dependent on multiple other factors beside the procedure itself. Preprocedure combined antiplatelet administration of aspirin and clopidogrel and its duration is critical. Preferably, this should be administered 5-7 days prior to the intended procedure and 90 days after the stent placement is preferred. Anticoagulation during the procedure is implemented routinely in the neurointerventional labs during intracranial intervention, with a goal of activated clotting time between 250 to 300 seconds. The preferred agent is unfractionated heparin as an intravenous bolus of 70-80 units/kg, without postprocedure reversal in most cases. Control of blood pressure intraprocedure and in the neurointensive care unit to avoid intracranial hemorrhage and hyperperfusion injury is of paramount significance. The preferred blood pressure is not well known, but lowering the blood pressure below the baseline after luminal gain with stenting would be recommended to prevent secondary injury. The use of general anesthesia versus local and monitored awake anesthesia is controversial and there are no data to support one method over another in cases of intracranial atherosclerosis interventional and endovascular therapy. If the patient is cooperative and would be able to tolerate the procedure under awake anesthesia, the latter would provide an immediate assessment of the neurological outcome and feedback from the patient. However, general anesthesia would provide the interventionalist with less movement artifact and less road mapping need and immediate and accurate assessment of the location of the microwire, catheter, and stent.
Zaidat
Osama O
OO
Medical College of Wisconsin / Froedtert Hospital, Milwaukee, Wisconsin 53226, USA. szaidat@mcw.edu
D001921:Brain / Q000601:surgery; D006801:Humans; D002537:Intracranial Arteriosclerosis / Q000188:drug therapy* / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011182:Postoperative Care; D011300:Preoperative Care; D015607:Stents
D010975:Platelet Aggregation Inhibitors