Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis-Related Large-Vessel Occlusion: The Rescue-LVO Survey.

Background: We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis-related large-vessel occlusion (ICAS-LVO) during mechanical thrombectomy. Methods: We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28-question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS-LVO. Results: A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS-LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS-LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS-LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS-LVO before mechanical thrombectomy treatment. Conclusions: The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS-LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS-LVO, which can then be incorporated into the design of future randomized clinical trials.