Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review

Basilar Stenosis Reduces the Impact of Successful Recanalization on Outcome in Basilar Artery Occlusion

BACKGROUND

Evidence from randomized controlled trials has shown a benefit for endovascular treatment in basilar artery occlusion. We aimed to show the effect of the recanalization result on outcome and determine the role of underlying basilar stenosis in a real-world setting.

METHODS

A retrospective, single-center study of patients who received endovascular treatment for basilar artery occlusion from March 2008 to June 2022 was conducted. Clinical and outcome characteristics were gathered. Multivariate logistic regression analysis was performed to predict poor outcomes (post-treatment mRS 5 or 6). MRS shift analysis was performed.

RESULTS

This study includes 210 patients (mean age, 71.4 years +/- 13.3 [standard deviation]; 124 men). The variables age (OR, 1.04; 95% CI: 1.01-1.08; p = 0.014), underlying basilar stenosis (OR: 4.86; 95% CI: 2.15-10.98; p < 0.001), admission NHISS (OR: 1.09; 95% CI: 1.04-1.13; p < 0.001), and TICI (OR: 1.89; 95% CI: 1.09-3.25; p = 0.022) independently predicted a poor outcome. Patients with occlusions due to underlying stenosis had significantly worse recanalization rates. Median post-treatment mRS in all patients with embolic occlusion was 4; IQR, 2-5 (only patients with embolic occlusion: mTICI 0-2a, median: 5 [IQR, 4-5.5]; mTICI 2b, median: 4 [IQR, 2.5-6]; mTICI 3, median: 3 [IQR, 1-5]; p = 0.037). Median post-treatment mRS in all patients with occlusions due to underlying stenosis was 5; IQR, 4-6 (only patients with embolic occlusions: mTICI 0-2a, median: 6 [IQR, 4.5-6]; mTICI 2b, median: 6 [IQR, 4.25-6]; mTICI 3, median: 5 [IQR, 3.5-5.25]; p = 0.059).

CONCLUSIONS

Successful recanalization is essential for preventing poor outcomes in basilar artery occlusion. Underlying basilar stenosis diminishes the effect of successful recanalization on the overall outcome.

Predictors of outcome and symptomatic intracranial hemorrhage in acute basilar artery occlusions: Analysis of the PC-SEARCH thrombectomy registry

INTRODUCTION

Recent randomized controlled trials demonstrated superiority of mechanical thrombectomy compared to medical therapy in acute basilar artery occlusions, however, little data is available to guide clinicians in functional prognosis and risk stratification.

PATIENTS AND METHODS

Data from the retrospectively established PC-SEARCH Thrombectomy registry, which included patients with basilar artery occlusion from eight sites from January 2015 to December 2021, was interrogated. Outcomes were dichotomized into 90-day favorable (mRS ⩽ 3) and unfavorable (mRS > 3). Multivariate logistic regression analysis was performed with respect to the outcome groups and were adjusted for potential confounding baseline characteristics.

RESULTS

Four-hundred-forty-four patients were included in this analysis. Mean age was 66 [SD 15], with 56% male, and comprised of 76% Caucasian. Patients presented with an initial median NIHSS of 18 and 199 patients (44.8%) achieved favorable 90-day functional outcomes. Independent predictors of favorable outcomes included younger age, pc-ASPECTS > 8 (OR 2.30 p < 0.001), and TICI ⩾ 2b (OR 7.56 p < 0.001). Unfavorable outcomes were associated with increasing number of passes (OR 1.29 p = 0.004) and sICH (OR 4.19 p = 0.015). IA-tPA was an independent risk factor for sICH (OR 7.15 p = 0.002) without improving favorable functional outcomes.

CONCLUSION AND DISCUSSION

PC-ASPECTS > 8, successful recanalization (TICI ⩾ 2b), first-pass recanalization, and younger age are independent predictors of favorable 90-day functional outcome in thrombectomy treated patients with acute basilar artery occlusion. Conversely, sICH were independent predictors of unfavorable outcomes. IA-tPA and unsuccessful recanalization are independently associated with sICH.

A case of acute basilar artery occlusion due to atherosclerotic disease revascularized by drug-coated balloon dilation

Acute basilar artery occlusion (ABAO) accounts for 1% of all ischemic stroke cases, but has a high rate of severe complications and mortality (75-91%). Intracranial atherosclerosis is an significant cause of ischemic stroke. Revascularization using stents has shown good efficacy. However, intra-stent thrombosis and in-stent restenosis (ISR) are significant complications following stent placement. Drug-coated balloons (DCB), coated with the anti-proliferative drug paclitaxel (an inhibitor of endothelial proliferation), can prevent in-stent restenosis. Successful use of DCB dilation in the coronary and lower extremity vasculature has been reported. In our case, a 68-year-old Chinese male with ABAO was successfully revascularized by DCB dilation and showed dramatic improvement in stroke symptoms. This report may inform future treatment of patients with ABAO.

Association of Renal Impairment with Clinical Outcomes Following Endovascular Therapy in Acute Basilar Artery Occlusion

Purpose

Renal impairment (RI) is associated with unfavourable outcome after acute ischaemic stroke with anterior circulation large vessel occlusion. We assessed the association of RI with clinical outcomes in patients with acute basilar artery occlusion (ABAO), and the impact of RI on the effects of endovascular therapy (EVT) versus standard medical treatment (SMT).

Patients and Methods

We used data from the BASILAR registry, an observational, prospective, nationwide study of patients with ABAO in routine clinical practice in China. Baseline estimated glomerular filtration rate (eGFR) was recorded at admission. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included favourable outcome (mRS score 0-3), mortality, and symptomatic intracranial haemorrhage (sICH). Multivariate logistic regression was used to assess the association of RI with mortality and functional improvement at 90 days.

Results

Among 829 patients enrolled, 747 patients were analysed. The median baseline eGFR was 89 mL/min/1.73m2 (IQR, 71-100), and 350 (46.8%), 297 (39.8%), and 100 (13.4%) patients had baseline eGFR values of ≥90, 60-89, and <60 mL/min/1.73m2, respectively. RI was associated with increased mortality (adjusted odds ratio [aOR], 1.97; 95% CI, 1.15-3.67) at 90 days and decreased survival probability (aOR 1.74; 95% CI, 1.30-2.33) within 1 year. EVT was associated with better functional improvement (common aOR, 2.50; 95% CI, 1.43-4.35), favourable outcome (aOR 5.42; 95% CI, 1.92-15.29) and lower mortality (aOR 0.47; 95% CI, 0.25-0.88) in ABAO patients with eGFR ≥90 mL/min/1.73m2. However, RI was not modified the relationship of EVT with functional improvement (common aOR, 3.03; 95% CI, 0.81-11.11), favourable outcome (aOR 2.10; 95% CI, 0.45-9.79), and mortality (aOR 0.56; 95% CI, 0.15-2.06) by eGFR categories.

Conclusion

RI is associated with reduced efficacy of EVT and worse functional outcome and higher mortality at 3 months and lower survival probability at 1 year in patients with ABAO.

Outcome of Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Patients with Intracranial Atherosclerotic Disease

INTRODUCTION

Intracranial atherosclerotic disease (ICAD) has been identified as a major cause of acute basilar artery occlusion (BAO).This study compared the characteristics and treatment outcomes in acute BAO patients with and without ICAD.

METHODS

A prospective cohort study was conducted at 115 People's Hospital, Ho Chi Minh city, Vietnam from August 2021 to June 2023. Patients with acute BAO who underwent endovascular treatment within 24 h from symptom onset were included (thrombectomy alone or bridging with intravenous alteplase). The baseline characteristics and outcomes were analyzed and compared between patients with and without ICAD. Good functional outcome was defined as mRS ≤3 at 90 days.

RESULTS

Among the 208 patients enrolled, 112 (53.8%) patients were categorized in the ICAD group, and 96 (46.2%) in the non-ICAD group. Occlusion in the proximal segment of the basilar artery was more common in patients with ICAD (55.4% vs. 21.9%, p < 0.001), whereas the distal segment was the most common location in the non-ICAD group (58.3% vs. 10.7%, p < 0.001). Patients in the ICAD group were more likely to undergo treatment in the late window, with a higher mean onset-to-treatment time compared to the non-ICAD group (11.6 vs. 9.5 h, p = 0.01). In multivariable logistic regression analysis, distal segment BAO was negatively associated with ICAD (aOR 0.13, 95% CI: 0.05-0.32, p < 0.001), while dyslipidemia showed a positive association (aOR 2.44, 95% CI: 1.15-5.17, p = 0.02). There was a higher rate for rescue stenting in the ICAD compared to non-ICAD group (15.2% vs. 0%, p < 0.001). However, no significant differences were found between the two groups in terms of good outcome (45.5% vs. 44.8%, p = 0.91), symptomatic hemorrhage rates (4.5% vs. 8.3%, p = 0.25), and mortality (42% vs. 50%, p = 0.25).

CONCLUSION

ICAD was a common etiology in patients with BAO. The location segment of BAO and dyslipidemia were associated with ICAD in patients with BAO. There was no difference in 90-day outcomes between BAO patients with and without ICAD undergoing endovascular therapy.

General anesthesia vs. conscious sedation and local anesthesia for endovascular treatment in patients with posterior circulation acute ischemic stroke: An updated systematic review and meta-analysis

INTRODUCTION

The best anesthetic choice for patients with acute posterior circulation stroke during endovascular treatment (EVT) remains uncertain.

METHOD

We searched five databases to identify studies that met the inclusion criteria. Our primary outcome measure was functional independence (FI). Secondary outcomes were 3-month mortality, any intracranial hemorrhage (ICH), symptomatic ICH (sICH), successful reperfusion, and procedure- and ventilator-associated complications.

RESULTS

A total of 10 studies were included in our meta-analysis. No significant differences were detected between the general anesthesia (GA) and conscious sedation and local anesthesia (CS/LA) groups in 3-month FI (nine studies; OR=0.69; 95% CI 0.45-1.06; P=0.083; I2=66%;), 3-month mortality (nine studies; OR=1.41; 95% CI 0.94-2.11; P=0.096; I2=61.2%;), any ICH (three studies; OR=0.75; 95% CI 0.44-1.25; P=0.269; I2=0%;), or sICH (six studies; OR=0.64; 95% CI 0.40-1.04; P=0.073; I2=0%;). No significant differences were observed for successful reperfusion (10 studies; OR=1.17; 95% CI 0.91-1.49; P=0.219; I2=0%;), procedure-related complications (four studies; OR=1.14; 95% CI 0.70-1.87; P=0.603; I2=7.9%;), or respiratory complications (four studies; OR=1.19; 95% CI 0.61-2.32; P=0.616; I2=64.9%;) between the two groups.

CONCLUSIONS

Our study showed no differences in 3-month FI, 3-month mortality, and successful reperfusion between patients treated with GA and those treated with CS/LA. Additionally, no increased risk of hemorrhagic transformation or pulmonary infection was observed in the CS/LA group. These results indicate that CS/LA may be an EVT option for acute posterior circulation stroke patients.

Nomogram model of functional outcome for endovascular treatment in patients with acute basilar artery occlusion

Background and purpose

The efficacy and safety of endovascular treatment (EVT) in acute basilar artery occlusion (ABAO) has been confirmed by four randomized clinical trials. Nevertheless, the predictors of a 90-day favorable outcome after EVT have not been elucidated. We attempted to establish a nomogram for the prediction of a 90-day favorable outcome in ABAO patients with EVT.

Methods

Clinical data of ABAO patients with EVT were obtained from two nationwide clinical trial registries in China. Factors associated with a 90-day favorable outcome were screened by multivariable step-wise regression on the basis of univariable analysis. A nomogram was established to predict 90-day favorable outcome after EVT.

Results

The proportion of ABAO patients with a favorable outcome was 41.53% (157/378). Seven variables, including baseline National Institutes of Health Stroke Scale (NIHSS) <20 [odds ratio (OR): 8.330; P-value < 0.0001], posterior circulation Alberta Stroke Program Early CT (pc-ASPECT) score ≥7 (OR: 1.948; P-value = 0.0296), Pons-Midbrain Index (PMI) score < 2 (OR: 2.108; P-value = 0.0128), Posterior Circulation Collateral Score (PC-CS) ≥5 (OR: 3.288; P-value < 0.0001), local anesthesia (OR: 0.389; P-value = 0.0017), time from onset to recanalization (OTR) <330 min (OR: 2.594; P-value = 0.0013), and no occurrence of early neurological deterioration (END; OR: 0.039; P-value < 0.0001) were included into the nomogram, with C-index values of 0.8730 and 0.8857 in the training and the internal validation set, respectively.

Conclusions

The proposed nomogram provided a reliable prognostic scale, which can be employed in clinical settings for the selection and clinical management of ABAO patients.

Registration

https://www.clinicaltrials.gov, identifier: NCT03370939.

The Efficacy and Safety of Mechanical Thrombectomy in Posterior Circulation Large Vessel Occlusion as Compared to Anterior Circulation Large Vessel Occlusion: A Systematic Review

Mechanical thrombectomy (MT) has been established as a standard of care for patients with stroke due to anterior circulation large vessel occlusion (AC-LVO). Due to a lack of robust evidence for the effectiveness of mechanical thrombectomy, intravenous thrombolysis (IVT) is still the only approved first-line acute reperfusion strategy for posterior circulation large vessel occlusion (PC-LVO). This systematic review analyzes and reports on the effectiveness and safety of MT in PC-LVO. A literature review was performed to identify all studies of patients with acute ischemic stroke due to PC-LVO who underwent MT with second-generation devices (stent retrievers and/or aspiration devices) that were reported between January 2017 and January 2023. The primary outcome was functional independence at 90 days, defined as a modified Rankin (mRS) score of ≤2. Secondary outcomes were successful recanalization (modified treatment in cerebral infarction score (mTICI) 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days post-procedure. We looked at 13 studies with a total of 30,407 participants in four meta-analyses and 5951 participants in nine observational studies. In most studies, patients in the PC-LVO group were male and younger than the AC-LVO group. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score, lower rates of IVT, longer onset-to-groin puncture time, lower likelihood of sICH, higher 90-day mortality rates, and higher futile recanalization rates were frequently observed in the PC-LVO group with a large discrepancy in the likelihood of functional independence at 90 days with majority studies showing comparable rates. Hence, in patients with acute ischemic stroke caused by the PC-LVO, successful reperfusion can be achieved via MT, though at the cost of higher mortality rates. Such futile recanalization can be avoided with the refinement of procedures through technical improvements, skills training, and recognition of reliable predictors associated with it, which might help increase the efficacy of MT in PC-LVO. Additionally, future large-scale RCTs comparing patient selection and interventional strategies to avoid futile interventions are also needed.

Prognostic factors for acute vertebrobasilar artery occlusion-reperfusion: a multicenter retrospective cohort study

BACKGROUND

This study aimed to analyze the long-term prognostic factors in acute vertebrobasilar artery occlusion (VBAO) patients treated with endovascular treatment (EVT).

METHODS

This study was performed using the acute posterior circulation ischemic stroke registry database from 21 stroke centers in 18 cities in China and retrospectively included consecutive patients aged 18 years or older with an acute, symptomatic, radiologically confirmed VBAO who were treated with EVT between December 2015 and December 2018. Favorable clinical outcomes were evaluated by machine-learning methods. A clinical signature was constructed in the training cohort using the least absolute shrinkage and selection operator regression and was validated in the validation cohort.

RESULTS

From 28 potential factors, 7 variables were independent prognostic factors and were included in the model: Modified Thrombolysis in Cerebral Infarction (M) [odds ratio (OR): 2.900; 95% confidence interval [CI]: 1.566-5.370], age (A) (OR, 0.977; 95% CI: 0.961-0.993), National Institutes of Health Stroke Scale (N) (13-27 vs. ≤12: OR, 0.491; 95% CI: 0.275-0.876; ≥28 vs. ≤12: OR, 0.148; 95% CI: 0.076-0.289), atrial fibrillation (A) (OR, 2.383; 95% CI: 1.444-3.933), Glasgow Coma Scale (G) (OR, 2.339; 95% CI: 1.383-3.957), endovascular stent-retriever thrombectomy (E) (stent-retriever vs. aspiration: OR, 0.375; 95% CI: 0.156-0.902), and estimated time of onset of the occlusion to groin puncture (Time) (OR, 0.950; 95% CI: 0.909-0.993) (abbreviated as MANAGE Time). In the internal validation set, this model was well calibrated with good discrimination [C-index (95% CI)=0.790 (0.755-0.826)]. A calculator based on the model can be found online ( http://ody-wong.shinyapps.io/1yearFCO/ ).

CONCLUSION

Our results indicate that optimizing for EVT, along with specific risk stratification, may improve long-term prognosis. However, a larger prospective study is needed to confirm the findings.

Factors influencing the prognosis of acute basilar artery occlusion patients treated endovascularly: the impact of treatment time window and preoperative symptoms

Objective

The aim of this study was to examine the factors influencing the prognosis of patients diagnosed with acute basilar artery occlusion (BAO) who receive endovascular treatment. Our particular emphasis was on the predictive implications of the time window for treatment (from symptom onset to femoral artery puncture) and preoperative symptoms for prognosis.

Methods

A retrospective analysis of data collected from 51 BAO patients who received endovascular treatment at the Neurosurgery Department of Jinhua Central Hospital from April 2018 to October 2021 was undertaken. The data included immediate post-interventional recanalization rates and the 90-day clinical prognoses of the patients. We used the Modified Rankin Scale (mRs) to categorize patients into two prognosis groups: a favorable prognosis group (mRs score ≤2) and an unfavorable prognosis group (mRs score >2). Preoperative symptoms were gauged using the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores. A logistic regression analysis was conducted to identify risk factors affecting the prognosis of BAO patients following endovascular treatment.

Results

The procedure resulted in complete recanalization in all patients (100%). However, four patients (7.8%) passed away during the postoperative hospitalization period. The remaining 47 patients were followed up for 3 months. It was found that 15 patients (31.91%) had a favorable prognosis, while 32 (68.09%) had an unfavorable prognosis. It was generally observed that patients with an unfavorable prognosis had notably higher preoperative GCS and NIHSS scores (p < 0.05). Logistic regression analysis revealed that preoperative symptom severity, as indicated by NIHSS score, and treatment time window were significant prognostic risk factors for patients undergoing endovascular treatment for BAO (p < 0.05).

Conclusion

Endovascular intervention for BAO appears to be safe and effective, with greater likelihood of a favorable prognosis in patients treated within ≤6 h. The chances of favorable prognosis could potentially be linked to the severity of the patient's preoperative symptoms.

Mechanical Thrombectomy for Stroke Due to Acute Basilar Artery Occlusion, a Safety and Efficacy Analysis

BACKGROUND

Acute basilar artery occlusion accounts for 1% of all ischemic strokes but often leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for these patients; however, there is increasing evidence that mechanical thrombectomy (MT) for these patients leads to better outcomes.

OBJECTIVE

To assess the safety and efficacy of MT for patients presenting with acute basilar artery occlusion (BAO).

METHODS

This study was a retrospective chart review of a prospectively maintained database for patients with acute BAO treated with MT from January 2014 through March 2022.

RESULTS

Our study included a total of 74 patients. The mean age was 62.7 years, and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes, and the mean procedure time was 54 minutes. 86.5% of patients had a good modified treatment in cerebral ischemia score (≥2b). There were 4 patients who had procedural complications and 3 who had symptomatic intracerebral hemorrhage. At 90 days, 62.5% of patients had a modified Rankin Scale, 0 to 3. The mortality rate was 32.4% and 2% during hospital admission and 90 days, respectively. On univariate analysis, adjunctive angioplasty/stenting and higher presenting National Institutes of Health Stroke Scale score were associated with modified Rankin Scale 4 to 6 at 90 days ( P -value, .03 and <.001, respectively). Shorter procedure time was associated with modified treatment in cerebral ischemia score ≥ 2b ( P -value, .0015).

CONCLUSION

Our findings showed that MT is safe and effective for patients presenting with acute BAO and is in conjunction with previous literature. The results from upcoming trials should hopefully establish MT as gold standard for these patients.

Functional recovery continues beyond 3 months post-basilar artery thrombectomy: A retrospective cohort study

INTRODUCTION

Untreated basilar artery occlusion (BAO) carries 70% mortality. Guidelines recommend thrombectomy with or without thrombolysis.

AIM

We compared Modified Rankin Scores (mRS) at 3 and 12 months post thrombectomy to determine benefit of long-term follow up.

METHODS

Retrospective, single centre analysis of BAO thrombectomies between 2015 and 2019. Inclusion criteria were symptomatic BAO on CT angiography, absent early ischemic changes, premorbid independence and intervention within 24 h. All received stroke ward care. Results were analysed with simple statistics and binary logistic regression as appropriate.

RESULTS

Of 82 patients: most were male (61%, 50/82) with median age 68 years (IQR 17 years) and median NIHSS 14 (IQR 15). Median door-to-puncture time was 42 min (IQR 72 min). Total deaths were 34.1% (28/82) at 3 months, and 37.8% (31/82) at 12 months. Of 51 patients alive at 12 months: 41% (21/51) had improved mRS, 16% (8/51) had worse mRS and 43% (22/51) had unchanged mRS, compared to 3 months. Improvements to mRS were: one point in 57.1% (14/21), two points in 28.9% (6/21) and three points in 4.8% (1/21). Nursing home admission was avoided in 11.8% (6/51) who improved from mRS4. Increased age was associated with decreased likelihood of reaching the primary outcome OR 0.87, 95% CI 0.76-0.99 (p value = 0.03).

CONCLUSION

Over a quarter of patients improved beyond 3 months. Future studies should adopt long-term follow up as primary outcome.

Effect of endovascular treatment within 6 hours for acute basilar artery occlusion

OBJECTIVE

The aim of this study was to investigate the efficacy and safety of endovascular treatment (EVT) plus standard medical treatment (SMT) in patients with acute basilar artery occlusion (BAO) within 6 hours of the estimated occlusion time, based on a Chinese population.

METHODS

The authors selected patients from the Endovascular Treatment of Acute Basilar Artery Occlusion Study (BASILAR) registry, which was a nationwide prospective registry, within 6 hours after the estimated time of onset of a stroke in acute BAO. Patients were divided into the SMT-alone group or the EVT+SMT group according to treatment modalities. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale score between 0 and 3 at 90 days. Safety outcomes included death at 90 days and symptomatic intracerebral hemorrhage.

RESULTS

The authors assessed 590 patients for eligibility. Of these patients, 127 received SMT alone and 463 were treated with EVT plus SMT. EVT was associated with a higher rate of a favorable functional outcome (adjusted OR 3.804, 95% CI 1.890-7.658; p < 0.001) and a lower proportion of deaths at 90 days (adjusted OR 0.364, 95% CI 0.223-0.594; p < 0.001). Lower age (adjusted OR 0.978, 95% CI 0.960-0.997; p = 0.022); lower baseline National Institutes of Health Stroke Scale score (adjusted OR 0.926, 95% CI 0.902-0.950; p < 0.001); higher baseline posterior circulation Alberta Stroke Program Early CT Score (adjusted OR 1.681, 95% CI 1.424-1.984; p < 0.001); absence of diabetes mellitus (adjusted OR 0.482, 95% CI 0.267-0.871; p = 0.016); and modified Thrombolysis in Cerebral Infarction scores 2b-3 (adjusted OR 5.117, 95% CI 2.304-11.367; p < 0.001) were independent factors for a favorable outcome in the EVT+SMT group.

CONCLUSIONS

Based on the study design, patients with acute BAO who received EVT within 6 hours were associated with improved favorable outcome and decreased deaths compared with patients who received SMT. Predictors of desirable outcome in patients undergoing EVT included lower age, lower baseline National Institutes of Health Stroke Scale score, higher baseline posterior circulation Alberta Stroke Program Early CT Score, absence of diabetes mellitus, and modified Thrombolysis in Cerebral Infarction scores 2b-3.

Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results?

Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.

Futile Recanalization After Endovascular Treatment in Patients With Acute Basilar Artery Occlusion

BACKGROUND

It is estimated that >50% of acute basilar artery occlusion (ABAO) patients with successful reperfusion after endovascular treatment (EVT) have futile recanalization. However, few studies investigated the reasons behind this.

OBJECTIVE

To identify the factors associated with futile recanalization in ABAO after successful reperfusion.

METHODS

We recruited patients with successful reperfusion (expanded Thrombolysis In Cerebral Infarction score of ≥2b) after EVT from the Basilar Artery Occlusion Study registry. Patients were divided into meaningful recanalization (90-day modified Rankin Scale 0-3) and futile recanalization (90-day modified Rankin Scale 4-6) groups. Multivariable logistic regression analyses were used to identify the predictors of futile recanalization.

RESULTS

A total of 522 patients with successful reperfusion were selected. Of these, 328 patients had futile recanalization and 194 had meaningful recanalization. Multivariable logistic regression shows that higher neutrophil-to-lymphocyte ratio ( P = .01), higher baseline National Institutes of Health Stroke Scale score ( P < .001), longer puncture to recanalization time ( P = .02), lower baseline posterior circulation Alberta Stroke Program Early CT score ( P < .001), lower posterior circulation collateral score ( P = .02), incomplete reperfusion ( P < .001), and diabetes mellitus ( P < .001) were predictors of futile recanalization.

CONCLUSION

Higher neutrophil-to-lymphocyte ratio, longer puncture to recanalization time, incomplete reperfusion, stroke severity, lower baseline posterior circulation Alberta Stroke Program Early CT score, poor collaterals, and diabetes mellitus were independent predictors of futile recanalization in patients with ABAO with successful reperfusion after EVT. Moreover, multiple stent retriever passes were associated with a high proportion of futile recanalization in patients with late time windows.

Influence of tirofiban on stroke outcome after mechanical thrombectomy in acute vertebrobasilar artery occlusion

BACKGROUND

Even undergoing mechanical thrombectomy (MT), patients with acute vertebrobasilar artery occlusion (AVBAO) still have a high rate of mortality. Tirofiban is a novel antiplatelet agent which is now widely empirically used in acute ischemic stroke (AIS). In this study, we aimed to evaluate the safety and efficacy of tirofiban as adjunctive therapy for MT in AVBAO.

METHODS

From October 2016 to July 2021, consecutive AVBAO patients receiving MT were included in the prospective stroke registry. The short-term outcomes were (1) symptomatic intracerebral hemorrhage (sICH); (2) in-hospital death; (3) National Institute of Health Stroke Scale (NIHSS) at discharge. The Long-term outcomes were: (1) modified Rankin Scale (mRS) at 3 months; (2) death at 3 months.

RESULTS

A total of 130 eligible patients were included in the study, 64 (49.2%) patients received tirofiban. In multivariate regression analysis, no significant differences were observed in all outcomes between the tirofiban and non-tirofiban group [sICH (adjusted OR 0.96; 95% CI, 0.12-7.82, p = 0.97), in-hospital death (adjusted OR 0.57; 95% CI, 0.17-1.89, p = 0.36), NIHSS at discharge (95% CI, -2.14-8.63, p = 0.24), mRS (adjusted OR 1.20; 95% CI, 0.40-3.62, p = 0.75), and death at 3 months (adjusted OR 0.83; 95% CI, 0.24-2.90, p = 0.77)].

CONCLUSIONS

In AVBAO, tirofiban adjunctive to MT was not associated with an increased risk of sICH. Short-term (in-hospital death, NIHSS at discharge) and long-term outcomes (mRS and death at 3 months) seem not to be influenced by tirofiban use.

Association of Intravenous Tirofiban with Functional Outcomes in Acute Ischemic Stroke Patients with Acute Basilar Artery Occlusion Receiving Endovascular Thrombectomy

INTRODUCTION

The aim of this study was to test the hypothesis that intravenous tirofiban improves functional outcomes without promoting the risk of intracranial hemorrhage (ICH) in stroke secondary to basilar artery occlusion (BAO) receiving endovascular thrombectomy.

METHODS

Patients with acute BAO stroke who were treated with endovascular thrombectomy and had tirofiban treatment information were derived from "BASILAR": a nationwide, prospective registry. All eligible patients were divided into tirofiban and no-tirofiban groups according to whether tirofiban was used intravenously. The primary endpoint was the 90-day severity of disability as assessed by the modified Rankin scale score. Safety outcomes were the frequency of ICH and mortality.

RESULTS

Of 645 patients included in this cohort, 363 were in the tirofiban group and 282 were in the no-tirofiban group. Thrombectomy with intravenous tirofiban reduced the 90-day disability level over the range of the modified Rankin scale (adjusted common odds ratio, 2.08; 95% confidence interval (CI), 1.45-2.97; p < 0.001). The 90-day mortality of patients in the tirofiban group was lower than that in the no-tirofiban group (41.6% vs. 52.1%; adjusted hazard ratio, 0.60; 95% CI, 0.47-0.77; p < 0.001). The frequency of any ICH (6.7% vs. 13.7%; p = 0.004) and symptomatic ICH (4.8% vs. 10.1%; p = 0.01) in the tirofiban group was significantly lower than that in the no-tirofiban group.

CONCLUSIONS

In patients with acute BAO stroke who underwent endovascular treatment, intravenous tirofiban might be associated with favorable outcome, reduced mortality, and a decreased frequency of ICH.

Endovascular treatment in patients with coma that developed secondary to acute basilar artery occlusion

OBJECTIVE

This study aimed to evaluate the efficacy of endovascular treatment (EVT) in patients with secondary coma following acute basilar artery occlusion (comatose patients) and to identify the impact of the Glasgow Coma Scale (GCS) score on medical decisions.

METHODS

Patients from the Endovascular Treatment for Acute Basilar Artery Occlusion study were divided into comatose and noncomatose cohorts. The primary outcome was favorable functional independence (modified Rankin Scale [mRS] scores 0-3). The safety outcome was 90-day mortality. Subgroup analysis was performed to identify populations best suited for EVT. Multivariate logistic regression was used to identify independent predictive factors of clinical outcomes.

RESULTS

Comatose patients who underwent EVT had more favorable functional outcomes and lower mortality compared with those who underwent standard medical treatment (functional outcomes: 15.98% vs 4.17%; mortality: 62.72% vs 82.29%). Moreover, EVT was associated with better outcomes in the cohort with GCS scores of 6-8 (mRS scores 0-3, 25.33% and mortality, 41.33%) than in the cohort with GCS scores of 3-5. Multivariate analysis indicated that EVT was an independent factor for favorable functional outcomes (adjusted OR 8.921, 95% CI 2.330-34.158) and mortality (adjusted OR 0.189, 95% CI 0.092-0.411) in comatose patients. The initial GCS score was an independent factor for favorable functional outcomes (adjusted OR 1.402, 95% CI 1.115-1.763) and mortality (adjusted OR 0.613, 95% CI 0.499-0.752) in comatose patients with EVT.

CONCLUSIONS

EVT significantly improved the prognosis of comatose patients, and patients with GCS scores of 6-8 were found to benefit more from EVT than those with GCS scores of 3-5. The initial GCS score was an independent predictive factor for prognosis in comatose patients.

Which is the most effective rescue treatment after the failure of mechanical thrombectomy for acute basilar artery occlusion?

Objective

The aim of this study was to evaluate the effectiveness and safety of rescue therapy, a therapy in which rescue devices such as balloon angioplasty, Apollo stent, Wingspan stent, Solitaire stent, or other self-expanding stents are used after the failure of mechanical thrombectomy (MT) and to determine the most effective rescue measure for acute basilar artery occlusion (BAO) after the failure of MT.

Methods

For this study, we recruited patients from the BASILAR registry. All participants were divided into three groups: the recanalized with rescue therapy group, the recanalized without rescue therapy group, and the non-recanalized group. Clinical outcomes at 90 days and 1 year were compared. The association of rescue measures with favorable outcomes (modified Rankin Scale [mRS] score of 0–3) in patients achieving successful recanalization via rescue therapy was estimated using multivariate logistic regression analyses.

Results

Among the participants, recanalization failure was found in 112 patients and successful recanalization in 473 patients, with 218 patients receiving rescue therapy and 255 patients without rescue therapy. Of these, 111 (43.5%) patients in the recanalized without rescue therapy group, 65 (29.8%) patients in the recanalized with rescue therapy group, and nine (8.0%) patients in the non-recanalized group achieved favorable outcomes at 90 days. Both the recanalization with rescue therapy and the recanalization without rescue therapy groups were associated with favorable outcomes at 90 days and 1 year compared with the non-recanalized group. Moreover, in patients receiving rescue therapy, Wingspan stents, Apollo stents, and balloon angioplasty were associated with higher rates of favorable outcomes at 90 days and 1 year than Solitaire stents.

Conclusion

Whether rescue therapy is administered or not, recanalization leads to favorable outcomes in patients with acute BAO. For acute BAO after MT failure, balloon angioplasty, Wingspan stenting, and Apollo stenting could be considered effective and safe rescue options but not Solitaire stenting.

Mechanical thrombectomy for vertebral and basilar artery occlusions: An institutional experience with 17 patients

Acute ischemic stroke of the posterior circulation as a result of vertebrobasilar artery occlusions is often associated with severe morbidity and mortality rates. Vertebrobasilar artery occlusion retrieval via mechanical thrombectomy (MT) is a novel treatment modality for occlusive strokes. Nevertheless, factors associated with positive outcomes have not yet been adequately investigated. Thus, the present study focused on factors associated with good prognosis following this type of treatment. The present study retrospectively analyzed a series of 17 patients with acute vertebral artery occlusions (VAOs) and basilar artery occlusions (BAOs) treated with MT. In all patients, information such as sex and age, time from admission to the onset of femoral artery access, the number of thrombi removed, the time of femoral artery access to recanalization, pre- and post-operative National Institutes of Health Stroke Scale (NIHSS) scores, pre- and post-operative thrombolysis in cerebral infarction, as well as modified Rankin scale scores were documented and analyzed. The analysis comprised of 11 patients with BAOs and 6 patients with VAOs. A recanalization rate of 70.6% was achieved with an overall good functional outcome of 58.8% at 90 days. Observationally, there was a notable improvement in outcomes when comparing the NIHSS prior to surgery with NIHSS at 1 week after the surgery. A lower NIHSS score prior to MT may be a good prognostic factor. An average time of ~5.5 h from patient admittance to recanalization with a 70.6% recanalization rate with an overall good functional outcome of 58.8% at 90 days suggested that, patients for whom the surgeries were performed within 5 h of admittance may still have hope for recanalization compared to an initial 1.5-h average time for recanalization.

Effect of vertebrobasilar dolichoectasia on endovascular therapy in acute posterior circulation infarction

Background and purpose

This study aimed to analyze the feasibility and safety of endovascular therapy (EVT) in patients with acute posterior circulation stroke and vertebrobasilar dolichoectasia (VBD).

Materials and methods

BASILAR was a national prospective registry of consecutive patients with symptomatic and imaging-confirmed acute stroke in the posterior circulation within 24 h of symptom onset. We evaluated EVT feasibility and safety in patients with VBD. Primary outcomes included improvement in modified Rankin Scale scores (mRS) at 90 days and mortality within 90 days. The secondary outcome was the rate of favorable functional outcome, defined as mRS ≤ 3 (indicating independent ambulation) at 90 days. Safety outcomes included surgery-related complications and other serious adverse events.

Results

A total of 534 cases were included: 159 with VBD and 375 controls. No significant difference in mRS at 90 days was found between groups, but patients with VBD had a higher baseline National Institutes of Health Stroke Scale (NIHSS) score [30 (19–33) vs. 25 (15–32)] and were older [65 (59–74) vs. 63 (55–72) year]. After propensity score matching, there were no significant differences in baseline NIHSS score between the two groups, and the efficacy and safety of EVT were similar between patients with or without VBD. Furthermore, the prognostic effect of puncture-to-recanalization time on the probability of mortality within 90 days in EVT-treated patients with VBD was significant {adjusted odds ratio, 1.008 [95% confidence interval (1.001–1.015)]}.

Conclusion

Endovascular therapy is safe and feasible in patients with acute posterior circulation stroke and VBD. The puncture-to-recanalization time is important for predicting the prognosis of EVT-treated patients with VBD.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy

BACKGROUND AND PURPOSE

The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT.

METHODS

We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS = (5 × age) + (10 × National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 × CTP cerebral blood volume index) and THRIVE (0-9 points) = age 60-79 years, 1 point; age ≥ 80 years, 2 points; NIHSS 11-20, 2 points; NIHSS ≥ 21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6.

RESULTS

Fifty-seven patients had mean age 66.6 (± 14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR] = 1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p = .008), whereas THRIVE was not (OR = 1.0326, 95% CI: 0.9478-1.1250, p = .466). CLEOS &gt; 503 best predicted poor outcomes.

CONCLUSIONS

A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.

Basilar Artery Thrombectomy Between Evidence-Based Medicine and the Real-World Practice: A Single-Center Experience

BACKGROUND AND AIM

Basilar artery occlusion (BAO) is known for its catastrophic outcomes, whether death or disability, in approximately 70% of patients. Mechanical thrombectomy (MT) has been approved as an intervention in large vessel occlusion of anterior circulation, based on multiple randomized controlled trials (RCTs) and meta-analyses. Even though two RCTs appeared recently, there is still uncertainty about the effect of MT in BAO. Our study aims to report the outcome of MT in BAO and the variables affecting good outcomes and mortality rate.

MATERIALS AND METHODS

We retrospectively collected the clinical and radiological data of 30 BAO patients treated in our center by MT between July 2016 and July 2021. A favorable clinical outcome was considered if mRS was ≤2. A favorable radiological result was considered if modified Thrombolysis in Cerebral Infarction (mTICI) was ≥2b at the end of the intervention. Multiple variables were tested for their effects on favorable clinical outcomes and mortality.

RESULTS

The mean age of the 30 patients was 61.23 ± 16.81 years; 20/30 (66.7%) were male. A favorable functional outcome was achieved in 40.7%. Successful revascularization was achieved in 26 patients (86.7%). Mortality at 90 days was observed in 11 patients (36.7%). The presenting National Institute of Health and Stroke Scale (NIHSS) was the only predictor of mortality, and the optimal cut-off value for death was 15 with area under the curve (AUC) = 0.758 (sensitivity 91% and specificity 59%) and P value = 0.02.

CONCLUSION

Thrombectomy is an effective procedure in BAO which has naturally a bad outcome. The presenting NIHSS might be the only predictor of mortality in our study.

The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

Background:

Whether endovascular treatment (EVT) is safe and effective for vertebrobasilar artery occlusion (VBAO) is yet incompletely understood. Two RCTs, the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST) trail and the Basilar Artery International Cooperation Study (BASICS), concentrating on this field were recently reported.

Objective:

We use real-world registry data of VBAO to compare the outcome of EVT inside and outside the inclusion and exclusion criteria of the BEST and BASICS study to testify the feasibility of the selection paradigms of VBAO in these trials.

Methods:

Consecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. The safety outcomes [3-month mortality, symptomatic intracranial hemorrhage (sICH), and effectiveness outcomes (the proportion of 3-month functional independence (mRS of 0–2) and favorable outcome (mRS of 0–3)] were compared between VBAO patients who meet or failed to meet the BEST/BASICS selection criteria for EVT.

Results:

Our study cohort consisted of 577 VBAO patients who underwent EVT. Of them, 446 patients had pc-ASPECTS ≧8. Successful reperfusion (mTICI 2b or 3) was achieved in 85.4% (n = 493). There were 418 patients fulfilling the BEST criterion for EVT and 194 fulfilling the BASICS criterion. Regression analysis indicated that adherence to BEST or BASICS criterion for EVT was not independently related to most of the safety and effectiveness outcome except that adherence to BEST was significantly associated with the 3-month favorable outcome (OR_BEST: 1.742, 95% CI: 1.087–2.790). However, when we put pc-ASPECTS into both criteria with a cut-off value of 8, meeting both BEST criterion plus pc-ASPECTS and BASICS criterion plus pc-ASPECTS was independently related to 3-month functional independence (OR_BEST: 1.687, 95% CI: 1.077–2.644; OR_BASIC: 1.653, 95% CI: 1.038–2.631) and favorable outcome (OR_BEST: 2.280, 95% CI: 1.484–3.502; OR_BASIC: 2.153, 95% CI: 1.372–3.378).

Conclusion:

Our study indicated that, based on real-world data of EVT, adherence to BEST or BASICS criterion for EVT was not independently associated with the safety and effectiveness outcome except that adherence to BEST was significantly related to the 3-month favorable outcome. However, the BEST or BASICS selection criterion and pc-ASPECTS ≧8 might be better paradigms for EVT patient selection.

General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

BACKGROUND AND PURPOSE

Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.

METHODS

Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days.

RESULTS

Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR=0.90 [95%CI 0.46-1.77] P=0.769) or mortality (OR=0.75 [0.37-1.49] P=0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR=0.43 [0.16-1.16] P=0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR=1.08 [0.62-1.88] P=0.767).

CONCLUSIONS

Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.

Precision medicine: how multiomics will shape the future of inflammatory bowel disease?

PURPOSE OF REVIEW

In this article, we provide an overview of studies examining multiomic profiling in various clinical scenarios in the management of inflammatory bowel diseases (IBDs).

RECENT FINDINGS

IBD arises as a result of an interplay between genetic, environmental, microbial and immunologic perturbations. The access to high throughput technology as well as the decrease in costs associated with such studies has led to a growing wealth of literature examining the utility of single or multiomic profiles in the management of IBD. Such studies have commonly examined the genome (and less frequently the epigenome), transcriptome, metabolome, proteome and the gut microbial metagenome in the context of overall IBD status or specific clinical scenarios, including the disease progression or response to treatment. The findings have provided important insight into how each of these compartments reflect underlying disease pathophysiologic processes and, in turn, can influence stratification of patients for clinical management.

SUMMARY

Multiomic profiling in IBD has the potential to advance the field of personalized precision medicine in the management of IBDs.

Prognostic factors for acute posterior circulation cerebral infarction patients after endovascular mechanical thrombectomy: A retrospective study

This article was to analyze the factors influencing the prognosis of posterior circulation cerebral infarction (PCCI) patients, retrospectively.One hundred forty five patients diagnosed with PCCI in Nanyang Central Hospital between June 25, 2016 and October 14, 2019 were included and underwent cerebral vascular mechanical thrombectomy. The clinical data of those patients were collected. The patients were followed up for 3 months to observe the prognostic efficacy and explore the influencing factors for poor prognosis. The potential prognostic factors for PCCI patients after emergency endovascular mechanical thrombectomy were analyzed by univariate and multivariable logistic regression. The thermodynamic diagram was drawn to explore the associations between the prognostic factors.The risk of poor prognosis in PCCI patients receiving emergency endovascular mechanical thrombectomy was reduced by 0.552 time with every 1-point increase of the Alberta Stroke Program Early CT in posterior circulation score (odds ratio [OR] = 0.448, 95% confidence interval [CI]: 0.276-0.727). The risk of poor prognosis was increased by 0.827 time for each additional grade in the digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading (OR = 1.827, 95% CI: 1.221-2.733, P = .003) and increased by 0.288 time for every 1-point increase in National Institutes of Health Stroke scale at 24 hours (OR = 1.288, 95% CI: 1.161-1.429). All P < .05.Alberta Stroke Program Early CT in posterior circulation score, digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading, National Institutes of Health Stroke scale score at 24 hours were factors affecting the prognosis of PCCI patients undergoing emergency endovascular mechanical thrombectomy, which might provide evidence for endovascular treatment of PCCI.

Thrombectomy in basilar artery occlusion

BACKGROUND AND PURPOSE

The benefit of thrombectomy (TE) for acute ischemic stroke (AIS) in patients suffering basilar artery occlusion (BAO) is still unclear. Our aim was to analyze functional outcome after 3 months in BAO compared to anterior circulation large vessel occlusion (ACLVO) in a nationwide registry.

METHODS

Patients enrolled into the Austrian Endostroke Registry from 2013 to 2018 were analyzed. We used propensity score matching to control for imbalances and to compare patients with BAO and ACLVO. The primary outcome was favorable functional outcome after 3 months measured by the modified Rankin Scale (mRS) (0-2). Multivariate models were applied to estimate the effect of localization (BAO vs ACLVO).

RESULTS

In total, 2288 patients underwent TE for AIS with proximal vessel occlusion, of these 267 with BAO. Two hundred and sixty-four patients with BAO were matched to 264 patients with ACLVO. Baseline characteristics were well-balanced. The 90-day mortality did not significantly differ between patients with BAO and ACLVO. In a multivariate logistic regression model, we did not detect a significant difference in functional outcome between BAO and ACLVO (odds ratio for favorable outcome defined as mRS = 0-2: 1.19; 95% confidence interval (CI) = 0.78-1.81; p = 0.42). In patients with an onset-to-door-time ⩾270 min, TE of BAO was associated with poor functional outcome defined as mRS 3-6 (odds ratio (OR) = 3.97; 95% CI = 1.32-11.94; p = 0.01) as compared to ACLVO.

CONCLUSION

In this study, functional outcome did not differ after TE in patients with BAO and ACLVO overall; however, we detected an association of BAO with poor outcome in patients arriving late.

Safety and Efficacy of Endovascular Treatment for Progressive Stroke in Patients With Acute Basilar Artery Occlusion

Background and Purpose: It is unknown the benefit of endovascular therapy (EVT) for progressive stroke in patients with basilar artery occlusion (BAO). The aim of this study was to compare the efficacy and safety of EVT with standard medical therapy (SMT) in a population of BAO patients with progressive stroke.

Methods: The EVT for Acute Basilar Artery Occlusion Study (BASILAR) is a national prospective registry of consecutive patients with acute BAO within 24 h of symptom onset. According to the applied therapy, all patients were divided into SMT and EVT groups. Subsequently, the EVT group was divided into early (≤6 h) and late groups (>6 h) according to the time window. The efficacy outcome was favorable functional outcomes (modified Rankin Scale score ≤ 3) at 90 days. The safety outcomes included mortality within 90 days and symptomatic intracerebral hemorrhage (sICH) after EVT.

Results: The EVT cohort presented more frequently with a favorable functional outcome (adjusted odds ratio, 5.49; 95% confidence interval, 2.06–14.61, p = 0.01) and with a decreased mortality (adjusted odds ratio, 0.3; 95% confidence interval, 0.17–0.54, p < 0.001). What's more, EVT still safe (P = 0.584, P = 0.492, respectively) and effective (P = 0.05) in patients with progressive stroke when the treatment time window exceeds 6 h.

Conclusions: EVT was more effective and safer than SMT for progressive stroke in patients with BAO. Besides, EVT remains safe and effective in patients with progressive stroke when the treatment time window exceeds 6 h. Predictors of desirable outcome in progressive stroke patients undergoing EVT included lower baseline NIHSS score, higher baseline pc-ASPECTs, successful recanalization and shorter puncture to recanalization time.

Outcomes of Endovascular Therapy in Acute Basilar Artery Occlusion With Severe Symptoms

IMPORTANCE

Endovascular therapy (EVT) has been reported to be safe and effective in improving clinical outcomes among patients with acute basilar artery occlusion (ABAO). The benefits associated with EVT remain uncertain for patients with ABAO with severe symptoms (ie, National Institutes of Health Stroke Scale [NIHSS] score ≥ 21).

OBJECTIVES

To assess the outcomes associated with EVT and identify factors associated with outcomes among patients with ABAO and severe symptoms.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, nationwide cohort study was conducted using data from January 2014 to May 2019 in China from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR). Included patients had ABAO and underwent EVT or standard medical treatment (SMT) alone in routine clinical practice. Patients were dichotomized into severe symptoms (ie, NIHSS score ≥ 21) and minor to moderate symptoms (NIHSS score < 21) groups. Patients were followed up for 90 days. Data were analyzed from December 2020 through June 2021.

EXPOSURES

EVT with SMT vs SMT alone.

MAIN OUTCOMES AND MEASURES

The primary outcome was improvement in modified Rankin Scale (mRS) score at 90 days, defined as a decrease by 1 grade in mRS score. Secondary outcomes included favorable functional outcome (ie, mRS score, 0-3) and mortality.

RESULTS

Among 542 patients with ABAO and severe symptoms (median [IQR] age, 65 [57-74] years; 147 [27.1%] women), 431 patients (79.5%) received EVT and 111 patients (20.5%) received SMT. Compared with SMT, EVT was associated with increased odds of improved mRS score (adjusted common odds ratio [OR], 3.44 [95% CI, 2.05-5.78]; P < .001), with increased odds of a favorable functional outcome (ie, mRS score, 0-3; adjusted OR, 4.52 [95% CI, 1.64-12.43]; P = .004) and decreased odds of mortality (adjusted OR, 0.27 [95% CI, 0.15-0.50]; P < .001). Among patients receiving EVT, baseline NIHSS score was associated with decreased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 0.90 [95% CI, 0.85-0.95]; P < .001) and increased odds of mortality (adjusted OR per 1-point increase in score, 1.13 [95% CI, 1.07-1.19]; P < .001), while posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) was associated with increased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 1.71 [95% CI, 1.41-2.07]; P < .001) and decreased odds of mortality (adjusted OR per 1-point increase in score, 0.74 [95% CI, 0.64-0.85]; P < .001). Different occlusion sites, compared with distal basilar artery, were associated with decreased odds of favorable functional outcome (eg, middle basilar artery: adjusted OR vs distal basilar artery, 0.36 [95% CI, 0.17-0.80]; P = .01).

CONCLUSIONS AND RELEVANCE

This study found that EVT was associated with increased odds of functional favorable outcomes among patients with ABAO and severe symptoms. Baseline NIHSS score, pc-ASPECTS, and occlusion site were independent factors associated with clinical outcomes.

Influence of renal impairment on clinical outcomes after endovascular recanalization in vertebrobasilar artery occlusions

BACKGROUND

Renal impairment (RI) is associated with worse outcomes in the treatment of intravenous thrombolysis and emergent endovascular treatment (EVT) in anterior circulation stroke. The objective of this study was to investigate the association of RI with short-term and long-term outcomes in patients with vertebrobasilar artery occlusions (VBAO) who received EVT.

METHODS

Consecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. Multivariate regression analyses were used to evaluate the association of RI with mortality and symptomatic intracranial hemorrhage (sICH) during the hospital stay, and also mortality, favorable functional outcome (modified Rankin Scale (mRS) score of 0-3), and functional improvement (shift in mRS score) at 3 months and 1 year follow-up. The association between RI and the risk of recurrent stroke was evaluated with multivariate competing-risk regression analyses.

RESULTS

After adjustment for potential confounders, RI was independently associated with sICH (OR 3.30, 95% CI 1.55 to 7.18), as well as mortality (OR 2.54, 95% CI 1.47 to 4.38; OR 3.07, 95% CI 1.72 to 8.08), favorable functional outcome (OR 0.33, 95% CI 0.17 to 0.66; OR 0.25, 95% CI 0.12 to 0.51), and functional improvement (OR 0.45, 95% CI 0.28 to 0.74; OR 0.35, 95% CI 0.21 to 0.60) at 3 months and 1 year follow-up, respectively, but RI was not associated with in-hospital mortality. Additionally, there was no significant association between RI and recurrent stroke within 1 year.

CONCLUSIONS

Our findings suggest that RI is associated with a higher risk of sICH in hospital and a decrease in survival, favorable functional outcome, and functional improvement at 90 days and 1 year follow-up.

TRIAL REGISTRATION NUMBER

URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Perfusion Imaging Predicts Favorable Outcomes after Basilar Artery Thrombectomy

OBJECTIVE

Perfusion imaging identifies anterior circulation stroke patients who respond favorably to endovascular thrombectomy (ET), but its role in basilar artery occlusion (BAO) is unknown. We hypothesized that BAO patients with limited regions of severe hypoperfusion (time to reach maximum concentration in seconds [Tmax] > 10) would have a favorable response to ET compared to patients with more extensive regions involved.

METHODS

We performed a multicenter retrospective cohort study of BAO patients with perfusion imaging prior to ET. We prespecified a Critical Area Perfusion Score (CAPS; 0-6 points), which quantified severe hypoperfusion (Tmax > 10) in cerebellum (1 point/hemisphere), pons (2 points), and midbrain and/or thalamus (2 points). Patients were dichotomized into favorable (CAPS ≤ 3) and unfavorable (CAPS > 3) groups. The primary outcome was a favorable functional outcome 90 days after ET (modified Rankin Scale = 0-3).

RESULTS

One hundred three patients were included. CAPS ≤ 3 patients (87%) had a lower median National Institutes of Health Stroke Scale score (NIHSS; 12.5, interquartile range [IQR] = 7-22) compared to CAPS > 3 patients (13%; 23, IQR = 19-36; p = 0.01). Reperfusion was achieved in 84% of all patients, with no difference between CAPS groups (p = 0.42). Sixty-four percent of reperfused CAPS ≤ 3 patients had a favorable outcome compared to 8% of nonreperfused CAPS ≤ 3 patients (odds ratio [OR] = 21.0, 95% confidence interval [CI] = 2.6-170; p < 0.001). No CAPS > 3 patients had a favorable outcome, regardless of reperfusion. In a multivariate regression analysis, CAPS ≤ 3 was a robust independent predictor of favorable outcome after adjustment for reperfusion, age, and pre-ET NIHSS (OR = 39.25, 95% CI = 1.34->999, p = 0.04).

INTERPRETATION

BAO patients with limited regions of severe hypoperfusion had a favorable response to reperfusion following ET. However, patients with more extensive regions of hypoperfusion in critical brain regions did not benefit from endovascular reperfusion. ANN NEUROL 2021.

Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice: Results of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry

BACKGROUND AND PURPOSE

The benefit of endovascular treatment (EVT) for posterior circulation stroke (PCS) remains uncertain, and little is known on treatment outcomes in clinical practice. This study evaluates outcomes of a large PCS cohort treated with EVT in clinical practice. Simultaneous to this observational study, several intervention centers participated in the BASICS trial (Basilar Artery International Cooperation Study), which tested the efficacy of EVT for basilar artery occlusion in a randomized setting. We additionally compared characteristics and outcomes of patients treated outside BASICS in trial centers to those from nontrial centers.

METHODS

We included patients with PCS from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry: a prospective, multicenter, observational study of patients who underwent EVT in the Netherlands between 2014 and 2018. Primary outcome was a score of 0 to 3 on the modified Rankin Scale at 90 days. Secondary outcomes included reperfusion status and symptomatic intracranial hemorrhage. For outcome comparison between patients treated in trial versus nontrial centers, we used ordinal logistic regression analysis.

RESULTS

We included 264 patients of whom 135 (51%) had received intravenous thrombolysis. The basilar artery was most often involved (77%). Favorable outcome (modified Rankin Scale score 0-3) was observed in 115/252 (46%) patients, and 109/252 (43%) patients died. Successful reperfusion was achieved in 178/238 (75%), and symptomatic intracranial hemorrhage occurred in 9/264 (3%). The 154 nontrial patients receiving EVT in BASICS trial centers had similar characteristics and outcomes as the 110 patients treated in nontrial centers (modified Rankin Scale adjusted cOR: 0.77 [95% CI, 0.5-1.2]).

CONCLUSIONS

Our study shows that high rates of favorable clinical outcome and successful reperfusion can be achieved with EVT for PCS, despite high mortality. Characteristics and outcomes of patients treated in trial versus nontrial centers were similar indicating that our cohort is representative of clinical practice in the Netherlands. Randomized studies using modern treatment approaches are needed for further insight in the benefit of EVT for PCS.

Predictors of Functional Outcome and Mortality in Endovascular Treatment for Acute Basilar Artery Occlusion: A Single-Centre Experience

Background and Purpose: The objective of this study was to identify prognostic factors of endovascular treatment in patients with acute basilar artery occlusion and add evidence about the efficacy and safety of endovascular treatment for acute basilar artery occlusion. Materials and Methods: We reviewed the data of 101 patients with acute basilar artery occlusion receiving endovascular treatment from January 2013 to September 2019. Baseline characteristics and outcomes were evaluated. A favourable functional outcome was defined as a mRS of 0 to 2 assessed at the 3 month follow-up. The association of clinical and procedural characteristics with the functional outcome and mortality was assessed. Results: The study population consisted of 101 patients: 83 males and 18 females. Successful recanalization was achieved in 99 patients (97.1%). A favourable clinical outcome was observed in 50 patients (49.5%), and the overall mortality rate was 26.7%. A favourable outcome was significantly associated with NIHSS score at admission and lung infection. Mortality was associated with NIHSS score at admission, the number of thrombectomy device passes, the postoperative pons-midbrain index, and diabetes mellitus. Conclusions: This study suggested that NIHSS score at admission, the number of thrombectomy device passes, the postoperative pons-midbrain index, diabetes mellitus, and lung infection can predict the functional outcome and mortality. These initial results add evidence about the efficacy and safety of endovascular treatment for acute basilar artery occlusion and need to be confirmed by further prospective studies.

Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome

Background:

Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin.

Case Description:

The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy.

Conclusion:

Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.

Value of machine learning to predict functional outcome of endovascular treatment for acute ischaemic stroke of the posterior circulation

PURPOSE

Clinical outcomes vary considerably among individuals with vessel occlusion of the posterior circulation. In the present study we evaluated machine learning algorithms in their ability to discriminate between favourable and unfavourable outcomes in patients with endovascular treatment of acute ischaemic stroke of the posterior circulation.

METHODS

This retrospective study evaluated three algorithms (generalised linear model, K-nearest neighbour and random forest) to predict functional outcomes at dismissal of 30 patients with acute occlusion of the basilar artery who were treated with thrombectomy. Input variables encompassed baseline as well as peri and postprocedural data. Favourable outcome was defined as a modified Rankin scale score of 0-2 and unfavourable outcome was defined as a modified Rankin scale score of 3-6. The performance of the algorithms was assessed with the area under the receiver operating curve and with confusion matrixes.

RESULTS

Successful reperfusion was achieved in 83%, with 30% of the patients having a favourable outcome. The area under the curve was 0.93 for the random forest model, 0.86 for the K-nearest neighbour model and 0.78 for the generalised linear model. The accuracy was 0.69 for the generalised linear model and 0.84 for the random forest and the K nearest neighbour models.

CONCLUSION

Favourable and unfavourable outcomes at dismissal of patients with acute ischaemic stroke of the posterior circulation can be predicted immediately after the follow-up non-enhanced computed tomography using machine learning.

Association of Regular Thrombus Surface Phenotype With Complete Recanalization in First-Line Contact Aspiration Thrombectomy for Basilar Artery Occlusion

Objective: To assess whether angiographic thrombus surface phenotype has an impact on efficacy of contact aspiration (CA) thrombectomy in patients with basilar artery occlusion (BAO). Methods: From January 2016 to December 2019, consecutive stroke patients with a BAO and first-line CA were analyzed in this retrospective study. We assessed baseline and imaging characteristics and treatment and clinical outcomes. We rated thrombus surface phenotype on pre-treatment digital subtraction angiography in a three-reader-consensus setting. Primary outcome was complete recanalization (modified treatment in cerebral ischemia [mTICI] 3 and arterial occlusive lesion [AOL] 3) after first-line CA without additionally stent retriever passes. Data analysis was stratified according to thrombus surface phenotype and complete first-line recanalization. Results: Seventy-eight patients met the inclusion criteria. Median age was 74 years (IQR 64-80), 64% were male, and median baseline NIHSS score was 24 (IQR 7-32). Thirty patients had a regular and 16 patients had an irregular thrombus phenotype. Thrombus surface was not assessable in 32 patients. In patients with a regular phenotype, complete recanalization was more often achieved compared to irregular and non-ratable phenotypes (50 vs. 18.8% and 21.9%; p = 0.027). Patients with a regular phenotype [odds ratio [OR] 8.3; 95% confidence interval [CI]: 1.9-35.8; p = 0.005], cardioembolic stroke (OR 12.1, 95% CI: 2.0-72.8; p = 0.007), and proximal end of the thrombus in the middle basilar artery segment (OR 5.2, 95% CI: 1.0-26.6; p = 0.046) were more likely to achieve complete recanalization after first-line CA without rescue therapy. Conclusion: The efficacy of CA may differ according to the angiographic thrombus surface phenotype in patients with BAO. A regular phenotype is associated with higher rates of complete recanalization in first-line CA. However, assessment of thrombus phenotype is frequently not feasible in BAO.

Cerebral blood volume index as a predictor of functional independence after basilar artery thrombectomy

BACKGROUND AND PURPOSE

The role of CT perfusion (CTP)in the evaluation of acute basilar artery occlusion (aBAO) patients undergoing endovascular thrombectomy (EVT) is unclear. We investigated the association of individual CTP parameters with functional outcomes in aBAO patients undergoing EVT.

METHODS

A health system's prospectively collected code stroke registry was used in this retrospective analysis of aBAO patients treated with EVT presenting between January 2017 and February 2021 with pre-EVT CTP. The primary outcome measure was modified Rankin Scale (mRS) score 0-2 at 90 days. Factors with a univariate association (p < .05) with mRS 0-2 were combined in a multivariable regression model to determine independent predictors of 90-day favorable functional outcome.

RESULTS

Forty-six subjects, with median age 67 years and median National Institutes of Health Stroke Scale 16, were included, of whom 17 (37%) achieved mRS 0-2 at 90 days. In the multivariable logistic regression model, CTP cerebral blood volume (CBV) index (per 0.1-point increase, odds ratio = 1.843; 95% confidence interval: 1.039, 3.268; p-value .0365) was independently associated with a favorable 90-day outcome.

CONCLUSIONS

CBV index was independently associated with a favorable 90-day outcome in aBAO patients treated with EVT, a novel finding in this patient population. CBV index may assist in treatment and prognosis discussions and inform future studies investigating the role of CTP in aBAO.

[Border areas of thrombectomy]

Mechanical thrombectomy (MT) has become the standard procedure in the treatment of patients with acute ischemic stroke (AIS) due to occlusion of a large proximal cerebral artery of the anterior circulation. Nevertheless, according to the current guidelines large patient collectives are still excluded from this highly effective treatment method. Therefore, this article gives an overview of possible extensions of the indications for treatment with MT. For example, patients in the extended time window with distal occlusions, with large infarct cores and also for very old (90+ years) or young (0-17 years) patients. Furthermore, we discuss recent developments in the interventional treatment of stroke, such as new triage concepts or the question whether an additional intravenous thrombolysis is necessary in patients with MT. We conclude with our own estimations for the discussed indications for treatment based on our clinical experience and the current literature.

Endovascular Thrombectomy Treatment: Beyond Early Time Windows and Small Core

ABSTRACT

Tremendous advancements in the treatment of acute ischemic stroke in the last 25 years have been based on the principle of reperfusion in early time windows and identification of small core infarct for intravenous thrombolysis and mechanical thrombectomy. Advances in neuroimaging have made possible the safe treatment of patients with acute ischemic stroke in longer time windows and with more specific selection of patients with salvageable brain tissue. In this review, we discuss the history of endovascular stroke thrombectomy trials and highlight the neuroimaging-based trials that validated mechanical thrombectomy techniques in the extended time window with assessment of penumbral tissue. We conclude with a survey of currently open trials that seek to safely expand eligibility for this highly efficacious treatment.

Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis

Background and Purpose: Endovascular treatment (EVT) is one of the promising treatment options in patients with intracranial atherosclerotic disease (ICAD)-related basilar artery occlusion (BAO). In this study, we compared the safety and efficacy of direct angioplasty (DA) with stent-retriever thrombectomy (SRT) with or without rescue treatment in ICAD-related BAO.

Methods: We retrospectively evaluated 187 patients who underwent EVT for BAO from January 2012 to July 2018. We identified patients who underwent EVT due to ICAD-related BAO. Patients who accepted SRT with or without rescue treatment were classified into the SRT group. Patients treated with DA with or without stent placement were classified into DA group. Clinical and laboratory findings and outcomes were compared between groups.

Results: A total of 108 patients were enrolled, among them 77 underwent SRT and 31 underwent DA; 61 (79.2%) SRT group patients underwent angioplasty with or without stent placement. Compared with patients in the SRT group, those in the DA group experienced a significantly shorter procedure time [60 min (60–120 min) vs. 120 min (60–120 min); p = 0.038] and a lower number of device passes [2 passes (1–2 passes) vs. 3 passes (2–4 passes); p < 0.001]. No significant differences in balloon angioplasty (35.5 vs. 22.1%; p = 0.150), emergent stent placement (64.5 vs. 57.1%; p = 0.481), successful recanalization (93.5 vs. 85.7%; p = 0.340), embolization in distal or new territory (3.2 vs. 9.1%, p = 0.314), and reocclusion (22.6 vs. 9.1%; p = 0.109) among DA and SRT groups were found. Additionally, no differences in symptomatic intracranial hemorrhage incidence [adjusted odds ratio (OR), 0.74; 95% CI, 0.06–9.44; p = 0.815], functional independence (adjusted OR, 1.44; 95% CI, 0.50–4.16; p = 0.497), and mortality rate (adjusted OR, 0.36; 95% CI, 0.06–2.04; p = 0.247) were noted among groups.

Conclusions: In certain patients with ICAD-related BAO, DA may shorten procedure time and reduce required device passes compared to SRT. In this study, DA was retrospectively found to be of similar safety and efficacy as SRT.

Predictors of a Good Outcome in Endovascular Treatment for Basilar Artery Occlusion with a Direct Aspiration First-Pass Technique

Objective

There is limited evidence for mechanical thrombectomy in patients with basilar artery occlusion. Despite recanalization, there are several reports on poor outcomes. Therefore, we retrospectively evaluated the outcomes and examined the predictors of mechanical thrombectomy in patients with basilar artery occlusion.

Methods

We recruited 22 consecutive patients who had received mechanical thrombectomy for basilar artery occlusion with a direct aspiration first-pass technique at our hospital between January 2016 and April 2020. The subjects were divided into good (modified Rankin Scale [mRS] ≤2) and poor outcome groups (mRS ≥3) and compared with one another. We conducted ROC analysis to identify the cut-off value that revealed a statistically significant difference in the univariate analysis.

Results

Of the 22 patients, the average age ± standard deviation (SD), median pretreatment NIHSS (interquartile range [IQR]), and median pretreatment posterior circulation acute stroke progression early CT score (pc-ASPECTS) (IQR) were 76 ± 10 years, 21 (8-31), and 8 (5-9), respectively. The predictors that showed statistically significant differences in the univariate analysis were age, pretreatment NIHSS score, and pretreatment pc-ASPECTS. Based on the ROC analysis, age (area under the curve [AUC] of 0.782, cutoff <74, and P = 0.028), pretreatment pc-ASPECTS (AUC of 0.850, cutoff ≥7, and P = 0.006), and pretreatment NIHSS (AUC of 0.803, cutoff <19, and P = 0.018) were significant prognostic factors.

Conclusion

In this study, aged <74 years, pc-ASPECTS ≥7, and NIHSS <19 were significant prognostic factors in endovascular treatment for basilar artery occlusion with a direct aspiration first-pass technique.

Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion

BACKGROUND

Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered.

OBJECTIVE

To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO).

METHODS

TOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events.

RESULTS

Among 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71).

CONCLUSION

Thrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.

Comparison of Risk Factors, Safety, and Efficacy Outcomes of Mechanical Thrombectomy in Posterior vs. Anterior Circulation Large Vessel Occlusion

Background and Purpose: It is believed that stroke occurring due to posterior circulation large vessel occlusion (PCLVO) and that occurring due to anterior circulation large vessel occlusion (ACLVO) differ in terms of their pathophysiology and the outcome of their acute management in relation to endovascular mechanical thrombectomy (MT). Limited sample size and few randomized controlled trials (RCTs) with respect to PCLVO make the safety and efficacy of MT, which has been confirmed in ACLVO, difficult to assess in the posterior circulation. We therefore conducted a meta-analysis to study to which extent MT in PCLVO differs from ACLVO. Materials and Methods: We searched the databases PubMed, Cochrane, and EMBASE for studies published between 2010 and January 2021, with information on risk factors, safety, and efficacy outcomes of MT in PCLVO vs. ACLVO and conducted a systematic review and meta-analysis; we compared baseline characteristics, reperfusion treatment profiles [including rates of intravenous thrombolysis (IVT) and onset-to-IVT and onset-to-groin puncture times], recanalization success [Thrombolysis In Cerebral Infarction scale (TICI) 2b/3], symptomatic intracranial hemorrhage (sICH), and favorable functional outcome [modified Rankin Score (mRS) 0-2] and mortality at 90 days. Results: Sixteen studies with MT PCLVO (1,172 patients) and ACLVO (7,726 patients) were obtained from the search. The pooled estimates showed higher baseline National Institutes of Health Stroke Scale (NIHSS) score (SMD 0.32, 95% CI 0.15-0.48) in the PCLVO group. PCLVO patients received less often IVT (OR 0.65, 95% CI 0.53-0.79). Onset-to-IVT time (SMD 0.86, 95% CI 0.45-1.26) and onset-to-groin puncture time (SMD 0.59, 95% CI 0.33-0.85) were longer in the PCLVO group. The likelihood of obtaining successful recanalization and favorable functional outcome at 90 days was comparable between the two groups. PCLVO was, however, associated with less sICH (OR 0.56, 95% CI 0.37-0.85) but higher mortality (OR 1.92, 95% CI 1.46-2.53). Conclusions: This meta-analysis indicates that MT in PCLVO may be comparably efficient in obtaining successful recanalization and 90 day favorable functional outcome just as in ACLVO. Less sICH in MT-treated PCLVO patients might be the result of the lower IVT rate in this group. Higher baseline NIHSS and longer onset-to-IVT and onset-to-groin puncture times may have contributed to a higher 90 day mortality in PCLVO patients.

Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy

BACKGROUND AND PURPOSE

The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex.

MATERIALS AND METHODS

We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery.

RESULTS

The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients.

CONCLUSIONS

Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.

Long-term outcome of endovascular therapy for acute basilar artery occlusion

The long-term functional outcome of acute basilar artery occlusion (BAO) patients who received modern endovascular therapy (EVT) is unclear. We sought to assess the long-term functional outcome of BAO patients treated with EVT and determine the prognostic factors associated with favorable outcome. We enrolled consecutive BAO patients who received EVT between December 2012 and December 2018 in this observational study. Baseline characteristics and outcomes were presented. Multivariable logistic regression analysis was performed to identify the prognostic factors associated with long-term outcome. Among the 177 BAO patients included in this study, 80 patients (45.2%) obtained favorable outcome and 97 patients (54.8%) had unfavorable outcome at long-term follow-up with a median observation time of 12 months (interquartile range, 3-19). A total of 67 patients (37.9%) died. National Institutes of Health Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS), time from stroke onset to recanalization, and recanalization condition were identified as independent predictors for long-term outcome. Over 40% of BAO patients who were treated with modern EVT achieved favorable outcome at long-term follow-up. NIHSS, pc-ASPECTS, time from stroke onset to recanalization, and recanalization condition were identified as independent prognostic factors of long-term outcome.

First-line contact aspiration versus first-line stent retriever for acute posterior circulation strokes: an updated meta-analysis

BACKGROUND

Both stent retriever (SR) and contact aspiration (CA) are widely used as first-line strategies for acute posterior circulation strokes (PCS). However, it is still unclear how CA and SR compare as the first-line treatment of acute PCS. Several new studies have been published recently, so we aimed to perform an updated meta-analysis.

METHODS

The meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. Random-effects models were performed to pool the outcomes and the value of I² was calculated to assess the heterogeneity.

RESULTS

Ten observational studies with 1189 patients were included, among whom 492 received first-line CA and 697 received first-line SR. The pooled results revealed that first-line CA could achieve a significantly higher proportion of modified Thrombolysis In Cerebral Infarction (mTICI) 2b/3 (OR 1.90, 95% CI 1.33 to 2.71, I²=0%), mTICI 3 (OR 1.95, 95% CI 1.15 to 3.31, I²=59.6%), first-pass effect (OR 2.91, 95% CI 1.51 to 5.58, I²=0%), lower incidence of new-territory embolic events (OR 0.20, 95% CI 0.05 to 0.83, I²=0%), and shorter procedure time (mean difference -29.4 min, 95% CI -46.8 to -12.0 min, I²=62.8%) compared with first-line SR. At 90-day follow-up, patients subjected to first-line CA showed a higher functional independence (modified Rankin Scale score 0-2; OR 1.38, 95% CI 1.01 to 1.87, I²=23.5%) and a lower mortality (OR 0.71, 95% CI 0.50 to 1.00, p=0.050, I²=0%) than those subjected to first-line SR.

CONCLUSIONS

This meta-analysis suggests that the first-line CA strategy could achieve better recanalization and clinical outcomes for acute PCS than first-line SR. Limited by the quality of included studies, this conclusion should be drawn with caution.

A Single-Center Experience of Endovascular Treatment in Subtypes of Basilar Artery Occlusion: Embolization Caused by Tandem Vertebral Artery Stenosis May Be Associated with Better Outcomes

OBJECTIVE

Basilar artery occlusion (BAO) is a severe condition with high mortality. However, surgical procedures and outcomes of BAO with different pathologic subtypes have not been fully clarified. This study compared the surgical procedures and clinical outcomes of mechanical thrombectomy in different subtypes of BAO.

METHODS

Eighty-six patients with acute BAO receiving endovascular treatment between October 2015 and July 2019 were retrospectively analyzed and placed in 3 groups: pure embolism (group 1), arterial-arterial embolism from steno-occlusion of the tandem vertebral artery (group 2), and in situ atherosclerotic thrombosis (group 3). Recanalization rates, procedure times, surgical characteristics, and clinical outcomes were analyzed.

RESULTS

Groups 1, 2, and 3 included 33 (38.4%), 17 (19.8%), and 36 (41.9%) patients, respectively. The overall successful recanalization rate was 95.3%, and the good outcome rate was 61.6%. The procedure time in group 1 was shorter than the time in groups 2 and 3 (P < 0.001). The clinical good outcome rate was higher in group 2 than in group 1 (88.2% vs. 54.5%; P = 0.017). Groups 1 and 3 had similar good outcome rates (54.5% vs. 55.6%; P = 0.933). Twenty-seven patients received stent angioplasty: 10 of 17 in group 2 (58.8%) and 17 of 36 in group 3 (47.2%).

CONCLUSIONS

The outcome of endovascular treatment for BAO varies among patients with different pathologic mechanisms. Patients with embolism from tandem vertebral artery steno-occlusion achieved the best outcomes. Rescue treatment was more common in patients with embolic BAO with tandem vertebral artery steno-occlusion and BAO with in situ atherosclerotic thrombosis.

Computed Tomography Perfusion Deficit Volumes Predict Functional Outcome in Patients With Basilar Artery Occlusion

[Figure: see text].