Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation

BackgroundPerforming mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence-based.ObjectiveTo compare patients’ outcome, relative merits of achieving recanalization, and predictors of futile recanalization (FR) between BAO and anterior circulation large vessel occlusion (ACLVO) MT.MethodsIn the multicenter BEYOND-SWIFT registry (NCT03496064), univariate and multivariate (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI) outcome comparisons between BAO (N=165) and ACLVO (N=1574) were performed. The primary outcome was favorable outcome at 90 days (modified Rankin Scale, mRS 0-2). Secondary outcome included mortality, symptomatic intracranial hemorrhage (sICH) and FR. The relative merits of achieving successful recanalization between ACLVO and BAO were evaluated with interaction terms.ResultsMT in BAO was more often technically effective and equally safe in regards to mortality and sICH when compared to ACLVO. When adjusting for baseline differences, there was no significant difference between BAO vs ACLVO regarding rates of favorable outcome (aOR 0.986, 95%-CI 0.553 – 1.758). However, BAO were associated with increased rates of FR (aOR 2.146, 95%-CI 1.267 – 3.633). Predictors for FR were age, stroke severity, maneuver count and intracranial stenting. No significant heterogeneity on the relative merits of achieving successful recanalization on several outcome parameters were observed when comparing BAO and ACLVO.ConclusionsIn selected patients, similar outcomes can be achieved in BAO and ACLVO patients treated with MT. Randomized controlled trials comparing patient selection and interventional strategies seem warranted to avoid FR.Trial registration numberNCT03496064

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

10.22514/sv.2021.038 ◽

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.

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Effectiveness and Safety of Mechanical Thrombectomy with Stent Retrievers in Basilar Artery Occlusion : Comparison with Anterior Circulation Occlusions

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2017.0404.008 ◽

2017 ◽

Vol 60 (6) ◽

pp. 635-643 ◽

Cited By ~ 12

Author(s):

Soo Young Hu ◽

Ho Jun Yi ◽

Dong Hoon Lee ◽

Jae Taek Hong ◽

Jae Hoon Sung ◽

...

Keyword(s):

Basilar Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Stent Retrievers

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Endovascular Treatment for Acute Basilar Artery Occlusion: A Single Center Retrospective Observational Study

10.21203/rs.2.10767/v1 ◽

2019 ◽

Author(s):

xuan sun ◽

xu tong ◽

feng gao ◽

huiting lao ◽

zhongrong miao

Keyword(s):

Endovascular Treatment ◽

Basilar Artery ◽

Mechanical Thrombectomy ◽

Balloon Dilation ◽

High Volume ◽

Functional Independence ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Intracranial Atherosclerotic Disease

Abstract Background and purpose: Endovascular treatment (EVT) is now considered the gold standard for select patient populations with anterior circulation stroke; however, data on the treatment of posterior circulation stroke are less clear. This study aims to determine the characteristics and treatment outcomes of patients with acute basilar artery occlusion (BAO) and to evaluate the effectiveness and safety of EVT for patients with acute BAO in a high-volume stroke center. Methods: This study included 187 consecutive patients with acute BAO who underwent EVT from January 2012 to July 2018 in Beijing Tiantan Hospital. The baseline characteristics, procedure parameters, and functional outcome were assessed. Results: Among the 187 patients, 138 (73.8%) underwent mechanical thrombectomy with a stent retriever, 33 (17.6%) underwent direct intracranial angioplasty (balloon dilation and/or stent implantation) for underlying severe intracranial atherosclerotic disease, and 91 (48.7%) underwent combined mechanical thrombectomy and angioplasty. Successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3] was achieved in 158 patients (84.5%). Overall, the rates of functional independence [modified Rankin Scale (mRS) 0-2] and favorable outcome (mRS 0-3) at 90 days were 36.4% and 49.2%, respectively, and 90- day all-cause mortality was 20.3%. Conclusion􀀌􀀁EVT was effective and safe for treating patients with acute BAO.

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Mechanical Thrombectomy for Basilar Artery Occlusion Compared with Anterior Circulation Stroke

World Neurosurgery ◽

10.1016/j.wneu.2019.10.097 ◽

2020 ◽

Vol 134 ◽

pp. e469-e475

Author(s):

Junji Uno ◽

Katsuharu Kameda ◽

Ryosuke Otsuji ◽

Nice Ren ◽

Shintaro Nagaoka ◽

...

Keyword(s):

Basilar Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation

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Endovascular Treatment for Acute Basilar Artery Occlusion: A Single Center Retrospective Observational Study

10.21203/rs.2.10767/v2 ◽

2019 ◽

Author(s):

xuan sun ◽

xu tong ◽

feng gao ◽

huiting lao ◽

zhongrong miao

Keyword(s):

Endovascular Treatment ◽

Basilar Artery ◽

Mechanical Thrombectomy ◽

Balloon Dilation ◽

High Volume ◽

Functional Independence ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Intracranial Atherosclerotic Disease

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Abstract T P23: Posterior Circulation CT Angiography Collaterals Predict Outcome of Endovascular Acute Ischemic Stroke Therapy for Basilar Artery Occlusion

Stroke ◽

10.1161/str.46.suppl_1.tp23 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nitin Goyal ◽

Georgios Tsivgoulis ◽

Vinodh T Doss ◽

Robert Laster ◽

Dan Hoit ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Basilar Artery ◽

Artery Occlusion ◽

Posterior Circulation ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Stroke Severity ◽

Nihss Score ◽

Pre Treatment

Background & Purpose: The outcomes of patients with acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) are poor. Endovascular therapy (EVT) improves rates of recanalization. We hypothesized that good collateral patterns by pre-treatment CT Angiography (CTA) would predict favorable outcome after EVT. Methods: We conducted a retrospective chart review of patients presenting with AIS due to BAO in a tertiary care stroke center during a four-year period. BAO was diagnosed by CTA in all cases, who received EVT as standard of care. Admission stroke severity was documented using NIHSS-score. Pretreatment collateral score (CS) for posterior circulation was defined as follows: 0 - no posterior communicating artery (PCOM), 1- unilateral PCOM, 2- bilateral PCOM. Complete recanalization was defined by Thrombolysis in Cerebral Infarction (TICI) scores of 2b or 3. Favorable outcome was defined as modified Rankin Scale score (mRS) of 0-2 at three months. Results: Our study population consisted of 15 AIS patients (age range; 31-84 years, median admission NIHSS-score: 21, range 2-38 points) who underwent EVT. Systemic thrombolysis was administered in 4 patients (27%). Seven of 15 patients (47%) had bilateral PCOMs, while unilateral PCOM was diagnosed in 2 cases (13%). Patients with bilateral PCOMs tended to have less severe stroke (p=0.199) at admission in comparison to patients with absent/unilateral PCOM (median NIHSS-score 18 vs. 28 points). The rate of favorable outcome was higher in patients with bilateral PCOMs (71%) in comparison to patients with absent or unilateral PCOM (0%; p=0.014). Patients with bilateral PCOMs tended to have higher recanalization in comparison with patients with absent/unilateral PCOM (86% vs. 33%, p= 0.076). CONCLUSION: Presence of bilateral PCOMs on pre-treatment CTA is associated with lower baseline stroke severity, higher rates of complete recanalization and favorable outcome in patients with AIS due to BAO who are treated with EVT. Future prospective studies including a larger sample of patients are required to define the potential association of posterior circulation collateral status with favorable outcome in this subgroup of ischemic stroke patients.

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Impact of anesthetic strategy on outcomes for patients with acute basilar artery occlusion undergoing mechanical thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018000 ◽

2021 ◽

pp. neurintsurg-2021-018000

Author(s):

Fengli Li ◽

Junfang Wan ◽

Jiaxing Song ◽

Junjie Yuan ◽

Weilin Kong ◽

...

Keyword(s):

Clinical Outcomes ◽

Basilar Artery ◽

Mechanical Thrombectomy ◽

Anesthetic Management ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anesthetic Technique ◽

Large Artery ◽

Anterior Circulation ◽

Vessel Occlusion

BackgroundThe best anesthetic management strategy for patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains uncertain. Most studies have focused on anterior–circulation stroke caused by large artery occlusion. Nevertheless, limited data are available on the appropriate choice of anesthetic for acute basilar artery occlusion (BAO). We aimed to investigate the effect of anesthetic method on clinical outcomes in patients with BAO undergoing MT.MethodsPatients undergoing MT for acute BAO in the BASILAR registry (Acute Basilar Artery Occlusion Study) were included. We divided patients into three groups according to the anesthetic technique used during MT: general anesthesia (GA), local anesthesia (LA), and conscious sedation (CS). Propensity score matching was performed to achieve baseline balance.Results639 patients were included. GA was used in 257 patients (40.2%), LA was used in 250 patients (39.1%), and CS was used in 132 patients (20.7%). After 1:1 matching, favorable outcome, mortality, and hemorrhagic transformation rates, as well as modified Rankin Scale (mRS) score at 90 days, did not differ between the GA, LA, and CS groups.ConclusionsThe choice of anesthetic strategy, GA, LA, or CS, did not affect the clinical outcomes of patients with acute BAO treated with MT in the BASILAR registry.

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

Stroke ◽

10.1161/strokeaha.111.622175 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3454-3459 ◽

Cited By ~ 42

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.

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Basilar Artery Occlusion Chinese Endovascular Trial: Protocol for a prospective randomized controlled study

International Journal of Stroke ◽

10.1177/17474930211040923 ◽

2021 ◽

pp. 174749302110409

Author(s):

Chuanhui Li ◽

Chuanjie Wu ◽

Longfei Wu ◽

Wenbo Zhao ◽

Jian Chen ◽

...

Keyword(s):

Sample Size ◽

Basilar Artery ◽

Symptom Onset ◽

Primary Outcome ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Controlled Study ◽

Randomized Controlled

Rationale There are no randomized trials examining the best treatment for acute basilar artery occlusion in the 6–24-hour time window. Aims To assess the safety and efficacy of thrombectomy for stroke due to basilar artery occlusion in patients randomized within 6–24 h from symptom onset or time last seen well. Sample size For an estimated difference of 20% in proportions of the primary outcome between the two groups, 318 patients will be included for 5% significance and 90% power with a planned interim analysis after two-thirds of the sample size (212 patients) have achieved the 90 days follow-up. Methods and design A prospective, multi-center, randomized, controlled, open-label and blinded-endpoint trial. The randomization employs a 1:1 ratio of mechanical thrombectomy with the detachable Solitaire thrombectomy device and best medical therapy (BMT) vs. BMT alone. Study outcomes The primary outcome will be the proportion of patients achieving modified Rankin Scale (mRS) 0–3 at 90 days. Key secondary outcomes are: dramatic early favorable response, dichotomized mRS score (0–2 vs. 3–6 and 0–4 vs. 5–6) at 90 days, ordinal (shift) mRS analysis at 90 days, infarct volume at 24 h, vessel recanalization at 24 h in both treatment arms, and successful recanalization in the thrombectomy arm according to the modified thrombolysis in cerebral infarction (mTICI) classification defined as mTICI 2 b or 3. Safety variables are mortality at 90 days, symptomatic intracranial hemorrhage rates at 24 h, and procedure-related complications. Discussion Results from this trial will indicate whether mechanical thrombectomy is superior to medical management alone in achieving favorable outcomes in subjects with acute stroke caused by basilar artery occlusion presenting within 6–24 h from symptom onset. Trial registration: URL: http://www.clinicaltrials.gov . ClinicalTrials.gov Identifier: NCT02737189.

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First-Pass Effect in Basilar Artery Occlusions: Insights From the Endovascular Treatment of Ischemic Stroke Registry

Stroke ◽

10.1161/strokeaha.120.030237 ◽

2021 ◽

Author(s):

Mathilde Aubertin ◽

David Weisenburger-Lile ◽

Benjamin Gory ◽

Sébastien Richard ◽

Raphael Blanc ◽

...

Keyword(s):

Basilar Artery ◽

Rescue Therapy ◽

Strong Predictor ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Unique Identifier ◽

First Pass Effect ◽

Improved Outcomes ◽

First Pass

Background and Purpose: In the settings of thrombectomy, the first-pass effect (FPE), defined by a complete recanalization after one pass with no rescue therapy, has been shown to be associated with an improved outcome. As this phenomenon has been predominantly described in anterior circulation strokes, we aimed to study the prevalence, outcomes, and predictors of FPE in patients with a basilar artery occlusion. Methods: From a prospective multicentric registry, we collected the data of all consecutive basilar artery occlusion patients who underwent thrombectomy and compared the outcomes of patients who achieved FPE and those who did not. We also compared FPE patients with those who achieved a complete recanalization with >1 pass. Finally, a multivariate analysis was performed to determine the predictors of FPE. Results: Data from 280 patients were analyzed in our study, including 84 of 280 patients (30%) with an atheromatous etiology. An FPE was achieved in 93 patients (33.2%), with a significantly higher proportion of good outcomes (modified Rankin Scale score 0-2 at 3 months) and lower mortality than non-FPE patients. An FPE was also associated with improved outcomes compared with patients who went on to have full recanalization with >1 pass. Contact aspiration as first-line strategy was a strong predictor of FPE, whereas baseline antiplatelets and atheromatous etiology were negative predictors. Conclusions: In our study, an FPE was achieved in approximately one-third of patients with a basilar artery occlusion and was associated with improved outcomes. More research is needed to improve devices and techniques to increase the incidence of FPE. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

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