Basilar Artery Occlusion: Clinical Management and Therapy

Basilar artery occlusion is a potentially life-threatening subset of the larger category of posterior circulation strokes, carrying > 80% fatality rate without treatment. This condition accounts for about 1% to 4% of all ischemic strokes and is generally related to local atherothrombosis or cardioembolism.Diagnosis can be challenging because presenting symptoms are often non focal, such as headache, dizziness, and vertigo. The onset of the symptomatology can be abrupt without preceding events, abrupt with prodromal symptoms, or progressive and stuttering. Finally, the severity of clinical presentation may range from isolated cranial nerve palsies to tetraplegia, locked-in state, or coma.If basilar artery occlusion is readily recognized and confirmed with the aid of neuroimaging, intravenous thrombolysis or endovascular treatment can be undertaken immediately in order to recanalize the occluded artery and thus reduce mortality and improve 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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Basilar Artery Occlusion. Clinical Evaluation and Contemporary Methods of Treatment

Clinical Cardiology and Cardiovascular Interventions ◽

10.31579/2641-0419/117 ◽

2021 ◽

Vol 4 (01) ◽

pp. 01-08

Author(s):

Damyan Boychev

Keyword(s):

Basilar Artery ◽

Neurological Diseases ◽

Intravenous Thrombolysis ◽

Mortality Rates ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Threatening Condition ◽

Life Threatening ◽

Methods Of Treatment ◽

Headache And Neck Pain

Acute occlusion of the basilar artery and its branches is a frequent cause of posterior circulation strokes. Although it accounts for only 1 to 3 % of ischemic strokes, it is a potentially life-threatening condition associated with high mortality rates. Exact clinical diagnosis is still challenging because symptoms such as vertigo, dizziness followed by headache, and neck pain are nonspecific and usually attributed to many other neurological diseases. The onset of symptoms can be abrupt or gradual and progressive. Establishing the time of symptoms onset and making a timely diagnosis is highly important. In case the diagnosis is made promptly, ideally with the help of an advanced neuroimaging, intravenous thrombolysis, or catheter-based endovascular treatment can be performed immediately to improve prognosis and reduce mortality.

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Top of Basilar Artery Infarction: A Case Series from Sudan

10.21203/rs.3.rs-1196891/v1 ◽

2021 ◽

Author(s):

Mahmoud Hussien Salih Daoud ◽

Ejlal Ahmed.E.Abushama ◽

Abdallah.H Mahmmoud ◽

Moh.Mah.Fadelallah Eljack ◽

Khabab Abbashar Hussein ◽

...

Keyword(s):

Basilar Artery ◽

Clinical Presentation ◽

Case Series ◽

Supportive Therapy ◽

Artery Occlusion ◽

Posterior Circulation ◽

Basilar Artery Occlusion ◽

Death Time ◽

The Brain ◽

Time Of Intervention

Abstract The posterior circulation represents 20% of blood supply of the brain and its occlusion commonly by embolism cause brainstem, cerebellar and lower cerebral infarction. The clinical presentation varies from mild innocent symptoms leading to sever neurological deficit or death. Time of intervention is vital commonly with antithrombatic drugs or through intervention. Here, we report two Sudanese patients who had a complicated medical sequence over months ended as top of basilar artery occlusion received anticoagulants and supportive therapy according to their condition showed a variable recovery over weeks.

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

Stroke ◽

10.1161/str.51.suppl_1.tmp13 ◽

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.

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

Stroke ◽

10.1161/str.51.suppl_1.wp64 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Carlo W Cereda ◽

Jeremy Heit ◽

Giovanni Bianco ◽

Marco Pileggi ◽

Abid Qureshi ◽

...

Keyword(s):

Multivariate Analysis ◽

Basilar Artery ◽

Perfusion Imaging ◽

Univariate Analysis ◽

Brain Regions ◽

Artery Occlusion ◽

Posterior Circulation ◽

Favorable Outcome ◽

Cerebellar Hemisphere ◽

Basilar Artery Occlusion

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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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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Timing of Recanalization After Microbubble-Enhanced Intravenous Thrombolysis in Basilar Artery Occlusion

Stroke ◽

10.1161/strokeaha.107.487454 ◽

2007 ◽

Vol 38 (11) ◽

pp. 2931-2934 ◽

Cited By ~ 22

Author(s):

Jorge Pagola ◽

Marc Ribo ◽

José Alvarez-Sabín ◽

Marcos Lange ◽

Marta Rubiera ◽

...

Keyword(s):

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Basilar Artery Occlusion

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Delayed Thrombosis of the Basilar Artery after Stenting for a Basilar Trunk Dissection Aneurysm

Interventional Neuroradiology ◽

10.1177/159101991001600110 ◽

2010 ◽

Vol 16 (1) ◽

pp. 77-82 ◽

Cited By ~ 7

Author(s):

L. Liu ◽

C. Jiang ◽

H. He ◽

Y. Li ◽

Z. Wu

Keyword(s):

Basilar Artery ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Basilar Artery Occlusion ◽

Aneurysm Neck ◽

Presenting Symptoms ◽

Venous Phase ◽

Digital Subtraction Angiogram ◽

Neurologically Normal ◽

Completion Angiography

A 30-year-old man was referred in our department for treatment of a midbasilar trunk aneurysm. His presenting symptoms included headache and dizziness. A CT scan at another hospital showed no significant findings whereas a digital subtraction angiogram disclosed a dissecting aneurysm in the midbasilar trunk, and there was severe stenosis in the basilar artery. After discussion, we planned to use stent-assisted-coil embolization technique. During the procedure, a LEO stent (Balt, Montmorency, France) was implanted into the basilar artery across the aneurysm neck, but fearing acute basilar artery occlusion because of stent collapse or thrombus we did not fill coils into the aneurysm. After the procedure, the completion angiography demonstrated considerably decreased flow into the aneurysm, with stasis persisting into the venous phase of angiography. The patient awoke from general anaesthesia after the procedure and had no additional neurological symptoms, he was discharged three days later and used clopidogrel and aspirin for antiplatelet therapy. Six months later when he was admitted for a recheck, a DSA showed the basilar artery was occluded completely and the aneurysm had disappeared even though the patient remained neurologically normal.

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