Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion

Single-center experience of endovascular treatment for patients with progressive posterior circulation cerebral infarction exceeding 24 h

Background

Evidence of endovascular treatment (ET) for patients with progressive infarction of the posterior circulation exceeding 24 h is lacking.

Objective

To evaluate the efficacy and safety of ET for progressive posterior circulation cerebral infarction.

Methods

This retrospective study evaluated the ET for 18 patients with posterior circulation infarction caused by vertebrobasilar artery occlusion from July 2017 to November 2018. The conditions of patients worsened despite receiving intravenous thrombolysis or combination therapy with clopidogrel and aspirin. The time from the onset of cerebral infarction to puncture was >24 h. The preoperative National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and related risk factors of patients at 3 months were analyzed postoperatively.

Results

The preoperative NIHSS score was 10.6 (IQR: 6.5), and the time from onset to puncture was 163.5 ± 144.7 h. Postoperative blood flow was modified thrombolysis in cerebral infarction (mTICI) grade 2b or above. During the follow-up period, 1 patient died of basilar artery re-occlusion and pulmonary infection, and 1 died of postoperative hyperperfusion hemorrhage, with a mortality rate of 11.1% (2/18). No recurrent ischemic events were observed in any of the 16 patients during the 3-month follow-up period. The mean mRS score was 1.3 (IQR: 2.3), and 75% patients (12/16) had an mRS score of 0-2. There were no significant differences in age, gender, clinical characteristics, and stroke subtype between patients with mRS scores ≤2 and >2.

Conclusion

In patients with progressive posterior circulation cerebral infarction caused by vertebral basilar artery occlusion, ET is effective and safe even if the time from onset to puncture exceeds 24 h.

Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery

Purpose

The study aimed to investigate the safety, effect, and risk factors of endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery (SNOVA).

Materials and methods

Patients with SNOVA were retrospectively enrolled and treated with endovascular recanalization. The clinical data, endovascular treatment, peri-procedural complications, and follow-up outcomes were analyzed.

Results

A total of 88 patients were enrolled, with an interval to recanalization of 2-89 days (median 23) and an mRS of 2-5 (median 3 and IQR 1). Occlusion was in the intracranial vertebral artery in 68 (77.27%) patients and basilar artery in 20 (22.73%), with an occlusion length of 4.5-43.7 mm (mean 18.3 ± 8.8). Endovascular recanalization was successful in 81 (92.0%) patients. Post-dilatation was performed in 23 (28.4%) patients. After stenting, the residual stenosis was 10%-40% (mean 20.2% ± 7.6%). Peri-procedural complications occurred in 17 (19.3%) patients, with a mortality rate of 5.7%. In total, 79 (95.18%) patients underwent follow-up 5-29 (mean 16.9 ± 5.5) months later, with an mRS score of 0-6 (median 1 and IQR 1) at follow-up, being significantly (p < 0.0001) better than that at discharge. Stroke occurred in 9 patients (11.4%) in 1 year. In-stent restenosis occurred in 19 (25.33%) patients. Significant (p < 0.05) independent risk factors were blunt occlusion for successful recanalization, duration to recanalization and blunt occlusion for peri-procedural complications, and post-dilatation for both in-stent restenosis and 1-year stroke or death events.

Conclusion

Endovascular recanalization of symptomatic non-acute occlusion of the vertebrobasilar artery is feasible even for a long occlusion segment, with a high recanalization rate, a low complication rate, and a good prognosis. Blunt occlusion and duration from the onset to recanalization may affect successful recanalization and peri-procedural complications while post-dilatation may affect in-stent restenosis and prognosis.

Safety and efficacy of intravascular therapy in patients with progressive stroke caused by intracranial large vascular occlusion exceeding the time window of 24 hours

PURPOSE

To compare endovascular and drug therapies for efficacy and safety in patients with a progressive stroke caused by intracranial large vascular occlusion exceeding the time window of 24 hours.

PATIENTS AND METHODS

A total of 58 patients with progressive stroke caused by large intracranial vascular occlusion exceeding the time window of 24 hours treated in the stroke center of our hospital for three years were retrospectively analyzed . According to the applied therapy, 58 patients were divided into the endovascular (n = 19) and drug (n = 39) therapy groups. Then, modified Rankin scale (mRS) scores, symptomatic intracranial hemorrhage rates, mortality rates and adverse events were assessed in both groups within 90 days.

RESULTS

The 90-day good prognosis rate was significantly higher in the endovascular therapy group compared with the drug group (68.4% VS 38.5%, odds ratio [OR] = 0.29; 95% confidence interval [CI], 0.09-0.92; P = 0.032). The 90-day NIHSS scores were lower in the endovascular therapy group compared with the drug group (3.3 ± 2.6 VS 5.2 ± 3.0, OR = -1.89; 95%CI, -3.50 to -0.27; P = 0.023). Meanwhile, the proportion of patients with a Barthel index of 90-100 was significantly higher in the endovascular therapy group compared with the drug group (53.0% VS 25.6%, OR = 0.31; 95%CI, 0.10-0.98; P = 0.042). Finally, both groups showed similar rates of adverse events.

CONCLUSION

In patients with progressive stroke caused by large intracranial vascular occlusion exceeding 24 hours, endovascular therapy probably results in improved efficacy at 90 days compared with drug therapy, without increasing the rates of adverse effects.

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.