Diving into a Shallow Pool: Endovascular Treatment for Basilar Artery Occlusion

Selection of patients with acute vertebrobasilar artery occlusion for endovascular treatment by magnetic resonance imaging

Background and purpose

The best method for selecting patients with acute vertebrobasilar artery occlusion (VBAO) who would benefit from endovascular treatment (EVT) is still the key question. This study aimed to assess the efficacy of magnetic resonance imaging (MRI) for selecting patients with acute VBAO for EVT.

Materials and methods

A total of 14 patients with suspected acute VBAO on MR angiography (MRA) in the EVT database (from April 2016 to August 2019) were enrolled. Acute Stroke Prognosis Early Computed Tomography Score (ASPECTS) and pons-midbrain index were assessed on diffusion-weighted imaging (DWI). EVT included a stent retriever and a rescue treatment (angioplasty and/or stenting). The proportion of successful reperfusion and favorable functional outcomes (modified Rankin Scale ≤ 3) at 90 days was documented.

Results

A total of 11 patients were included in the final analysis. The median DWI-ASPECTS and pons-midbrain index were 7 and 2, respectively. Underlying stenosis was detected in 10 of 11 (90.9%) patients. Balloon angioplasty and/or stenting were used as rescue therapy for five patients and two patients, respectively. A total of nine patients (81.8%) achieved successful reperfusion (mTICI, 2b, or 3). The 90-day mRS score of 0-3 was achieved in six (54.5%) patients. The mortality rate within 90 days was 18.2% (two of 11 patients).

Conclusion

DWI plus MRA could help select the patients with acute VBAO for EVT by assessing ASPECTS and the pons-midbrain index. Patients could achieve good reperfusion and favorable functional outcomes.

A New Era of Extended Time Window Acute Stroke Interventions Guided by Imaging

Ischemic stroke is one of the most debilitating and deadliest conditions worldwide. Intravenous t-PA is the current standard treatment within 4 hours after onset of symptoms. Recent randomized controlled trials have demonstrated the efficacy of neurointerventional intra-arterial treatment in acute ischemic stroke. About 20% of acute ischemic stroke are classified as wake-up strokes, which falls out of the conventional treatment time window. New evidence suggests that some patients with longer time from symptom onset (up to 24 hours) may benefit from thrombectomy, probably in part due to variations in collateral circulation among individual patients. Advanced imaging can play a crucial role in identifying patients who could benefit from endovascular intervention presenting within extended treatment time windows. In this article, we review the advanced imaging algorithm for ischemic stroke workup in the multiple studies published to date and summarize the results of the clinical trials for late ischemic stroke that can be clinically useful.