The challenge of basilar artery occlusion wake-up stroke: too late for intravenous thrombolysis?

Background: Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase. The recent Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that increased reperfusion with TNK compared to alteplase prior to endovascular thrombectomy (EVT) in large vessel occlusion ischaemic strokes. However, only 6 patients with basilar artery occlusion (BAO) were included. We aimed to investigate the efficacy of TNK versus alteplase before EVT in patients with basilar artery occlusion (BAO). Methods: Clinical and procedural data of consecutive BAO diagnosed on CT Angiography or MR Angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or absence of retrievable thrombus at the time of the initial angiographic assessment. Results: We included 119 BAO patients treated with intravenous thrombolysis prior to EVT; mean age 68 (SD 14), median NIHSS 16 (IQR 7-32). Eleven patients were treated with TNK (0.25mg/kg or 0.4mg/kg) and 108 with alteplase (0.9mg/kg). Overall, 113 patients had catheter angiography or early repeat imaging after thrombolysis. Reperfusion of greater than 50% of the ischemic territory or absence of retrievable thrombus occurred in 4/11 (36%) of patients treated with TNK vs 8/102 (8%) treated with alteplase (p=0.02). Onset-to-needle time did not differ between the two groups (p=0.4). Needle-to-groin-puncture time was 61 (IQR 33-100) mins in patients reperfused with TNK vs 111 (IQR 86-198) mins in patients reperfused with alteplase (p=0.048). Overall, the rate of symptomatic haemorrhage was 3/119 (2.5%). No differences were found in the rate of symptomatic intracranial haemorrhage (p=0.3) between the two thrombolytic agents. Conclusions: Despite shorter needle-to-groin-puncture times, tenecteplase was associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients before endovascular thrombectomy are warranted.

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Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2020.51 ◽

2020 ◽

Vol 47 (4) ◽

pp. 479-485

Author(s):

Christopher R. Pasarikovski ◽

Houman Khosravani ◽

Leodante da Costa ◽

Chinthaka Heyn ◽

Stefano M. Priola ◽

...

Keyword(s):

Computed Tomography ◽

Functional Outcome ◽

Basilar Artery ◽

Treatment Time ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Posterior Circulation ◽

Basilar Artery Occlusion ◽

Related Complication ◽

Endovascular Thrombectomy

ABSTRACT:Background and Purpose:Large prospective observational studies have cast doubt on the common assumption that endovascular thrombectomy (EVT) is superior to intravenous thrombolysis for patients with acute basilar artery occlusion (BAO). The purpose of this study was to retrospectively review our experience for patients with BAO undergoing EVT with modern endovascular devices.Methods:All consecutive patients undergoing EVT with either a second-generation stent retriever or direct aspiration thrombectomy for BAO at our regional stroke center from January 1, 2013 to March 1, 2019 were included. The primary outcome measure was functional outcome at 1 month using the modified Rankin Scale (mRS) score. Multivariable logistic regression was used to assess the association between patient characteristics and dichotomized mRS.Results:A total of 43 consecutive patients underwent EVT for BAO. The average age was 67 years with 61% male patients. Overall, 37% (16/43) of patients achieved good functional outcome. Successful reperfusion was achieved in 72% (31/43) of cases. The median (interquartile range) stroke onset to treatment time was 420 (270–639) minutes (7 hours) for all patients. The procedure-related complication rate was 9% (4/43). On multivariate analysis, posterior circulation Alberta stroke program early computed tomography score and Basilar Artery on Computed Tomography Angiography score were associated with improved functional outcome.Conclusion:EVT appears to be safe and feasible in patients with BAO. Our finding that time to treatment and successful reperfusion were not associated with improved outcome is likely due to including patients with established infarcts. Given the variability of collaterals in the posterior circulation, the paradigm of utilizing a tissue window may assist in patient selection for EVT. Magnetic resonance imaging may be a reasonable option to determine the extent of ischemia in certain situations.

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Timing of Recanalization After Microbubble-Enhanced Intravenous Thrombolysis in Basilar Artery Occlusion

Stroke ◽

10.1161/strokeaha.107.487454 ◽

2007 ◽

Vol 38 (11) ◽

pp. 2931-2934 ◽

Cited By ~ 22

Author(s):

Jorge Pagola ◽

Marc Ribo ◽

José Alvarez-Sabín ◽

Marcos Lange ◽

Marta Rubiera ◽

...

Keyword(s):

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion

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Intravenous Thrombolysis of Basilar Artery Occlusion

Stroke ◽

10.1161/strokeaha.114.004884 ◽

2014 ◽

Vol 45 (6) ◽

pp. 1733-1738 ◽

Cited By ~ 17

Author(s):

Daniel Strbian ◽

Tiina Sairanen ◽

Heli Silvennoinen ◽

Oili Salonen ◽

Perttu J. Lindsberg

Keyword(s):

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion

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Basilar Artery Occlusion. Clinical Evaluation and Contemporary Methods of Treatment

Clinical Cardiology and Cardiovascular Interventions ◽

10.31579/2641-0419/117 ◽

2021 ◽

Vol 4 (01) ◽

pp. 01-08

Author(s):

Damyan Boychev

Keyword(s):

Basilar Artery ◽

Neurological Diseases ◽

Intravenous Thrombolysis ◽

Mortality Rates ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Threatening Condition ◽

Life Threatening ◽

Methods Of Treatment ◽

Headache And Neck Pain

Acute occlusion of the basilar artery and its branches is a frequent cause of posterior circulation strokes. Although it accounts for only 1 to 3 % of ischemic strokes, it is a potentially life-threatening condition associated with high mortality rates. Exact clinical diagnosis is still challenging because symptoms such as vertigo, dizziness followed by headache, and neck pain are nonspecific and usually attributed to many other neurological diseases. The onset of symptoms can be abrupt or gradual and progressive. Establishing the time of symptoms onset and making a timely diagnosis is highly important. In case the diagnosis is made promptly, ideally with the help of an advanced neuroimaging, intravenous thrombolysis, or catheter-based endovascular treatment can be performed immediately to improve prognosis and reduce mortality.

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Intended Bridging Therapy or Intravenous Thrombolysis Alone in Minor Stroke With Basilar Artery Occlusion

Stroke ◽

10.1161/strokeaha.120.030992 ◽

2021 ◽

Author(s):

Pierre Seners ◽

Cyril Dargazanli ◽

Michel Piotin ◽

Denis Sablot ◽

Serge Bracard ◽

...

Keyword(s):

Propensity Score ◽

Scale Score ◽

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Minor Stroke ◽

Bridging Therapy ◽

Excellent Outcome ◽

Propensity Score Weighting

Background and Purpose: Whether bridging therapy (intravenous thrombolysis [IVT] followed by mechanical thrombectomy) is superior to IVT alone in minor stroke with basilar artery occlusion remains uncertain. Methods: Multicentric retrospective observational study of consecutive minor stroke patients (National Institutes of Health Stroke Scale score ≤5) with basilar artery occlusion intended for IVT alone or bridging therapy. Propensity-score weighting was used to reduce baseline between-groups differences, and residual imbalance was addressed through adjusted logistic regression, with excellent outcome (3-month modified Rankin Scale score 0–1) as the dependent variable. Results: Fifty-seven patients were included (28 and 29 in the bridging therapy and IVT alone groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the 2 patient groups, except age, posterior circulation Alberta Stroke Program Early CT Score, history of hypertension and smoking, and onset-to-IVT time. Compared with IVT alone, bridging therapy was associated with excellent outcome (adjusted odds ratio=3.37 [95% CI, 1.13–10.03]; P =0.03). No patient experienced symptomatic intracranial hemorrhage. Conclusions: Our results suggest that bridging therapy may be superior to IVT alone in minor stroke with basilar artery occlusion.

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Management challenge of basilar artery occlusion in SUS: Case report

10.5327/1516-3180.151 ◽

2021 ◽

Author(s):

Isadora Santos Ferreira ◽

Mauricio Elias Nunes da Silva ◽

Liz Barros Rebouças ◽

Rafael Bernhart Carra ◽

Rene de Araújo Gleizer ◽

...

Keyword(s):

Case Report ◽

Basilar Artery ◽

Intravenous Thrombolysis ◽

Tertiary Hospital ◽

Artery Occlusion ◽

Neurological Deficits ◽

Basilar Artery Occlusion ◽

High Morbidity ◽

Basilar Artery Thrombosis ◽

The Right

Context: Stroke caused by basilar artery occlusion is rare, corresponding to 1% of strokes. There is no consensus in the literature on the ideal management of this disease at acute phase. However, mechanical thrombectomy may be a viable treatment option. Case report: 68-year-old female, with no comorbidities, admitted to a secondary hospital 14h after headache, dizziness, vomiting and difficulty walking. She was disoriented, with severe dysarthria and dysphonia, horizontal and vertical ophthalmoparesis and pronation of the right upper limb (NIHSS: 4). Cranial tomography was normal and cranial angiotomography showed a basilar artery thrombosis. Patient was out of the window for intravenous thrombolysis and our hospital did not have another possibility of treatment. Due to high morbidity and mortality, also the possibility of neurological deterioration, medical contact was made with a tertiary hospital with hemodynamic service. During patient transference, she evolved with decreased level of consciousness, aphasia and tetraparesis (NIHSS: 18). Upon arrival at the hospital, a thrombectomy was performed due to an important clinical-radiological mismatch, 19 hours within symptoms onset and 3 hours after neurological worsening. After discharge, patient walked with assistance and physical examination showed a significant improvement in neurological deficits (NIHSS: 6). Conclusions: This case demonstrates the importance of engaging Brazil’s public health system in the management of acute ischemic stroke, especially in challenging cases such as basilar artery occlusion. This patient was the first admitted to our hospital to perform a thrombectomy after effective transference for a tertiary hospital and staff engagement of both hospitals.

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OPL106 Therapy of basilar artery occlusion — a systematic analysis comparing intraarterial and intravenous thrombolysis

Journal of the Neurological Sciences ◽

10.1016/s0022-510x(05)80282-5 ◽

2005 ◽

Vol 238 ◽

pp. S73

Keyword(s):

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Systematic Analysis

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Tenecteplase Versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

Neurology ◽

10.1212/wnl.0000000000011520 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011520

Author(s):

Fana Alemseged ◽

Felix C Ng ◽

Cameron Williams ◽

Volker Puetz ◽

Gregoire Boulouis ◽

...

Keyword(s):

Basilar Artery ◽

Endovascular Therapy ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Class Iii ◽

Endovascular Thrombectomy ◽

Randomized Controlled ◽

Symptomatic Intracranial Hemorrhage

Objective:To investigate the efficacy of tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, prior to endovascular thrombectomy (EVT) in patients with basilar artery occlusion (BAO).Methods:To determine whether tenecteplase is associated with better reperfusion rates than alteplase prior to EVT in BAO, clinical and procedural data of consecutive BAO patients from the Basilar Artery Treatment and MANagement (BATMAN) registry and the Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial were retrospectively analyzed. Reperfusion >50% or absence of retrievable thrombus at the time of the initial angiogram was evaluated.Results:We included 110 BAO patients treated with intravenous thrombolysis prior to EVT [mean age 69(SD 14); median NIHSS 16(IQR 7-32)]. Nineteen patients were thrombolysed with TNK (0.25mg/kg or 0.40mg/kg) and 91 with alteplase (0.9mg/kg). Reperfusion>50% occurred in 26% (n=5/19) of patients thrombolysed with TNK vs 7% (n=6/91) thrombolysed with alteplase (RR 4.0 95%CI 1.3-12; p=0.02), despite shorter thrombolysis-to-arterial-puncture time in the TNK-treated patients (48[IQR 40-71]mins) vs alteplase-treated patients (110[IQR 51-185]mins, p=0.004). No difference in symptomatic intracranial hemorrhage was observed (0/19(0%) TNK, 1/91(1%) alteplase, p=0.9).Conclusions:Tenecteplase may be associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients are warranted.Classification of evidence:This study provides Class III evidence that tenecteplase leads to higher reperfusion rates in comparison with alteplase prior to EVT in BAO patients.

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