Impact of the Perioperative Blood Pressure on Clinical Outcome after Thrombectomy in Acute Basilar Artery Occlusion

Background and purposeTo determine the initial factors, including patient characteristics, stroke etiology and severity, time factors, and imaging findings, that could affect the clinical outcome of patients with acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) where successful recanalization was achieved via mechanical thrombectomy.MethodsBetween March 2011 and December 2014, 35 patients with AIS caused by BAO received MRI/MR angiography-based mechanical thrombectomies, and recanalization was achieved with a Thrombolysis In Cerebral Infarction score of >2b. The patients were divided into a good outcome group (n=19), defined as those with a modified Rankin Scale (mRS) score of 0–2 at 3 months after stroke onset, and a poor outcome group (n=16), defined as a mRS score of 3–6. The differences between the groups were analyzed.ResultsInitial National Institutes of Health Stroke Scale (NIHSS) score (good vs poor: 17.9±8.9 vs 27.6±8.5, p=0.003), posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) based on initial diffusion-weighted images (DWI) (good vs poor: 7.8±1.6 vs 5.4±1.8, p=0.001), pc-ASPECTS based on contrast staining on the post-thrombectomy control CT (good vs poor: 9.2±1.5 vs 6.3±2.2, p<0.001), and presence of contrast staining in the brainstem on that CT (good vs poor: 15.8% vs 81.6%, p<0.001) were significantly different between the groups.ConclusionsPatients with AIS caused by BAO with a lower initial NIHSS score, fewer lesions on initial DWI, and less contrast staining on the post-thrombectomy control CT have higher probabilities of a good clinical outcome after successful recanalization via a mechanical thrombectomy.

Download Full-text

Abstract 1122‐000068: Basilar Artery Occlusion Thrombectomy Between Evidence Based Medicine and the Real‐World Practice, Single Centre Experience

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000068 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Islam El Malky ◽

Ali Hendi ◽

Hazem Abdelkhalek

Keyword(s):

Clinical Outcome ◽

Intracranial Hemorrhage ◽

Basilar Artery ◽

Real World ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Early Reperfusion ◽

Good Outcome ◽

Symptomatic Intracranial Hemorrhage ◽

Multiple Variables

Introduction : BAO (basilar artery occlusion) is well known by catastrophic outcomes whether death or disability in approximately 70 %. 1 Thrombectomy as an intervention in large vessel occlusion of anterior proximal circulation was approved after multiple RCTs and meta‐analyses. 2 In spite of two RCTs that appeared lately, there is still uncertainty about the effect of thrombectomy in BAO. 9, 10 Our study aims to report the outcome of BAO, as a further clue of MT effectiveness in BAO and variables affecting good outcome and mortality rate. Methods : We retrospectively collected the clinical and radiological data of 30 BAO patients treated in our center between 2016 and 2020. There is no limitation as regard age or presenting NIHHS. Twenty‐two patients who came to the emergency within 4.5 hours had I.V. thrombolytic therapy (73.3%). A favorable clinical outcome was considered if mRS ≤ 2. Angioplasty, stenting, or I.A thrombolysis were used as a rescue treatment. Symptomatic intracranial hemorrhage within two days after the initiation of treatment and mortality at 90 days were reported. The radiological outcome was assessed by modified Thrombolysis in Cerebral Infarction (mTICI) score where mTICI ≥ 2b or 3 at the end of the intervention was considered a favorable radiological result. Multiple variables were tested for their effect on favorable clinical outcomes and mortality (Table 1). Results : Among 30 patients, the mean age was 61.23 ± 16.81 years; 20/30 (66.7%) male. A favorable functional outcome was achieved in (40.7%). Successful revascularization was achieved in 26 patients (86.7 %). Four patients had procedural complications (13.3%). Symptomatic intracranial hemorrhage occurred in three cases (11%) and mortality at 90 days was 11 patients (36.7 %). The presenting NIHSS is the only predictor of mortality and the optimal cut‐off value for death was 15 with AUC = 0.758 (sensitivity 91 % and specificity 59%) and p‐value = 0.02. TOR (time of onset to recanalization) had no effect on the clinical outcome which is controversy with the paradigm of early reperfusion leading to a good outcome Conclusions : In spite of two RCSs approved no statistical difference between medical treatment and thrombectomy, thrombectomy is still an effective procedure in real‐world practice in selected cases. The presenting NIHSS is the only predictor of mortality in our studies. More studies are warranted to discover other predictors of BAO thrombectomy outcome to improve case selection and avoid futile recanalization.

Download Full-text

Abstract WP26: Improved Clinical Outcome of Acute Basilar Artery Occlusion Since Introduction of Endovascular Thrombectomy Devices

Stroke ◽

10.1161/str.44.suppl_1.awp26 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Peter A Ringleb ◽

Lars Kellert ◽

Markus Moehlenbruch ◽

Simon Nagel ◽

Julian Boesel ◽

...

Keyword(s):

Clinical Outcome ◽

Functional Outcome ◽

Basilar Artery ◽

Treatment Strategies ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Good Clinical Outcome ◽

Entire Cohort ◽

Before And After ◽

Common Clinical Practice

Background: Survival and functional outcome of patients with acute basilar artery occlusion (BAO) are highly dependent on vessel recanalization. Therefore intra-arterial thrombolysis is recommended in international guidelines. For several years, thrombectomy-devices are used for intra-arterial therapy. We analyzed if the use of those devices modified the outcome of patients with BAO in our institution. Method: Retrospective analysis of prospectively collected data on consecutive patients with acute BAO since 1998. In July 2009 for the first time a thrombectomy device was used in a patient with BAO. Thereafter the cohort was split into two chronological groups. All patients were treated at a dedicated neurological ICU following institutional SOPs. Functional outcome was assessed three months after treatment using the modified Rankin Scale (mRS); good clinical outcome was defined as mRS 0-2. Symptomatic intracranial hemorrhage (sICH) was defined as intracranial blood on follow-up imaging up to 36 hours after treatment associated with clinical worsening of at least 4 points of the NIHSS or leading to death. Results: From the entire cohort of N=124 patients, n=91 patients were treated before and n=33 after July 2009. A “bridging concept” (i.e. IVT + IAT) was applied in 20% vs. 64% of the patients before and after July 2009, respectively. Complete recanalization (TICI 3) was achieved in 45% before and 77% after July 2009 (p=0.005). SICH occurred in 7% of the earlier and 3% of the later cohort (p=0.67); good clinical outcome was observed in 10% of the earlier and 33% of the later cohort (p=0.004); mortality was 57% in the earlier and 30% in the later group (p=0.01). After adjustment for baseline imbalances (proportion of patients with previous stroke, time until first treatment) the differences remained significant for good clinical outcome (OR 3.86; 95%CI 1.27 - 11.7; p=0.017) and mortality (OR 0.38; 95%CI 0.15-0.99; p=0.047). Conclusion: Modern thrombectomy-devices as well as the increased use of bridging approaches for treatment of BAO have significantly improved good clinical outcome and attenuated mortality. Especially in patients with BAO - where endovascular treatment strategies are common clinical practice - those devices should be used more frequently.

Download Full-text

Blood pressure characteristics in patients with acute basilar artery occlusion undergoing endovascular thrombectomy

Scientific Reports ◽

10.1038/s41598-019-49769-8 ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Slaven Pikija ◽

Katharina Millesi ◽

Monika Killer-Oberpfalzer ◽

J. Sebastian Mutzenbach ◽

Laszlo K. Sztriha ◽

...

Keyword(s):

Blood Pressure ◽

Basilar Artery ◽

Reference Value ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Good Outcome ◽

Frequent Use ◽

Life Threatening ◽

Lowering Drug ◽

The Individual

Abstract Acute basilar artery occlusion (BAO) is a rare but potentially life-threatening neurological condition. While endovascular therapy (EVT) has been shown to improve outcome, there is limited knowledge about prognostic factors beyond early recanalization. We studied whether blood pressure (BP) exceeds or falls below suggested thresholds during intervention and whether these changes are associated with complications and outcome. BP measurements mostly with one-minute intervals were available in 39 patients. An individual systolic blood pressure (SBP) reference value was defined as the median of the first five intra-procedural measurements. Half of the patients (51.3%) received drugs for BP augmentation and two a BP lowering drug (5.1%). Thrombolysis in cerebral infarction grade 2b and 3 (TICI) was achieved in 29 (74.4%) and 23 patients (58.9%) had good outcome at three months. We observed a continuous intra-procedural increase of median SBP (+11%) and mean arterial pressure (MAP, +10%, both p < 0.001), and a unique temporal pattern of intermittent peaks and troughs. Successful recanalization was more common in patients whose intra-procedural duration with SBP under 140 mmHg was shorter (p = 0.009). Patients with isolated tip of basilar artery (TBA) occlusion had significantly more BP excursion of 20% below the reference SBP and required more frequent use of sympathomimetic drugs compared to vertebrobasilar occlusion (p = 0.008 and p = 0.041, respectively). Brain hemorrhage was more prevalent in patients who experienced SBP excursions at least 20% above the individual reference value (p = 0.038) and a longer duration of time spent with SBP above 180 mmHg (p = 0.029). Patients with higher pre-procedural mean SBP had a greater chance of a good outcome (p = 0.03). This study using high resolution BP monitoring suggests a relationship between intra-procedural BP characteristics and recanalization, hemorrhagic complications and outcome in patients receiving EVT for acute posterior circulation cerebrovascular syndromes. Differences with regard to BP regulation during recanalization therapy for vertebrobasilar and TBA occlusion deserves further attention.

Download Full-text

Mechanical Thrombectomy in Subtypes of Basilar Artery Occlusion: Relationship to Recanalization Rate and Clinical Outcome

Radiology ◽

10.1148/radiol.2019181924 ◽

2019 ◽

Vol 291 (3) ◽

pp. 730-737 ◽

Cited By ~ 13

Author(s):

Sung Hyun Baik ◽

Hyung Jong Park ◽

Jun-Hwee Kim ◽

Chang Ki Jang ◽

Byung Moon Kim ◽

...

Keyword(s):

Clinical Outcome ◽

Basilar Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Basilar Artery Occlusion

Download Full-text

Improved Clinical Outcome after Acute Basilar Artery Occlusion since the Introduction of Endovascular Thrombectomy Devices

Cerebrovascular Diseases ◽

10.1159/000356185 ◽

2013 ◽

Vol 36 (5-6) ◽

pp. 394-400 ◽

Cited By ~ 28

Author(s):

S. Nagel ◽

L. Kellert ◽

M. Möhlenbruch ◽

J. Bösel ◽

S. Rohde ◽

...

Keyword(s):

Clinical Outcome ◽

Basilar Artery ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Endovascular Thrombectomy

Download Full-text

Treatment and Clinical Outcome in Patients With Basilar Artery Occlusion

Stroke ◽

10.1161/01.str.0000237127.84408.c0 ◽

2006 ◽

Vol 37 (9) ◽

pp. 2206-2206 ◽

Cited By ~ 6

Author(s):

Wouter Schonewille ◽

Christine Wijman ◽

Patrik Michel

Keyword(s):

Clinical Outcome ◽

Basilar Artery ◽

Artery Occlusion ◽

Basilar Artery Occlusion

Download Full-text

ADC quantification in basilar artery occlusion as an indicator of clinical outcome after endovascular treatment

The Neuroradiology Journal ◽

10.1177/1971400917706197 ◽

2017 ◽

Vol 30 (6) ◽

pp. 586-592 ◽

Cited By ~ 3

Author(s):

Daniela Pereira ◽

Isabel Fragata ◽

José Amorim ◽

João Reis

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Basilar Artery ◽

Rank Correlation ◽

Clinical Results ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Strongly Correlated ◽

Ischemic Area ◽

Dismal Prognosis

Background Acute ischemic stroke due to basilar artery occlusion (BAO) is associated with a dismal prognosis and, even though endovascular treatment (EVT) contributed to an improvement in clinical outcomes, patient selection is difficult and frequently results in futile recanalization. We investigated the prognostic value of baseline ADC quantification in patients with BAO undergoing EVT. Methods We retrospectively evaluated MRI at admission in 11 patients with BAO undergoing EVT. Ischemic lesions were defined on baseline DWI and minimum ADC (minADC), ADC ratio and total area were quantified. Final infarction area was determined on follow-up T2WI/CT. We assessed the correlation between imaging parameters, recanalization grade and clinical scores (NIHSS at admission, NIHSS and mRS at discharge and mRS at three months) using Spearman rank correlation coefficient and correcting for multiple comparisons with the false discovery rate (FDR). Results Lower values of minADC at admission MRI are strongly correlated with higher scores in NIHSS (rs = −0.845, p = 0.001) and mRS at discharge (rs = −0.743, p = 0.009). We also found a negative correlation between minADC and NIHSS at admission (rs = −0.67, p = 0.02), mRS at three months and difference between pre- and post-treatment ischemic area (rs = −0.664, p = 0.026) that lost significance with FDR correction. Ischemic area and TICI grade were not significantly associated with clinical results. Conclusions ADC quantification of ischemic lesions at baseline MRI seems to predict clinical outcome in patients with BAO undergoing EVT, more importantly than ischemic area or TICI grade.

Download Full-text