Bridging versus direct endovascular therapy in basilar artery occlusion

2021 ◽  
pp. jnnp-2020-325328
Author(s):  
Sergio Nappini ◽  
Francesco Arba ◽  
Giovanni Pracucci ◽  
Valentina Saia ◽  
Danilo Caimano ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Basilar Artery ◽  
Endovascular Therapy ◽  
Recombinant Tissue Plasminogen Activator ◽  
Artery Occlusion ◽  
Lower Mortality ◽  
Basilar Artery Occlusion ◽  
Bridging Therapy ◽  
Procedural Complications

BackgroundWe evaluated safety and efficacy of intravenous recombinant tissue Plasminogen Activator plus endovascular (bridging) therapy compared with direct endovascular therapy in patients with ischaemic stroke due to basilar artery occlusion (BAO).MethodsFrom a national prospective registry of endovascular therapy in acute ischaemic stroke, we selected patients with BAO. We compared bridging and direct endovascular therapy evaluating vessel recanalisation, haemorrhagic transformation at 24–36 hours; procedural complications; and functional outcome at 3 months according to the modified Rankin Scale. We ran logistic and ordinal regression models adjusting for age, sex, National Institutes of Health Stroke Scale (NIHSS), onset-to-groin-puncture time.ResultsWe included 464 patients, mean(±SD) age 67.7 (±13.3) years, 279 (63%) males, median (IQR) NIHSS=18 (10–30); 166 (35%) received bridging and 298 (65%) direct endovascular therapy. Recanalisation rates and symptomatic intracerebral haemorrhage were similar in both groups (83% and 3%, respectively), whereas distal embolisation was more frequent in patients treated with direct endovascular therapy (9% vs 3%; p=0.009). In the whole population, there was no difference between bridging and direct endovascular therapy regarding functional outcome at 3 months (OR=0.79; 95% CI=0.55 to 1.13). However, in patients with onset-to-groin-puncture time ≤6 hours, bridging therapy was associated with lower mortality (OR=0.53; 95% CI=0.30 to 0.97) and a shift towards better functional outcome in ordinal analysis (OR=0.65; 95% CI=0.42 to 0.98).ConclusionsIn ischaemic stroke due to BAO, when endovascular therapy is initiated within 6 hours from symptoms onset, bridging therapy resulted in lower mortality and better functional outcome compared with direct endovascular therapy.

Age and discharge modified Rankin score are associated with 90-Day functional outcome after basilar artery occlusion treated with endovascular therapy

2021 ◽  
pp. 159101992098704
Author(s):  
Rahul R Karamchandani ◽  
Dale Strong ◽  
Jeremy B Rhoten ◽  
Tanushree Prasad ◽  
Jacob Selig ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Basilar Artery ◽  
Endovascular Therapy ◽  
Univariate Analysis ◽  
Prognostic Indicator ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Multivariable Logistic Regression Analysis ◽  
Stroke Registry ◽  
Good Outcome

Introduction Prognostic factors for functional outcome after basilar artery occlusion (BAO) treated with modern endovascular therapy (EVT) are sparse. We investigated the association between clinical characteristics, readily available imaging variables, and outcome in BAO patients treated with EVT. Methods Retrospective analysis from a large healthcare system’s prospectively collected code stroke registry of acute BAO patients treated with EVT between January 2017–January 2020. The primary outcome measure was a favorable 90-day modified Rankin score (mRS) of 0-2. Results 65 patients (median age 67 years, 57% male, median NIHSS 16) met the study inclusion criteria. Thrombolysis in Cerebral Infarction (TICI) 2 b-3 revascularization was achieved in 57/65 patients (88%) with a median time to revascularization of 445 minutes [IQR 302-840]. Ninety-day good outcome was seen in 35% (23/65) of patients. In a univariate analysis, age, history of ischemic stroke, baseline NIHSS, BAO site, and discharge mRS were associated with significant differences between the good and poor outcome groups. A multivariable logistic regression analysis demonstrated an independent association with 90-day good outcome and younger age (per 1-year, OR 0.79, 95% CI 0.64, 0.98) and good discharge mRS (0-2) (OR > 999.99, 95% CI 13.26, > 999.99). Conclusions Patients presenting with an acute BAO treated with modern EVT have a good 90-day outcome in over one-third of cases. Age and discharge mRS are independently associated with good 90-day outcome. Additional studies may focus on factors that can enhance discharge function after BAO, a novel prognostic indicator for favorable 90-day outcome in our study.

Dominant vertebral artery status and functional outcome after endovascular therapy of symptomatic basilar artery occlusion

2017 ◽  
Vol 44 (2) ◽  
pp. 151-157 ◽  
Author(s):  
Jun Young Chang ◽  
Seunguk Jung ◽  
Cheolkyu Jung ◽  
Hee-Joon Bae ◽  
Oki Kwon ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Functional Outcome ◽  
Basilar Artery ◽  
Endovascular Therapy ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion

scholarly journals Extent of Hypoattenuation on CT Angiography Source Images in Basilar Artery Occlusion

Stroke ◽  
2011 ◽  
Vol 42 (12) ◽  
pp. 3454-3459 ◽  
Author(s):  
Volker Puetz ◽  
Andrei Khomenko ◽  
Michael D. Hill ◽  
Imanuel Dzialowski ◽  
Patrik Michel ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Ct Angiography ◽  
Basilar Artery ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Favorable Outcome ◽  
Basilar Artery Occlusion ◽  
Modified Rankin Scale ◽  
Scale Scores

Background and Purpose— The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) quantifies the extent of early ischemic changes in the posterior circulation with a 10-point grading system. We hypothesized that pc-ASPECTS applied to CT angiography source images predicts functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). Methods— BASICS was a prospective, observational registry of consecutive patients with acute symptomatic basilar artery occlusion. Functional outcome was assessed at 1 month. We applied pc-ASPECTS to CT angiography source images of patients with CT angiography for confirmation of basilar artery occlusion. We calculated unadjusted and adjusted risk ratios (RRs) of pc-ASPECTS dichotomized at ≥8 versus <8. Primary outcome measure was favorable outcome (modified Rankin Scale scores 0–3). Secondary outcome measures were mortality and functional independence (modified Rankin Scale scores 0–2). Results— Of 158 patients included, 78 patients had a CT angiography source images pc-ASPECTS ≥8. Patients with a pc-ASPECTS ≥8 more often had a favorable outcome than patients with a pc-ASPECTS <8 (crude RR, 1.7; 95% CI, 0.98–3.0). After adjustment for age, baseline National Institutes of Health Stroke Scale score, and thrombolysis, pc-ASPECTS ≥8 was not related to favorable outcome (RR, 1.3; 95% CI, 0.8–2.2), but it was related to reduced mortality (RR, 0.7; 95% CI, 0.5–0.98) and functional independence (RR, 2.0; 95% CI, 1.1–3.8). In post hoc analysis, pc-ASPECTS dichotomized at ≥6 versus <6 predicted a favorable outcome (adjusted RR, 3.1; 95% CI, 1.2–7.5). Conclusions— pc-ASPECTS on CT angiography source images independently predicted death and functional independence at 1 month in the CT angiography subgroup of patients in the BASICS registry.

scholarly journals A Simplified NIH Stroke Scale for Acute Basilar Artery Occlusion Treated with Endovascular Therapy

2020 ◽  
Author(s):  
Xu Tong ◽  
Jiayi An ◽  
Raynald Liu ◽  
Xuan Sun ◽  
Feng Gao ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Endovascular Therapy ◽  
Interobserver Reliability ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Favorable Outcome ◽  
Basilar Artery Occlusion ◽  
Predictive Tool ◽  
Assessment Time ◽  
Stroke Center

Abstract Background To design a simplified NIH Stroke Scale (sNIHSS) that requires minimal training but can reflect acute basilar artery occlusion (BAO) severity and is predictive for the 90-day outcome after endovascular therapy (EVT). Methods We analyzed the prospectively gathered data of acute BAO treated with EVT in a tertiary stroke center during a 6-year period. The sNIHSS (range: 0 to 20 points) consisted of 4 NIHSS items: level of consciousness - (1) questions and (2) commands; motor function - (3) arms and (4) legs. The 90-day outcomes included functional independence (mRS ≤ 2), favorable outcome (mRS ≤ 3) and death. Results Of 173 patients, 62, 83 and 36 achieved functional independence, favorable outcome and death, respectively. Interobserver reliability of sNIHSS was high (ICC = 0.95), and compared with NIHSS, sNIHSS had a significant reduction of assessment time (median: 1.5 min vs. 5 min, P < 0.01). A multivariable logistic model demonstrated that sNIHSS was independently associated with functional independence (OR = 0.82, 95% CI = 0.77-0.87), favorable outcome (OR = 0.86, 95% CI = 0.81-0.92) and death (OR = 1.24, 95% CI = 1.12-1.37). Additionally, the sNIHSS predicted 90-day outcomes almost as same discrimination as NIHSS by using DeLong test. The optimal cutoff value of sNIHSS was determined to be 12 points for predicting any outcome. Conclusions The sNIHSS reflects acute BAO severity well and predicts 90-day outcomes with reasonable accuracy. Nevertheless, the sNIHSS needs further validation before it can be applied as a predictive tool for acute BAO outcome.

Abstract TMP13: Tenecteplase versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fana Alemseged ◽  
Volker Puetz ◽  
Gregoire Boulouis ◽  
Alessandro Rocco ◽  
Timothy Kleinig ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Endovascular Therapy ◽  
Primary Outcome ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Randomized Controlled ◽  
Repeat Imaging

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.

Endovascular treatment for acute basilar artery occlusion: descriptive analysis of the experience in a comprehensive stroke centre

2021 ◽  
Keyword(s):  
General Anaesthesia ◽  
Basilar Artery ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Anterior Circulation ◽  
Significant Difference ◽  
Epidemiological Characteristics

Objectives: To describe the clinical and epidemiological characteristics of patients with basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT) in Aragón, and to compare its anaesthetic management, technical effectivity, security, and prognosis with those of anterior circulation. Methods: 322 patients from the prospective registry of mechanical thrombectomies from Aragon were assessed: 29 with BAO and 293 with an anterior circulation large vessel occlusion. Baseline characteristics, procedural, clinical and safety outcomes variables were compared. Results: Out of 29 patients with BAO that underwent endovascular therapy (62.1% men; average age 69.8 ± 14.05 years) 18 (62.1%) received endovascular therapy (EVT) alone and 11 (37.9%) EVT plus intravenous thrombolysis. Atherothrombotic stroke was the most common etiology (41%). The BAO group had longer Door-to-groin (160 vs 141 min; P = 0.043) and Onset-to-reperfusion times (340 vs 297 min; P = 0.005), and higher use of general anaesthesia (60.7% vs 14.7%; P < 0.01). No statistically significant difference was found for Procedure time (60 vs 50 min; P = 0.231) nor the rate of successful recanalization (72.4% vs 82.7%; P = 0.171). Functional independence at 90 days was significantly worse in the BAO group (17.9% vs 38.2%; P < 0.01). Conclusions: Patients with basilar artery occlusion had higher morbimortality despite similar angiographic results. Mechanical thrombectomy for BAOs is a safe and effective procedure in selected patients. A consensus about the effect of anaesthesia has yet to be reached, for BAO general anaesthesia remains the most frequently used technique.

scholarly journals Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion

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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