Outcome Predictors in Acute Basilar Artery Occlusion

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Meta-analysis of clinical and safety profiles after reperfusion therapy in acute posterior circulation strokes: insights and implications

BACKGROUND

Posterior circulation stroke (PCS) accounts for approximately 20% of all acute ischemic strokes. The optimal reperfusion therapy for PCS management remains uncertain.

PURPOSE

To evaluate the prevalence and outcomes of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and bridging therapy in PCS patients.

MATERIAL AND METHODS

We conducted a meta-analysis of 19 studies examining reperfusion therapy outcomes in PCS patients, including 9765 individuals. We pooled prevalence data and assessed associations between reperfusion therapies and clinical, safety, and recanalization outcomes using random-effects models.

RESULTS

The pooled prevalence of reperfusion therapies post-acute PCS was 39% for IVT, 54% for EVT, and 48% for bridging therapy. EVT was associated with significantly higher odds of favorable functional outcomes (modified Rankin Score [mRS] 0-3) at 90 days compared to standard medical therapy (odds ratio [OR] = 5.68; 95% confidence interval [CI]=2.07-15.59; P = 0.001). Conversely, bridging therapy was linked to reduced odds of favorable functional outcomes at 90 days compared to EVT (OR = 0.35; 95% CI=0.26-0.47; P < 0.001). Bridging therapy was also significantly associated with lower odds of good functional outcomes (mRS 0-2) (OR = 0.25; 95% CI=0.11-0.54; P < 0.001), reduced risk of symptomatic intracranial hemorrhage (OR = 0.26; 95% CI=0.07-0.68; P = 0.009), lower mortality (OR = 0.13; 95% CI=0.04-0.44; P = 0.001), and less successful recanalization (OR = 0.35; 95% CI=0.13-0.94; P = 0.038) relative to EVT.

CONCLUSION

Our meta-analysis underscores the favorable outcomes associated with EVT in PCS cases. With notable reperfusion rates, understanding factors influencing PCS outcomes can inform patient selection and prognostic considerations.

European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Repeated Intravenous Thrombolysis in Patients with Recurrent Ischemic Stroke in the Vertebrobasilar Territory

Acute ischemic vertebrobasilar stroke (AIVBS) is usually associated with poor outcome and prognosis and in case of basilar artery occlusion (BAO) with high mortality. Intravenous thrombolysis (IVT), as a standard recanalization therapy of acute ischemic stroke (IS) within first 4.5 h, can be administrated beyond this therapeutic time window in case of symptomatic BAO. Repeated IVT is generally contraindicated in case of early recurrent IS, despite a risk of poor outcome or death after recurrent IS. The aim was to present 2 cases of repeated IVT for recurrent AIVBS and discuss specific situations where repeated IVT may be considered. Up to now, repeated IVT has been reported only in recurrent stroke in anterior circulation.

PREMISE: Posterior Circulation Results Comparing Embolectomy to Medical Intervention in Stroke Emergencies

Background Intravenous (IV) tissue plasminogen activator (rt-PA) is a proven therapy for stroke in the acute treatment window. Recent published data has shown efficacy for embolectomy for acute ischemic strokes within up to six, 16 and 24 hours in the anterior circulation but there is no guideline for optimal therapy for patients with posterior circulation stroke, specifically basilar artery occlusion (BAO) outside the standard IV rt-PA treatment window. Aim To evaluate differences in outcomes between maximal medical treatment versus thrombectomy in BAO. Method We retrospectively evaluated prospectively collected acute stroke code patients from our stroke registry from 7/2004 to 7/2016. Patients who received IV rt-PA were excluded. Patients with evidence of posterior circulation ischemia and a hyper dense artery sign on initial non-contrast CT were included as a surrogate for direct vessel data before 2014. Patients after 9/2014 were selected by evidence of BAO on vessel imaging. All patients were categorized either as endovascular therapy or standard medical treatment alone. Demographics, hospital discharge location and Modified Rankin Scale (mRS) at 90 days were compared. Two-sample t-test and Fisher's exact test compared continuous and categorical variables across groups respectively. Results A total of 18 patients were included (three embolectomy and 15 medical therapy only). There were no significant differences in demographic data (age, gender, race, ethnicity, blood pressure, diabetes mellitus, hypertension, atrial fibrillation, tobacco use, alcohol use and initial NIHSS). Results for outcome and efficacies showed no statistical difference between medical management and endovascular intervention for functional outcome mRS (0-3) at 90 days (p = 0.2) and discharge location of home/inpatient rehabilitation vs other locations (p = 0.52). Conclusions Our single-center review showed the expected transition from predominantly medically treated posterior circulation BAOs, to a mixed pattern including embolectomy. Although the sample size was small, this study also illustrates the lack of clear efficacy data for optimal treatment strategies, and the ongoing treatment challenges in posterior circulation stroke population in a population of patients outside the rt-PA window.

Intravenous Thrombolysis in Posterior Circulation Stroke

Background: Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischemic stroke (ACIS) and posterior circulation ischemic stroke (PCIS). PCIS is a clinical syndrome associated with ischemia-related changes in the territory of the posterior circulation arteries. Embolism is the most common stroke mechanism in posterior circulation. PCIS represents 12–19% of all IVT-treated strokes.

Methods and Results: We searched the PubMed database for assessments of intracerebral hemorrhage (ICH) and clinical outcome in PCIS patients treated with IVT. ICH occurs in 0–6.9% of posterior ischemic stroke depending on the definition of symptomatic ICH, and any ICH in 17–23.4% of posterior ischemic stroke. For patients with PCIS, 38–49% have a favorable outcome (mRS 0–1) after IVT. Better clinical outcomes occur more often in patients with PCIS than in those with ACIS. The mortality rate among PCIS patients treated with IVT ranges from 9 to 19%; it does not differ significantly between PCIS and ACIS.

Conclusions: Up to date, no data about PCIS and IVT are available from RTCs. Based on limited results from retrospective clinical studies and case series, IVT is safer for use in PCIS than in ACIS. Patients with brainstem ischemia, vertebral artery occlusion, and absence of basilar or posterior cerebral artery occlusion could be considered for treatment with IVT even in borderline cases. Time to IVT in PCIS seems to be a less crucial factor than in ACIS. IVT for PCIS may be beneficial even after 4.5 h from symptom onset.

Posterior vs. anterior circulation infarction: demography, outcomes, and frequency of hemorrhage after thrombolysis

BACKGROUND

Intravenous thrombolysis is considered to be the standard specific reperfusion therapy in acute ischemic stroke in both anterior and posterior cerebral circulation.

AIMS

Our aim was to evaluate the 90-day outcome and rate of intracranial hemorrhage after recombinant tissue plasminogen activator administration in posterior circulation stroke and to compare the intracranial hemorrhage risk for posterior circulation stroke and anterior circulation stroke.

METHODS

The set consisted of 877 consecutive acute ischemic stroke patients (777 anterior circulation stroke; 100 posterior circulation stroke) who underwent intravenous thrombolysis with recombinant tissue plasminogen activator in a standard dose of 0·9 mg/kg. The role of following factors was assessed: presenting characteristics, intracranial hemorrhage classification according to ECASS I, mortality, and 90-day clinical outcome assessed using the modified Rankin scale.

RESULTS

Good clinical outcomes (modified Rankin scale 0-2) were noted in 59% of posterior circulation stroke patients, with a mortality rate of 19%. Intracerebral hemorrhage was significantly less frequent in posterior circulation stroke than in anterior circulation stroke patients (5·1 vs. 17·2%; P = 0·002). The risk of large hemorrhage (parenchymal hematoma 1 and 2) was 5·2 times higher in anterior circulation stroke patients (P = 0·007). The following additional statistically significant differences were found between posterior circulation stroke and anterior circulation stroke patients: median age, male gender, presence of atrial fibrillation, hyperlipidemia, median time to treatment, and median blood glucose level on admission.

CONCLUSIONS

Our study suggests that posterior circulation stroke is associated with a lower risk of intracranial hemorrhage than anterior circulation stroke is.

Endovascular treatment of acute basilar artery occlusion: time to treatment is crucial

AIM

To evaluate the safety and efficacy of multimodal endovascular treatment (EVT) of acute basilar artery occlusion (BAO), including bridging therapy [intravenous thrombolysis (IVT) with subsequent EVT], to compare particular EVT techniques and identify predictors of clinical outcome.

MATERIALS AND METHODS

This retrospective, multi-centre study comprised 72 acute ischaemic stroke patients (51 males; mean age 59.1 ± 13.3 years) with radiologically confirmed BAO. The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings. Thirty- and 90-day outcomes were evaluated using the modified Rankin scale with a good clinical outcome defined as 0-3 points.

RESULTS

Successful recanalization was achieved in 94.4% patients. Stepwise binary logistic regression analysis identified the presence of arterial hypertension (OR = 0.073 and OR = 0.067, respectively), National Institutes of Health Stroke Scale (NIHSS) at the time of treatment (OR = 0,829 and OR = 0.864, respectively), and time to treatment (OR = 0.556 and OR = 0.502, respectively) as significant independent predictors of 30- and 90-day clinical outcomes.

CONCLUSION

Data from this multicentre study showed that multimodal EVT was an effective recanalization method in acute BAO. Bridging therapy shortens the time to treatment, which was identified as the only modifiable outcome predictor.