Abstract WP64: Perfusion Imaging Can Identify Basilar Occlusion Patients With a Favorable Response to Thrombectomy

Introduction: Perfusion imaging can identify patients who respond favorably to endovascular therapy (EVT) in the anterior circulation; no data are available for the posterior circulation. We evaluated perfusion patterns, assessed with RAPID software, in a consecutive cohort of patients with basilar artery occlusion treated with EVT and assessed the association between reperfusion and favorable clinical outcome based on the perfusion profile. Hypothesis: We hypothesized that patients with limited regions of severe hypoperfusion (Tmax > 10s) would have a favorable response (mRS 0-2) to reperfusion (mTICI 2b-3) while patients with multiple critical brain regions severely hypoperfused would have poor outcome (mRS 4-6) despite reperfusion. Methods: From a multicenter cohort of perfusion imaging in posterior circulation stroke, we included patients with basilar artery occlusion and EVT. We pre-specified a Critical Area Perfusion Score (CAPS, 0 - 8 points) to identify severe hypoperfusion (Tmax >10s) in the following regions: inferior and/or superior cerebellar hemisphere (1-4 points), pons (2 points), midbrain/thalamus (2 points). We compared the outcome between reperfusers and non reperfusers based on the CAP score with univariate and multivariate analysis. Results: 38 patients met the inclusion criteria. Mean age was 63±17, 34% female, NIHSS 17±11. In patients who reperfused (n=30, 79%) 63% had favorable outcome, while no patient without reperfusion survived, p=0.003 OR=29 (95%CI 1.5-547). Ninety percent (19/21) of reperfused patients with CAPS ≤2 had a favorable outcome, while none of the 9 with reperfusion and a score >2 survived, p<0.001, OR=148 (95%CI 6.5-3,333). In univariate analysis, favorable outcome was associated with NIHSS OR=0.87 (95% CI 0.80-0.96), p=0.003, and mismatch volume OR=0.98 (95% CI 0.97-0.997) p=0.013. In the multivariate analysis, only CAPS was an independent predictor of favorable outcome. Conclusions: Patients with limited regions of severe hypoperfusion (Tmax > 10s) had a robust response to basilar artery EVT, however, all patients with multiple critical brain regions severely hypoperfused died despite successful reperfusion. Perfusion imaging profiles may help identify optimal patients for basilar EVT.

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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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Abstract 2972: Perfusion CT in Patients with Basilar Artery Occlusion: Diagnostic and Prognostic Value in the Basilar Artery International Cooperation Study

Stroke ◽

10.1161/str.43.suppl_1.a2972 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Lars P Pallesen ◽

Volker Puetz ◽

Johannes Gerber ◽

Imanuel Dzialowski ◽

Patrik Michel ◽

...

Keyword(s):

International Cooperation ◽

Basilar Artery ◽

Mean Transit Time ◽

Univariate Analysis ◽

Artery Occlusion ◽

Perfusion Ct ◽

Posterior Circulation ◽

Basilar Artery Occlusion ◽

Relative Reduction ◽

Prognostic Impact

Background: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients with basilar artery occlusion (BAO). Compared with CTA-SI, perfusion CT (CTP) may provide added information. We assessed the diagnostic and prognostic impact of CTP compared with CTA-SI among patients in the Basilar Artery International Cooperation Study (BASICS) Methods: BASICS was a prospective observational registry of consecutive patients with acute symptomatic BAO. We applied pc-ASPECTS to CTA-SI and cerebral blood volume (CBV), cerebral blood flow (CBF), time-to-peak (TTP) and mean-transit-time (MTT) parameter maps in a 3-reader-consensus with readers blinded to clinical data. Hypoattenuation on CTA-SI, a relative reduction in CBV or CBF, or relative increase in MTT or TTP was rated as abnormal. Clinical outcome was measured with the modified Rankin Scale (mRS) score at 1 month. Results: Among 592 patients in the BASICS registry, 27 patients (4.6%) had CTP studies performed. Median (interquartile-range) pc-ASPECTS values on TTP/MTT, CTA-SI, CBF and CBV were 6 (5-8), 7 (5-9), 8 (6-9) and 10 (8.75-10), respectively (p<0.001). The proportion of patients with any perfusion abnormalities in the posterior circulation was highest for TTP/MTT (93%; CI 95% 74% to 99%), compared with 78% (CI 95% 57% to 91%) for both CTA-SI and CBF and 46% (CI 95% 27% to 66%) for CBV (p<0.001). At 1 month, 9 patients (33%) had a favourable outcome (mRS scores 0-3), 8 patients (30%) had an unfavourable outcome (mRS scores 4-5) and 10 patients (37%) were deceased. In univariate analysis, pc-ASPECTS scores did not correlate with outcome mRS scores for all imaging modalities (Spearman’s Rho, p>0.1 for all). All three patients (100%) with a CBV pc-ASPECTS <8 compared to 6 of 23 patients (26%) with a CBV pc-ASPECTS >8 died (p=0.03). Conclusion: CTP was performed in a minority of patients in the BASICS registry population. Perfusion disturbances in the posterior circulation were most frequent and most pronounced on TTP and MTT parameter maps. Extensive reduction of CBV, defined as a pc-ASPECTS <8, may indicate patients with a high case fatality.

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Effect of anesthesia strategy during endovascular therapy on 90-day outcomes in acute basilar artery occlusion: a retrospective observational study

BMC Neurology ◽

10.1186/s12883-020-01979-8 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Haibin Du ◽

Xu Tong ◽

Xuan Sun ◽

Zhiyong Shi ◽

Bin Liu ◽

...

Keyword(s):

General Anesthesia ◽

Clinical Outcomes ◽

Basilar Artery ◽

Endovascular Therapy ◽

Univariate Analysis ◽

Multivariable Analysis ◽

Functional Independence ◽

Artery Occlusion ◽

Favorable Outcome ◽

Basilar Artery Occlusion

Abstract Background and objective The research on the effect of anesthesia on endovascular therapy (EVT) of acute ischemic stroke is mainly focused on the anterior circulation, and little is known about the data of basilar artery occlusion (BAO). This study aims to investigate the association of anesthesia strategy with 90-day clinical outcomes of patients with acute BAO treated with EVT. Methods We reviewed our prospectively collected data from the endovascular treatment database at the Beijing Tiantan Hospital. This included patients with acute BAO who had a documented 90-day modified Rankin Scale (mRS) score from January 2012 to July 2018. Options for EVT included general anesthesia (GA) and conscious sedation (CS) performed by an anesthesia care team in the institution. The recommendation of anesthesia for patients was a joint decision between anesthesiologist and neurointerventionalist according to a pre-designed scheme. Patients who required tracheal intubation for airway protection prior to EVT were excluded. The clinical outcomes we observed were functional independence (mRS ≤2), favorable outcome (mRS ≤3), and mortality at 90 days after the procedure. Univariate and multivariable logistic regression analyses were used to explore the relationship between anesthesia methods and 90-day outcomes. Results A total of 187 patients with BAO were treated by EVT in this study. Nine cases requiring emergent intubation prior to EVT were excluded. 139 patients (78.1%) underwent GA and 39 patients (21.9%) underwent CS. In univariate analysis, GA was associated with less functional independence [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.13–0.59] and less favorable outcome (OR, 0.23; 95% CI, 0.10–0.52) than was CS. After adjusting for potential confounders, multivariable analysis showed that there were still significant differences between GA and CS in functional independence (OR, 0.31; 95%CI, 0.10–0.97) and favorable outcome (OR, 0.24; 95%CI, 0.07–0.75). Conclusion Our retrospective analysis suggested that the anesthesia strategy may affect outcome, in which general anesthesia may result in less favorable outcomes. Nevertheless, future multicenter randomized controlled trials are needed to confirm our findings.

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

10.21203/rs.3.rs-21836/v1 ◽

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.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014516 ◽

2019 ◽

Vol 11 (12) ◽

pp. 1174-1180 ◽

Cited By ~ 18

Author(s):

Thomas Raphael Meinel ◽

Johannes Kaesmacher ◽

Panagiotis Chaloulos-Iakovidis ◽

Leonidas Panos ◽

Pasquale Mordasini ◽

...

Keyword(s):

Basilar Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Secondary Outcome ◽

Stroke Severity ◽

Anterior Circulation ◽

Link Type ◽

Significant Difference

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 of Vertebrobasilar Aneurysms

Interventional Neuroradiology ◽

10.1177/15910199990050s113 ◽

1999 ◽

Vol 5 (1_suppl) ◽

pp. 71-78 ◽

Cited By ~ 1

Author(s):

M. Leonardi ◽

M. Pastore-Trossello ◽

L. Simonetti ◽

R. Agati

Keyword(s):

Basilar Artery ◽

Artery Occlusion ◽

Posterior Circulation ◽

Basilar Artery Occlusion ◽

Clinical Criteria ◽

Vertebral Arteries ◽

Posterior Circulation Aneurysms ◽

Wide Neck ◽

Vertebrobasilar Aneurysms ◽

Indication For Treatment

In posterior circulation aneurysms, GDC endosaccular occlusion is the treatment of choice, when indicated. This report assessed anatomical, morphological and clinical criteria in the choice of vertebral or basilar artery occlusion in posterior circulation aneurysms, when CDC endosaccular treatment, with or without the “remodelling technique”, is not indicated, as in giant or wide-neck aneurysms. Over five years we observed eleven patients harboring posterior circulation aneurysms with no indication for treatment with GDC, or only vertebral occlusion. In our experience, the endovascular occlusion of a single or both vertebral arteries or basilar artery, following a detailed anatomical and clinical assessment, has proved a good, reliable treatment in large or giant vertebrobasilar aneurysms or those without a neck.

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Association Between Time to Endovascular Therapy and Outcomes in Patients With Acute Basilar Artery Occlusion

Neurology ◽

10.1212/wnl.0000000000012858 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012858

Author(s):

Hong fei Sang ◽

Jun jie Yuan ◽

Zhongming Qiu ◽

Min Zhang ◽

Xiao gang Hu ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Clinical Outcomes ◽

Basilar Artery ◽

Endovascular Therapy ◽

Cubic Spline ◽

Artery Occlusion ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Spline Regression ◽

Symptomatic Intracerebral Hemorrhage

Objective:To characterize the association of onset to puncture time (OPT) with clinical outcomes among patients with acute basilar artery occlusion receiving endovascular therapy (EVT) in clinical practice.Methods:Using the EVT for Acute Basilar Artery Occlusion (BASILAR) study, we identified consecutive patients with acute basilar artery occlusion receiving EVT in 47 comprehensive stroke centers in China from January 2014 to May 2019. The primary outcome was favorable functional outcome (defined as modiﬁed Rankin Scale score [mRS] 0–3) at 90 days. Secondary outcomes included function independence (mRS 0–2), mortality, and symptomatic intracerebral hemorrhage. The associations of OPT with clinical outcomes were analyzed using multivariable logistic regression (OPT as a categorical variable) and restricted cubic spline regression (OPT as a continuous variable).Results:Among 639 eligible patients, the median age was 65 years, and median OPT was 328 min (interquartile range, 220–490). Treatment within 4–8 hours and 8–12 hours were associated with lower rates of favorable outcome (adjusted OR, 0.63 [95% CI, 0.40–0.98] and 0.47 [95% CI, 0.23–0.93], respectively) compared with treatment within 4 hours. Restricted cubic spline regression analysis showed that the OPT had L-shaped associations with favorable outcome (Pnon-linearity=0.028) and functional independence (Pnon-linearity=0.025), with significant benefit loss throughout the first 9 hours but then appeared relatively flat. The odds of mortality increased relatively for OPT up to 9 hours, but then levelled off (Pnon-linearity=0.042). The association between symptomatic intracerebral hemorrhage and OPT was not significant.Conclusion:Among patients with acute basilar artery occlusion in routine practice, earlier treatment with EVT was associated with better outcomes throughout the first 9 hours after onset, but benefit may sustain unchanged afterwards.Classification of Evidence:This study provides Class II evidence that for patients with acute ischemic stroke due to basilar artery occlusion, earlier endovascular treatment is associated with better outcomes.

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