SYMPTOMATIC INTRACRANIAL HEMORRHAGE AFTER THROMBOLYSIS AND ADJUNCT ANTICOAGULATION IN BASILAR ARTERY OCCLUSION

Background and Purpose: Studies on rescue therapy for acute posterior circulation stroke due to basilar artery occlusion (BAO) are limited in the modern era of mechanical thrombectomy (MT). The aim of this study was to evaluate the safety and efficacy of rescue stenting (RS) following MT failure in patients with BAO.Methods: Data were collected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) prospective registry in China. Patients who underwent MT for BAO with failure of recanalization were enrolled in this study. The patients were divided into the RS and non-RS groups. Clinical and laboratory findings, procedural details, and clinical outcomes were compared between the two groups.Results: Overall, 93 patients with acute BAO were analyzed. The RS group included 81 (87.1%) patients, and the non-RS group included 12 patients. A modified treatment in cerebral infarction (mTICI) score of 2b/3 was achieved in 75 (92.6%) patients in the RS group. Compared with the non-RS group, the RS group had a significantly higher rate of successful recanalization and favorable clinical outcomes (modified Rankin Scale score at 90 days post-procedure, 0–3: 16.7 vs. 51.9%, respectively; P = 0.023) without an increase in the rate of symptomatic intracranial hemorrhage and a significantly lower mortality rate (58.3 vs. 18.5%, respectively; P = 0.006). Furthermore, the use of a glycoprotein IIb/IIIa inhibitor improved the rate of recanalization of the target artery without increasing the rate of symptomatic intracranial hemorrhage.Conclusions: Permanent stenting appears to be a feasible rescue modality when MT fails and might provide functional benefits in patients with acute ischemic stroke due to BAO.

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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.

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Extended Thrombolysis In Cerebral Infarction (eTICI) grade 2c: a potential angiographic target for endovascular treatment in acute basilar artery occlusion?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018026 ◽

2021 ◽

pp. neurintsurg-2021-018026

Author(s):

Luming Chen ◽

Chenghao Zhao ◽

Jiaxing Song ◽

Wenjie Zi ◽

Hongfei Sang ◽

...

Keyword(s):

Cerebral Infarction ◽

Endovascular Treatment ◽

Clinical Outcomes ◽

Intracranial Hemorrhage ◽

Basilar Artery ◽

Functional Outcomes ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Symptomatic Intracranial Hemorrhage ◽

The Impact

BackgroundHigher extended Thrombolysis In Cerebral Infarction (eTICI) grades are associated with better clinical outcomes after endovascular treatment (EVT) for proximal intracranial occlusion of the anterior circulation. However, the relationship between eTICI grade and outcomes after EVT in patients with acute basilar artery occlusion (BAO) remains unclear. We aimed to explore which eTICI category was the cut-off correlating with better clinical outcomes in patients with BAO undergoing EVT.MethodsWe included patients treated via EVT from the BASILAR study. Multivariable logistic regression analyses were performed to assess the impact of eTICI grades on 90-day favorable functional outcomes, defined as a modified Rankin Scale (mRS) score of 0–3. Other outcomes were functional independence (mRS 0–2), all-cause mortality, and symptomatic intracranial hemorrhage.ResultsAmong 647 patients treated with EVT, 127 (19.6%), 128 (24.5%), 110 (21.1%), and 282 (54%) patients achieved eTICI grades of 0–2a, 2b, 2c, and 3, respectively. Compared with eTICI grades 0–2a, higher rates of favorable functional outcomes (adjusted OR (aOR) 2.96, 95% CI 1.33 to 6.57, and aOR 7.40, 95% CI 3.63 to 15.09, respectively) were observed for grades 2c and 3, not 2b (aOR 1.93, 95% CI 0.86 to 4.36). The risks of mortality and symptomatic intracranial hemorrhage were also lower for eTICI grades 2c and 3 than for grades 0–2a.ConclusionsAn eTICI grade of 2c/3 may be a target for successful reperfusion after EVT in patients with acute BAO; however, further studies with larger sample sizes and clinical trials are needed.

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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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Frontline thrombectomy strategy and outcome in acute basilar artery occlusion

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018180 ◽

2022 ◽

pp. neurintsurg-2021-018180

Author(s):

Mohamed Abdelrady ◽

Julien Ognard ◽

Federico Cagnazzo ◽

Imad Derraz ◽

Pierre-Henri Lefevre ◽

...

Keyword(s):

Basilar Artery ◽

Primary Outcome Measure ◽

Artery Occlusion ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Complete Revascularization ◽

Symptomatic Intracranial Hemorrhage ◽

The Relationship ◽

Day By Day ◽

Switch Group

BackgroundNovel thrombectomy strategies emanate expeditiously day-by-day counting on access system, clot retriever device, proximity to and integration with the thrombus, and microcatheter disengagement. Nonetheless, the relationship between native thrombectomy strategies and revascularization success remains to be evaluated in basilar artery occlusion (BAO).PurposeTo compare the safety and efficacy profile of key frontline thrombectomy strategies in BAO.MethodsRetrospective analyses of prospectively maintained stroke registries at two comprehensive stroke centers were performed between January 2015 and December 2019. Patients with BAO selected after MR imaging were categorized into three groups based on the frontline thrombectomy strategy (contact aspiration (CA), stent retriever (SR), or combined (SR+CA)). Patients who experienced failure of clot retrieval followed by an interchanging strategy were categorized as a fourth (switch) group. Clinicoradiological features and procedural variables were compared. The primary outcome measure was the rate of complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c–3). Favorable outcome was defined as a 90 day modified Rankin Scale score of 0–2.ResultsOf 1823 patients, we included 128 (33 underwent CA, 35 SR, 35 SR +CA, and 25 switch techniques). Complete revascularization was achieved in 83/140 (59%) primarily analyzed patients. SR +CA was associated with higher odds of complete revascularization (adjusted OR 3.04, 95% CI 1.077 to 8.593, p=0.04) which was an independent predictor of favorable outcome (adjusted OR 2.73. 95% CI 1.152 to 6.458, p=0.02). No significant differences were observed for symptomatic intracranial hemorrhage, functional outcome, or mortality rate.ConclusionAmong BAO patients, the combined technique effectively contributed to complete revascularization that showed a 90 day favorable outcome with an equivalent complication rate after thrombectomy.

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Endovascular intervention for basilar artery occlusion in the elderly

Therapeutic Advances in Neurological Disorders ◽

10.1177/17562864211000453 ◽

2021 ◽

Vol 14 ◽

pp. 175628642110004

Author(s):

Weidong Luo ◽

Wenguo Huang ◽

Min Zhang ◽

Xing Liu ◽

Zhangbao Guo ◽

...

Keyword(s):

Elderly Patients ◽

Functional Outcome ◽

Basilar Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Nihss Score ◽

Symptomatic Intracranial Hemorrhage ◽

Favorable Functional Outcome

Background: To date, few data have been reported on clinical outcomes following interventions in elderly populations with acute basilar artery occlusion. Using data from the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR), we evaluated the efficacy and safety of intervention and determined predictors of outcomes among elderly patients in China. Methods: Patients from January 2014 to May 2019 were dichotomized into elderly (75 years or older) and nonelderly patients (under 75 years). Pearson’s Chi-square test and multivariate logistic regression were performed to assess 90-day favorable functional outcome (defined as a modified Rankin scale score of 0–3), mortality and symptomatic intracranial hemorrhage between intervention and conservative cohorts in elderly patients. Results: Among the 829 patients in the BASILAR, 182 patients aged 75 years or older were analyzed. These patients were divided into intervention (127 patients) and conservative (55 patients) cohorts. Compared with the conservative cohort, the intervention cohort presented more frequently with a favorable functional outcome (28.3% versus 12.7%; p = 0.023) and with a decreased mortality (54.3% versus 76.4%; p = 0.005). There was no difference in symptomatic intracranial hemorrhage (4.7% versus 0, p = 0.235). Multivariate analysis indicated that intervention was associated with favorable functional outcome (adjusted odds ratio, 0.262; 95% confidence interval, 0.088–0.778, p = 0.016) and lower mortality (adjusted odds ratio, 0.257; 95% confidence interval, 0.109–0.606, p = 0.002). In the intervention cohort, initial National Institutes of Health Stroke Scale (NIHSS) score and occlusion site were associated with functional outcome, and initial NIHSS score and recanalization were associated with mortality. Conclusions: Although the overall outcome following intervention was worse with age, intervention was more effective and safer than conservative treatment for elderly Chinese patients with basilar artery occlusion. Predictors of desirable outcome in elderly patients undergoing intervention included lower initial NIHSS score, occlusion site and successful recanalization. Clinical Trial Registration-URL: http://www.chictr.org . Unique identifier: ChiCTR-1800014759

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