Hemodynamic Differences Between Basilar Artery Fenestration and Normal Vertebrobasilar Artery: A Pilot Study

Background: Basilar artery fenestration has been proposed as a contributor to ischemic stroke, as unique flow patterns induced by fenestration may be related to thrombus formation or insufficiency. This study aimed to evaluate the hemodynamics of basilar artery fenestration (BAF) using computational fluid dynamics (CFD).Methods: Patients with BAF and normal vertebrobasilar system were recruited and separately evaluated using CFD. Specific geometric vascular models were reconstructed based on 3D-rotational angiography (3D-RA). Patients were divided into the BAF group and control group (i.e., patients with the normal vertebrobasilar system). Hemodynamic and geometric variables were calculated and compared between groups using Student's t-test or Wilcoxon rank-sum test.Results: Overall, 24 patients were included, with 12 patients each in the BAF group and the control group. The BAF group had a significantly smaller basilar artery diameter than the control group (3.1 ± 0.51 vs. 3.76 ± 0.4, p = 0.002). Compared to the control group, the BAF group had higher values of maxOSI (median, 0.3 vs. 0.09, p = 0.028), TAWSSG (median, 983.42 vs. 565.39, p = 0.038) in the flow confluence, higher SAR-TAWSSG in bifurcation (median, 70.22 vs. 27.65, p = 0.002) and higher SAR-TAWSSG in basilar artery (median, 48.75 vs. 16.17, p < 0.001) of the vertebrobasilar artery.Conclusions: This pilot study suggested that hemodynamic differences between BAF and normal vertebrobasilar artery across multiple shear flow parameters. The disturbed flow in the BAF may increase the risk of thrombus formation, plaque instability, and subsequent ischemic cerebrovascular events. These should be confirmed by future studies.

Acute Basilar Artery Occlusion Presenting With Convulsive Movements: A Systematic Review

Background and Purpose: Convulsive seizures related to posterior circulation stroke are considered rare. However, some patients with acute basilar artery occlusion (BAO) can present with convulsive movements. Misdiagnosed as seizures may delay the reperfusion therapy for acute BAO. In this study, we have summarized the clinical features and possible mechanisms of BAO presenting with convulsive movements.Methods: We performed an Institutional Review Board-approved institutional database query from 2015 to 2020 and a literature search of the online database PubMed. Clinical data were collected and analyzed.Results: In total, 14 patients with acute BAO presented with convulsions. There were 10 men and 4 women, with a mean age of 53 (range, 23–77) years. All of these patients had different degrees of impaired consciousness (100.0%, 14/14). Convulsive movements were the initial symptoms in 78.6% (11/14) of patients. Further, 64.3% (9/14) of patients presented with paralysis or cranial nerve abnormalities, and 85.7% (12/14) of patients were treated with reperfusion therapy (thrombolysis, 35.7% [5/14]; endovascular thrombectomy, 64.3% [9/14]). The BAO etiology and mechanism were related to embolism, vessel dissections, and severe stenosis of the right vertebral artery in 57.1% (8/14), 21.4% (3/14), and 7.1% (1/14) of patients, respectively; they were undefined in 14.3% (2/14) of patients. Moreover, 42.9% (6/14) of patients had a 90-day modified Rankin Scale score of 0–2, and the mortality rate was 21.4% (3/14).Conclusions: Acute BAO, especially that related to embolism or vessel dissection, may present with convulsive movements. Acute BAO is a devastating, but treatable disease if diagnosed in time. Considering the possibility of BAO is important when dealing with patients presenting with acute-onset convulsive movements. Prompt diagnosis and reperfusion therapy may help achieve a better prognosis.

Frontline thrombectomy strategy and outcome in acute basilar artery occlusion

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.

Higher baseline blood glucose is associated with reduced likelihood for successful recanalization in patients with basilar artery occlusion

Purpose Evidence regarding the effect of mechanical thrombectomy (MT) of basilar artery occlusion (BAO) stroke is yet sparse. As successful recanalization has been suggested as major determinant of outcome, the early identification of modifiable factors associated with successful recanalization could be of importance to improve functional outcome. Hyperglycemia has been associated with enhanced thrombin generation and unfavorably altered clot features. Objective We hypothesized that serum baseline glucose is associated with likelihood of vessel recanalization mediated by collateral quality and clot burden in BAO stroke. Methods BAO stroke patients who received multimodal CT on admission were analyzed. The association of vessel recanalization defined using modified Thrombolysis in cerebral infarction scale (mTICI) scores 2b-3, and baseline imaging and clinical parameters were tested in logistic regression analyses. Collateral quality and clot burden were evaluated using the Basilar Artery on CT-Angiography (BATMAN) score. Results Out of 117 BAO patients, 91 patients (78%) underwent MT. In 70 patients (77%), successful recanalization could be achieved (mTICI 2b/3). In multivariable logistic regression analysis, only a higher BGL (aOR 0.97, 95% CI 0.96–0.99, p = 0.03) and higher BATMAN score (aOR 1.77, 95% CI 1.11–2.82, p = 0.02) were independently associated with vessel recanalization. Application of alteplase, or time from symptom onset-imaging revealed no independent association with recanalization status. Conclusion Higher BGL was significantly associated with reduced likelihood for recanalization success besides BATMAN score as a measure of collateral quality and clot burden. BGL could be tested as a modifiable parameter to increase likelihood for recanalization in BAO stroke, aiming to improve functional outcome.