Thrombectomy in patients with basilar artery thrombosis

Introduction. This article is devoted to the discussion of a life-threatening condition - basilar artery thrombosis (BAT). The article presents the results of a comparative analysis of two groups of patients with angiographically confirmed BAT: with and without reperfusion therapy.Relevance. Basilar artery thrombosis is a life-threatening condition in which mortality can reach 95%, and severe neurological deficits and dependence in everyday life on others (modified Ran-kin Scale (mRS), score 4–5) are observed in 65% of surviving patients. Ischemic stroke (IS) due to BAT is diagnosed in 1–4% of patients with acute cerebrovascular event (ACVE). Currently, reperfusion therapy (RT) in the form of systemic thrombolytic therapy (sTLT) with rt-PA and/or thrombectomy (TE) is the only effective and safe method for treating patients with IS. In randomized trials, it was found that RT, whether it is sTLT, TE or a combination of these techniques, despite the best degree of functional recovery in patients by day 90 from the onset of the disease, does not lead to a statistically significant decrease in mortality. Nevertheless, the results of 10 prospective studies of the use of endovascular treatment in patients with IS in the posterior circulation system indicate that this type of therapy leads to a decrease in 90-day mortality from 95% to 16–47% in case of successful recanalization (mTICI (modified Thrombolysis in Cerebral Infarction), 2–b–3).Aim of study. To assess the safety and efficacy of TE in patients with BAT.Material and methods. This study included 15 patients with IS, admitted within the 6-hour therapeutic window, and confirmed BAT by CT and/or MRangiography. The baseline level of wakefulness was assessed using the Glasgow Coma Scale (GCS), and the severity of neurological deficit was assessed by the National Institutes of Health Stroke Scale (NIHSS).Results. Basilar artery thrombectomy was performed in 7 patients (endovascular treatment group), 8 patients received no endovascular treatment (standard therapy group). Good clinical outcomes by day 90 from the onset of the disease (mRS, score 0–2) were observed in 57.1% of patients in the endovascular treatment group and in 12.5% of patients in the standard therapy group. However, these differences were not statistically significant (p>0.05). There were also no differences between the two groups in functional outcomes and Rivermead mobility index (RMI) by day 90 from the onset of the disease (Barthel Index of Activities of Daily Living (BI) score 97±5.0 and 100, RMI score 14.0±0.0 and 15 in the endovascular treatment group and standard therapy group, respectively). Mortality by day 90 in the endovascular treatment group was 42.9% (3 patients), in the standard therapy group — 87.5% (7 patients). In the subgroup of patients with GCS score at admission no more than score 8, there was a statistically significant strong two-way negative correlation between TE performance and mortality (r=-1.0; p=0.000), as well as a positive correlation between TE and a Rankine score by day 90 (r=0.956; p=0.003). Mortality was statistically significantly lower in the endovascular treatment group compared to the standard therapy group (0% versus 100%, respectively, p=0.025). Clinical outcomes of the disease by day 90 were statistically significantly better in the endovascular treatment group: mRS, score 0–2 in 100% of cases versus 0% in the standard treatment group (p=0.028).Conclusion. Currently, the only effective treatment for basilar artery thrombosis is thrombectomy. The possibility of performing thromboectomy in these cases should be considered in all patients, regardless of the severity of the stroke and the decrease in the level of wakefulness, since endovascular treatment in this case is a life-saving procedure. The symptom of a hyperdense basilar artery can be used as a diagnostic tool for suspected basilar artery thrombosis, but should not rule out angiography. In our series of observations, the mortality rate in patients who underwent thrombectomy was 42.9%. Good functional outcomes (mRS, score 0–2) and the absence mobility limitation (RMI, score 14) were observed in 57.1% of patients by day 90 after thrombectomy.

Abstract 1122‐000230: Unique Clinical Finding of Localized Bifacial Hyperhydrosis in a Patient with Basilar Artery Thrombosis

Introduction : Sweating abnormalities accompanied with other neurological deficits have been reported after cerebral infarcts involving the operculum, medulla and pons; however, these have always caused hyperhydrosis of the entire unilateral side of the body including the face, arms and legs. Methods : A 59 year old male who was found unresponsive to verbal and noxious stimuli after being admitted to our hospital for a vascular surgery procedure. He did not withdraw to pain in any of the extremities including to sternal rub. Pupils were bilaterally equal and reactive to light and the patient did not have any facial asymmetry. He did have intact brainstem reflexes initially in the first day. He was admitted to the Medical ICU and a brain MRI was obtained after initial head CT head was found to be unremarkable. MRI demonstrated a large bilateral pontine acute infarct, more prominent on the left side. There was also acute infarction in the left thalamus as well as some involvement of left midbrain. An MRA of Brain showed complete occlusion of the mid‐distal basilar artery. Results : The patient subsequently was found to have excessive sweating of both sides of his face, forehead and head from day 1 of the stroke onwards. This occurred independent of the patient’s body temperature (37C) and room temperature (28C).The patient remained afebrile for the next few days; however, profuse sweating continued for the next two weeks when he passed away. The patient continued to remain intubated and unresponsive off sedation during this time. Conclusions : Pure Bifacial hyperhydrosis might indicate bilateral pontine lesions. This appears to be due to disruption of a putative inhibitory pathway that controls sweating of the contralateral face and body. This pathway originates in the operculum and ends in the sympathetic sudomotor neurons in the contralateral thoracic spinal cord via the hypothalamus and brainstem. It is likely that in our patient, only the bulbar fibers of this pathway were disrupted making the face the only part with excessive sweating.

Headache secondary to cerebrovascular disease

Objectives To discuss headache secondary to cerebrovascular disease. Background Headache is an important symptom in cerebrovascular diseases. In some conditions, headache is the leading symptom. Migraine is associated with an increased risk of stroke. Methods The authors undertook a literature search for the terms “headache” and “cerebrovascular diseases”. Results We report studies on headache in subarachnoidal hemorrhage, intracerebral hemorrhage, ischemic stroke, TIA, basilar artery thrombosis, cervical artery dissection, cerebellar stroke, arteritis and cerebral sinus venous thrombosis. In addition, we discuss migraine and stroke and thunderclap headache. Conclusions Headache is a leading symptom in many cerebrovascular diseases. Headache in combination with focal neurological deficits requires immediate diagnosis and treatment.

Management challenge of basilar artery occlusion in SUS: Case report

Context: Stroke caused by basilar artery occlusion is rare, corresponding to 1% of strokes. There is no consensus in the literature on the ideal management of this disease at acute phase. However, mechanical thrombectomy may be a viable treatment option. Case report: 68-year-old female, with no comorbidities, admitted to a secondary hospital 14h after headache, dizziness, vomiting and difficulty walking. She was disoriented, with severe dysarthria and dysphonia, horizontal and vertical ophthalmoparesis and pronation of the right upper limb (NIHSS: 4). Cranial tomography was normal and cranial angiotomography showed a basilar artery thrombosis. Patient was out of the window for intravenous thrombolysis and our hospital did not have another possibility of treatment. Due to high morbidity and mortality, also the possibility of neurological deterioration, medical contact was made with a tertiary hospital with hemodynamic service. During patient transference, she evolved with decreased level of consciousness, aphasia and tetraparesis (NIHSS: 18). Upon arrival at the hospital, a thrombectomy was performed due to an important clinical-radiological mismatch, 19 hours within symptoms onset and 3 hours after neurological worsening. After discharge, patient walked with assistance and physical examination showed a significant improvement in neurological deficits (NIHSS: 6). Conclusions: This case demonstrates the importance of engaging Brazil’s public health system in the management of acute ischemic stroke, especially in challenging cases such as basilar artery occlusion. This patient was the first admitted to our hospital to perform a thrombectomy after effective transference for a tertiary hospital and staff engagement of both hospitals.

Basilar artery thrombosis due to hyperhomocysteinemia treated conservatively: a therapeutic success

Basilar artery thrombosis is a rare and potentially fatal cause of posterior circulation stroke. Among the various etiologies, hyperhomocysteinemia is crucial and often under diagnosed, especially in developing countries. Authors describe the case of a 15-year male who presented with 1-day history of headache, vomiting and altered mental status. Non-contrast CT Head revealed multiple acute infarcts in posterior circulation of brain. Laboratory investigations revealed hyperhomocysteinemia. Contrast enhanced MRI Brain showed acute infarcts in bilateral cerebellar hemispheres, pons, midbrain, medulla and vermis. MR venography was suggestive of Basilar Artery thrombosis. Thrombolysis was not done due to delayed presentation; hence authors resorted to conservative management with folic acid and vitamin B supplementation. The patient showed gradual clinical improvement and had complete clinical recovery during follow up visit. A favorable outcome with conservative management of basilar artery thrombosis is rarely reported in literature.