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Zhou X, Lu Y, Lin Y, Lin W, Deng J, Liu X. Association between Blood Pressure Variability and Clinical Outcomes after Successful Thrombectomy in Acute Basilar Artery Occlusion Stroke Patients: A Multicenter Cohort Study. J Stroke Cerebrovasc Dis 2024:107893. [PMID: 39179189 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Limited data are available on the appropriate choice of blood pressure management strategy for patients with acute basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT). We evaluated the impact of blood pressure variability on clinical outcomes after MT in patients with acute BAO. METHODS This multicenter cohort study included 108 patients with acute BAO who underwent successful emergency thrombectomy at two comprehensive stroke centers from 2016 to 2021. Blood pressure was measured hourly during the first 24 hours after successful reperfusion. Blood pressure variability was calculated as mean arterial pressure (MAP) assessed by the standard deviation (SD). Multivariate logistic models were used to investigate the association between BPV, the primary outcome (futile recanalization, 90-day modified Rankin Scale score 3-6), and the secondary outcome (30-day mortality). Subgroup analysis was performed as a sensitivity test. RESULTS Futile recanalization occurred in 60 (56%) patients, while 26 (24%) patients died within 30 days. In the fully adjusted model, MAP SD was associated with a higher risk of futile recanalization (OR adj=1.36, per 1 mmHg increase, 95% CI: 1.09-1.69, P=0.006) and 30-day mortality (OR adj=1.56, per 1 mmHg increase, 95% CI: 1.20-2.04, P=0.001). A significant interaction between MAP SD and the lack of hypertension history on futile recanalization (P<0.05) was observed. CONCLUSIONS Among recanalized acute BAO ischemic patients, higher blood pressure variability during the first 24 hours after MT was associated with worse outcomes. This association was stronger in patients without a history of hypertension.
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Affiliation(s)
- Xiaoyu Zhou
- Department of Neurology, Shanghai Tenth People's Hospital, School of clinical medicine of Nanjing Medical University, Shanghai, China.
| | - You Lu
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Yingying Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Wenjian Lin
- Department of Neurology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Jiangshan Deng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People's Hospital, School of clinical medicine of Nanjing Medical University, Shanghai, China.
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Shang X, Pan L, Xu Y, Guo Y, Yang K, Yang Q, Zhou Z. Effect of endovascular treatment on patients with basilar artery occlusion presenting with different pathologic mechanisms: a systematic review and meta-analysis. J Thromb Thrombolysis 2024; 57:124-131. [PMID: 37605064 DOI: 10.1007/s11239-023-02884-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE This study aimed to summarize the clinical outcomes of endovascular treatment in patients with basilar artery occlusion (BAO) with different pathologic mechanisms. METHODS Two independent reviewers searched PubMed/MEDLINE, Embase and Cochrane Library database up to December 2022, patients with different BAO pathological mechanisms (BAO with in situ atherosclerosis vs. embolism alone without vertebral artery steno-occlusion vs. embolism from tandem vertebral artery steno-occlusion) were collected and analyzed. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) to assess the associations between clinical outcomes and BAO pathological mechanisms. RESULTS A total of 1163 participants from 12 studies were identified. Compared with embolism alone, patients with in situ atherosclerotic BAO had a lower favorable outcome rate (modified Rankin score [mRS] 0-2: 34.5% vs. 41.2%; OR 0.83, 95% CI 0.70-0.98; P = 0.03) and moderate outcome rate (mRS 0-3: 45.8% vs. 55.4%; OR 0.65, 95% CI 0.47-0.90; P = 0.01) at 3 months and a higher risk of mortality (29.9% vs. 27.2%; OR 1.31, 95% CI 0.96-1.79, P = 0.09; adjusted OR 1.46, 95% CI 1.08-1.96). Tandem BAO had a comparable mortality risk to that of in situ atherosclerotic BAO (OR 1.37, 95% CI 0.84-2.22; P = 0.48) or embolism alone (OR 1.44, 95% CI 0.65-3.21; P = 0.43), and there were no significant differences in favorable or moderate outcomes between tandem BAO and each of the other two BAO mechanisms. CONCLUSION Among BAO patients with endovascular treatment, embolism mechanism had better clinical outcomes than in situ atherosclerosis, and atherosclerotic mechanism was associated with a higher mortality at 3 months. RCTs are needed to further confirm clinical outcomes of BAO by different mechanisms.
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Affiliation(s)
- Xianjin Shang
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China.
| | - Liying Pan
- Department of Neurology, Longyan First Hospital of Fujian Medical University, Longyan, Fujian Province, China
| | - Youqing Xu
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China
| | - Ke Yang
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui Province, China
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Feng S, Li T, Wu Y, Shi H, Liu Y, Xu B, Xu C, Zhou Q, Qu F, Li R, Tao C, Sun W, Hu W, Liu X. Endovascular treatment of acute basilar artery occlusion in patients with and without atrial fibrillation: results from the ATTENTION registry. Ther Adv Neurol Disord 2023; 16:17562864231159438. [PMID: 37114069 PMCID: PMC10126602 DOI: 10.1177/17562864231159438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/31/2023] [Indexed: 04/29/2023] Open
Abstract
Background Previous studies have shown a potential beneficial effect of endovascular therapy (EVT) in patients with acute basilar artery occlusion (BAO). It was unclear that whether atrial fibrillation (AF) can affect the clinical outcomes for BAO patients treated with EVT. Objectives To investigate the association between AF and clinical outcomes, and whether AF can modify the efficacy and safety of EVT in patients with BAO. Design We conducted a multicenter, nationwide, retrospective analysis to investigate how the presence of AF affects treatment allocation for BAO patients. Methods The endovascular treatment for acute basilar artery occlusion (ATTENTION) registry was a multicenter, prospective study in China that included acute BAO patients who underwent EVT or received best medical management (BMM) between 2017 and 2021. The outcomes include the distribution of 3-month modified Rankin scale (mRS) score, functional independence (defined as mRS 0-3), symptomatic intracerebral hemorrhage, and mortality. Results 2134 patients were included in the study, of which 619 had AF and 1515 did not have AF. The median age was 65 (interquartile range [IQR]: 56-73) years, and 689 (32.3%) patients were female. Multivariate regression analysis indicated no significant association existed between AF and the distribution of mRS (adjusted common odds ratio, 1.05 [95% CI: 0.88, 1.25]; p = 0.564) at 90 days. Similarly, AF was not found to have a significant association with and other measured outcomes, or with the effects of EVT in AF subgroups for at 90 days as measured by ordinal mRS (p for heterogeneity = 0.247). Finally, no significant differences were found for symptomatic intracerebral hemorrhage and mortality within 90 days between the EVT and BMM groups across AF subgroups. Conclusions Our results illustrated that the effect of EVT did not differ statistically in acute ischemic stroke patients with and without AF. Moreover, no significant association between AF and functional or safety outcomes could be detected at 90 days.
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Affiliation(s)
| | | | | | - Hongchao Shi
- Department of Neurology, Nanjing First Hospital, Nanjing, China
| | - Yongchang Liu
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Bo Xu
- Department of Neurology, Affiliated Qingdao Central Hospital, Qingdao University, Qingdao, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People’s Hospital, Taizhou, China
| | - Qingqing Zhou
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Fengling Qu
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Rui Li
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chunrong Tao
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
| | | | - Xinfeng Liu
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, China
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Liu H, Zeng G, Zeng H, Yu Y, Yue F, Ke Y, Yan Z, Pu J, Zhang J, Wei W, He D, Wu Y, Huang X, Zhou P. Endovascular treatment for acute basilar artery occlusion due to different stroke etiologies of large artery atherosclerosis and cardioembolism. Eur Stroke J 2022; 7:238-247. [PMID: 36082244 PMCID: PMC9446314 DOI: 10.1177/23969873221101285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/27/2022] [Indexed: 10/07/2023] Open
Abstract
Introduction Stroke etiology may affect the prognosis of acute basilar artery occlusion (BAO). This study aimed to estimate the efficacy and safety of endovascular treatment (EVT) in BAO strokes due to the underlying stroke etiologies of large artery atherosclerosis (LAA) and cardioembolism (CE). Patients and methods Patients with LAA and CE subtypes from the registry EVT for Acute Basilar Artery Occlusion Study (BASILAR) were selected for this analysis. We estimated the EVT treatment effect relative to standard medical treatment (SMT) in these patients by using a propensity score approach with inverse probability of treatment weighted estimation. Outcomes included 90-day favorable functional outcomes (modified Rankin scale (mRS) 0-3), functional independence (mRS 0-2), all-cause mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 744 patients were included in the final analysis. After weighting with inverse probability of treatment estimation, the patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated higher rates of favorable functional outcomes in both the LAA (29.2% vs 11.7%, adjusted OR with 95% CI: 4.34 [2.15-8.78], p < 0.001) and the CE subtype (36.0% vs 8.1%, adjusted OR with 95% CI: 9.14 [1.96-42.55], p = 0.005). A similar finding was also observed for functional independence. EVT patients also demonstrated lower rates of mortality than SMT. Among EVT patients, no significant difference was observed in mortality or sICH between LAA and CE groups, but LAA patients had lower rates of favorable functional outcome and functional independence (29.2% vs 37% and 24.2% vs 32.9%, respectively), where the latter remained significant after adjustment for imbalances in baseline data (p = 0.04). Conclusions In acute BAO strokes, both LAA and CE patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated better outcomes. Among EVT patients, LAA and CE subtypes displayed important baseline and treatment differences, and LAA patients were less likely to achieve functional independence at 3 months, but mortality and sICH were similar between LAA or CE subtypes. These results need to be confirmed in future clinical trials.
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Affiliation(s)
- Huihui Liu
- Department of Neurology and Suzhou
Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of
Soochow University, Suzhou, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou
People’s Hospital, Ganzhou, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou
People’s Hospital, Ganzhou, China
| | - Yang Yu
- Department of Neurology, Nanyang
Central Hospital, Nanyang, China
| | - Feixue Yue
- Department of Neurology, The First
Affiliated Hospital of Jilin University, Changchun, China
| | - Yingbing Ke
- Department of Neurology, Yangluo Branch
of Hubei Zhongshan Hospital, Wuhan, China
| | - Zhizhong Yan
- Department of Neurology, The 904th
Hospital of The People’s Liberation Army, Wuxi, China
| | - Jie Pu
- Department of Neurology, Renmin
Hospital of Wuhan University, Wuhan, China
| | - Jun Zhang
- Department of Neurology, The First
Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wan Wei
- Department of Neurology, Affiliated
Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou,
China
| | - Dengke He
- Department of Neurology, Air Force
Health Care Center For Special Services Hangzhou, Hangzhou, China
| | - Yupeng Wu
- Department of Neurology, Xuzhou
Central Hospital, Xuzhou, Chin
| | - Xianjun Huang
- Department of Neurology, Xiangyang
No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Peiyang Zhou
- Department of Neurology, Yijishan
Hospital of Wannan Medical College, Wuhu, China
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Kwon H, Lee D, Lee DH, Suh DC, Kwon SU, Kang DW, Kim JS. Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke. J Stroke 2022; 24:245-255. [PMID: 35677979 PMCID: PMC9194548 DOI: 10.5853/jos.2022.01095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients.
Methods We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology.
Results We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group.
Conclusions The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.
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Affiliation(s)
- Hanim Kwon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dongwhane Lee
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeugbu, Korea
| | - Deok Hee Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U. Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence: Jong S. Kim Department of Neurology, Stroke Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3442 Fax: +82-2-474-4691 E-mail:
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Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design. Transl Stroke Res 2022; 13:913-922. [PMID: 35349051 DOI: 10.1007/s12975-022-01008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
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