Fully Endoscopic Microvascular Decompression for Trigeminal Neuralgia Caused by Vertebrobasilar Artery: A Case Series Review: 2-Dimensional Operative Video

BACKGROUND AND OBJECTIVE

Microvascular decompression (MVD) is the most definitive and preferred surgical treatment for trigeminal neuralgia (TN). Treatment of TN caused by the vertebrobasilar artery (VBA) has been reported to be challenging and less satisfactory in complications and recurrence. Endoscopy has been implemented to provide a comprehensive view of neurovascular conflicts and minimize brain tissue stretch injury while exploring the trigeminal nerve. However, there are few retrospective studies on the treatment of TN caused by VBA by fully endoscopic microvascular decompression (E-MVD). This article aimed to illustrate the safety and efficacy of E-MVD for TN caused by the VBA.

METHODS

Clinical data for 26 patients with TN caused by the VBA who underwent E-MVD from 2019 to 2022 were retrospectively analyzed. The characteristics of vertebrobasilar-associated TN were summarized. The safety and efficacy of E-MVD for vertebrobasilar-associated TN were estimated based on the analysis of intraoperative manipulation, postoperative symptom relief, and complications.

RESULTS

Intraoperatively, the vertebrobasilar artery was regarded as a direct offending vessel in all 26 patients with TN, the vertebral artery in 18 (69.23%) and the basilar artery in 10 (38.46%). In addition to the vertebrobasilar artery, other vessels involved included the superior cerebellar artery in 12 patients, anterior inferior cerebellar artery in 9, posterior inferior cerebellar artery in 1, and veins in 4. All patients underwent E-MVD, and TN was entirely resolved in 26 (100%) patients immediately postoperatively. During the follow-up period of 12-45 months, no recurrence or serious complications were found. There were no serious postoperative complications, such as cerebellar swelling, intracranial hemorrhage, or death.

CONCLUSION

E-MVD for vertebrobasilar-associated TN is effective and safe.

Anatomical Features of Posterior Cerebral Arteries and Basilar Artery in 170 Anatolian Fresh Cadavers: Implications for Surgical Planning and Intervention

BACKGROUND

The posterior cerebral arteries (PCAs) are terminal branches of the basilar artery (BA) and are responsible for the primary supply of the occipital lobe. Saccular aneurysm is most commonly seen close to the bifurcation of the BA. Various surgical interventions are performed for aneurysms. Therefore, the anatomy and localization of the BA and PCA are crucial. The aim of this study was to determine the characteristics of these arteries in a large Anatolian population.

METHODS

The study included 170 Anatolian fresh cadavers. The diameters of the BA and PCA were measured. Correlations according to sex and age groups were analyzed. The Q1, Q2, and Q3 angles between the right and left PCA, between the right PCA and BA, and between the left PCA and BA, respectively, were measured. The location of the PCA relative to the sulcus pontocruralis (pontocrural groove) was also evaluated.

RESULTS

The diameter of the artery increased with age and was higher in males than in females. Q1 and Q2 diameters were larger in males, while the Q3 diameter was larger in females. The Q1 angle between the right and left PCAs was found to be higher in age range 40-59 years with a mean of 87.33 ± 17.91 mm. Finally, the bifurcation point of the PCA was most frequently located above the sulcus pontocruralis (pontocrural groove) and least frequently located on the sulcus pontocruralis (pontocrural groove).

CONCLUSIONS

The findings of our study will contribute to the planning of surgical approaches, the development of endovascular devices, the success of invasive procedures, and the reduction of complications.

Asymmetric deep cerebral venous filling predicts poor outcome of acute basilar artery occlusion after endovascular treatment

OBJECTIVE

To explore the relationship between asymmetric deep cerebral venous (ADCV) filling and poor outcomes after endovascular treatment (EVT) in patients with acute basilar artery occlusion (ABAO).

METHODS

ABAO patients were selected from a prospectively collected data at our center. The DCV filling was evaluated using computed tomography perfusion (CTP)-derived reconstructed 4D-DSA or mean venous map. ADCV filling was defined as the internal cerebral vein (ICV), thalamostriate vein (TSV), or basal vein of Rosenthal (BVR) presence of ipsilateral filling defects or delayed opacification compared to the contralateral side. Poor prognosis was defined as a modified Rankin scale score >3 at the 90-day follow-up.

RESULTS

A total of 90 patients were enrolled in the study, with a median Glasgow Coma Scale of 6, 46 (51.1%) showed ADCV filling, 59 (65.6%) had a poor prognosis, and 27 (30.7%) had malignant cerebellar edema (MCE). Multivariate adjusted analysis revealed significant associations between asymmetric TSV and poor prognosis (odds ratio, 9.091, p = 0.006); asymmetric BVR (OR, 9.232, p = 0.001) and asymmetric ICV (OR, 4.028, p = 0.041) were significantly associated with MCE.

CONCLUSION

Preoperative ADCV filling is an independent influencing factor for the poor outcome after EVT in ABAO patients.

Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms

BACKGROUND

Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms.

METHODS

Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls.

RESULTS

9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2.

CONCLUSIONS

Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.

Ruptured basilar artery perforator aneurysm mimicking superior cerebellar artery aneurysm

BACKGROUND AND IMPORTANCE

The diagnosis of basilar artery perforator aneurysm is difficult due to their small size, with high rates of negative angiography. Furthermore, due to the considerable variation of basilar artery perforator (BAP), even if an aneurysm originates from a BAP, it is often difficult to clearly identify its origin on angiography.

CLINICAL PRESENTATION

A 46-female patient presented with World Federation of Neurological Surgeons Scale 1 subarachnoid hemorrhage. Initial imaging study, including digital subtraction angiography (DSA), revealed no vascular lesions. Two-week after admission, DSA revealed an aneurysm arising from the left superior cerebellar artery (SCA). Endovascular coil embolization was planned first. However, aneurysm selection using microcatheter was failed. Then, surgical approach was done via pre-temporal approach. We identified SCA, but there was no aneurysm. Further dissection revealed an aneurysm arising from basilar artery perforator, which was overlapped by SCA. The parent artery of the aneurysm arose from juxtaproximal to the orifice of left SCA, and crossed SCA at the juxtadistal to the aneurismal sac. Complete clip occlusion was done preserving BAP. After the surgery, the patient developed diplopia without extraoccular movement limitations. Two-month after the surgery, she was fully recovered without any neurologic deficits.

CONCLUSION

It is crucial to adequately consider the possibility of open surgery as a viable option in case that endovascular treatment of aneurysms originated from the distal segment of basilar artery proves unsuccessful.

Role of a Tortuous Vertebrobasilar Artery and Anchoring Perforators in the Etiology of Hemifacial Spasm

BACKGROUND

In >70% of patients with hemifacial spasm (HFS), the offending artery is either the anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA), without a tortuous vertebrobasilar artery (VBA). We hypothesized that anchoring perforators around the root exit zone (REZ) of the AICA or PICA might induce vascular deviation and compression. We investigated the occurrence of these perforators from the AICA or PICA and the extent of VBA tortuosity to reveal the pathology of vascular compression.

METHODS

This retrospective review included 110 patients after excluding those with vertebral artery (VA) compression alone. The occurrence of perforators was determined according to operative findings within 5 mm of the REZ, and VBA tortuosity was evaluated using MATLAB. We analyzed the association between perforators, VBA tortuosity, and the surgical implications.

RESULTS

The occurrence of perforators from the offending AICA or PICA around the REZ was significantly higher in the group without VA compression (Group A) than in the group with VA compression (Group B). VBA tortuosity was significantly lower in Group A. VBA tortuosity was inversely correlated with the presence of AICA or PICA perforators in all 110 patients. Operative results were similar between the groups, although patients with low VBA tortuosity tended to require interposition in decompression procedures.

CONCLUSIONS

Anchoring perforators around the REZ play a crucial role in vascular compression for patients with less tortuous VBAs. Moreover, surgeons should be prepared to deal with multiple perforators in a more complicated surgery in cases of less tortuous VBA.

Persistent trigeminal artery in a patient with moyamoya disease:a case report and literature review

BACKGROUNDS

Persistent trigeminal artery (PTA) is a rare anastomosis between internal carotid artery (ICA) and basilar artery. In rare conditions, the PTA could be combined with others cerebrovascular anomalies, moyamoya disease (MMD) is one of them.

CASE PRESENTATION

Here, we reported one rare case of MMD associated with PTA, the patient admitted to our department for severe dizziness and headache, imaging examination suggested MMD combined with right PTA, which arising from the ipsilateral cavernous portion of ICA. The patient received phased bilaterral revascularization with no any complication. In the subsequent follow-up, the patient's symptoms and intracranial vascular condition gradually improved. Moreover, we conducted a literature review of coexistence of PTA and MMD, the results of a web of science regarding such condition, and a deep discussion providing brief insight into the status of co-occurrence of PTA and MMD, including its manifestation, treatment and outcome.

CONCLUSIONS

The coexistence of PTA and MMD was rarely reported, the pathogenesis of such condition remains unknown. We found that the features of the coexistence of PTA and MMD were diverse, revascularization might be a feasible for such patient.

Half-and-Half Approach for Multiple Aneurysms at the Superior Cerebellar and Middle Cerebral Arteries

Aneurysms at the superior cerebellar artery (SCA) are commonly treated endovascularly because of their location around the basilar artery,1,2 but they are not intimately related with thalamoperforators. Therefore in younger patients, those with wide-necked aneurysms, or those with multiple ipsilateral aneurysms, surgery remains a treatment option.3 We present a 52-year-old woman with dizziness in whom multiple, unruptured intracranial aneurysms were identified. Imaging demonstrated a 9-mm right-sided SCA aneurysm and 5-mm right and mirror 3-mm left M1 segment middle cerebral artery aneurysms. The patient gave consent to undergo surgery after counseling regarding her treatment options. A pterional and temporal craniotomy was performed to allow for half-and-half subtemporal and transsylvian approaches (Video 1). Here, we discuss the nuances of the approach related to the anatomy of SCA aneurysms. The challenges of the surgery can be mediated with techniques including division of the tentorium for enhanced exposure and early proximal control with temporary clinping or the use of adenosine (cardiac arrest). Our patient remained neurologically stable postoperatively and in 1-year follow-up. SCA aneurysms are easily visualized by the subtemporal and transsylvian approaches; they are frequently located adjacent to the posterior cerebral artery above and the SCA below. A modified transcavernous approach using the orbitozygomatic craniotomy has been described for access to basilar tip aneurysms.4 While comparable, this case demonstrates the efficient workflow to clip multiple aneurysms using a single, combined approach. In patients with multiple aneurysms presenting ipsilaterally or with comorbid conditions that complicate endovascular embolization, surgery should be considered as a definitive and safe treatment strategy. The patient consented to publication.

Intermediate-porosity stent for coil-reconstruction of mixed saccular-fusiform basilar trunk aneurysm

Vertebrobasilar junction and basilar trunk aneurysms are extremely difficult to treat, with significant morbidity associated with bypass-trapping procedures. As a result, endovascular techniques including flow diversion and stent-assisted coil embolization have become the mainstay of treatment.1-3 Traditional flow diverters pose risk of occlusion of basilar perforator arteries while traditional stents used as adjuncts for coil-embolization often have high porosity and cannot function as flow diverters. On the other hand, the LVIS stent uniquely provides more porosity than other flow diverters,4,5 allowing patency of perforators while also being amenable to stent-assisted coiling. We present a case of a mixed saccular and fusiform basilar trunk aneurysm that underwent LVIS stent-assisted coil embolization. Using bifemoral access with triaxial systems, one microcatheter was placed in the aneurysm sac and another was used to deploy a stent from the basilar apex into the right vertebral artery. A durable angiographic outcome was observed at 9 months.

Bailout endovascular techniques applied in a complicated basilar thrombectomy case

Patients with stroke symptoms due to acute basilar artery occlusion can benefit from endovascular thrombectomy.1 2 Several papers have reported unwanted events during thrombectomy procedures such as breakage, fragmentation, or even intravascular migration of the devices or catheter pieces. These papers also presented methods or techniques to retrieve defective devices such as a snare, retrievable stents, or balloons.3-6 Video 1 presents a case of basilar thrombectomy that was complicated with fragmentation and then distal migration of a Marksman microcatheter tip into the left posterior cerebral artery. The video shows the bailout technique that was used to retrieve the migrated catheter tip using a gentle/simple and posterior circulation-friendly technique-a technique based on fundamental neurointerventional concepts. neurintsurg;16/2/217/V1F1V1Video 1 This video demonstrates the use of a bailout technique to retrieve a migrated microcatehter tip after basilar artery thrombectomy.

[Microvascular Decompression for Trigeminal Neuralgia Caused by Trigeminocerebellar Artery]

The trigeminocerebellar artery(TCA)is a unique branch of the basilar artery. The TCA was first described in detail by Markovic et al. in 1996. The incidence of TCA was 6.9%-13.3% in previous cadaveric studies. The TCA branches from the distal part of the basilar artery, courses very close to the trigeminal nerve root entry zone, and occasionally twists or encircles the nerve root. A close relationship between the TCA and trigeminal nerve can cause trigeminal neuralgia(TN). This characteristic course of TCA requires adjuvant decompression techniques performed by the operators. In the microvascular decompression for TN caused by the TCA, operators should pay attention to the following: 1)sufficient arachnoid dissection around the TCA, 2)combined transposition and interposition technique, 3)decompression of perforators and vessels penetrating the nerve, and 4)recognition of the existence of the TCA.

[Microsurgical Procedures of Microvascular Decompression for Trigeminal Neuralgia]

Microvascular decompression for trigeminal neuralgia was successfully performed following the secure surgical steps. The most crucial step involves creating a safe operative field in the dural opening. The petrotentorial junction should be identified without cerebellar retraction before proceeding to the deeper areas. Dissecting the petrosal vein and opening the horizontal fissure contributed to the expansion of the operative field. Bleeding often occurs from the dorsal cerebellar bridging vein and junction of the petrosal vein into the superior petrosal sinus. Transposition of the most common offenders, the superior and anterior inferior cerebellar arteries, is effectively achieved by dissecting both the proximal and distal sides of the neurovascular compression site. Teflon should be placed at a sufficient distance to prevent contact with the nerve, which can lead to recurrence. Treating vertebrobasilar artery-related cases is challenging and involves the risk of cranial nerve injuries. Multiple offending vessels are commonly involved. In such cases, it is essential to be aware of the course of the trochlear and abducens nerves during decompression. Applying the most effective and least risky maneuver is necessary for treating cases involving the vertebrobasilar artery.

Basilar tip morphology: impact on mechanical thrombectomy for acute distal basilar artery occlusion

BACKGROUND

The morphology of the basilar artery tip (BAT) varies between patients. The morphologic anatomy of the BAT could affect the efficacy of mechanical thrombectomy (MT).

METHODS

108 patients with acute distal basilar artery occlusion (dBAO) who underwent MT from January 2013 to December 2021 were retrospectively analyzed. These patients were divided into two groups based on their BAT morphology: those with symmetrical cranial or caudal fusion of the BAT (symmetric group) and those with asymmetrical fusion of the BAT (asymmetric group). Morphological variables and angiographic and clinical outcomes were compared between the two groups.

RESULTS

Of the 108 enrolled patients, 42 were in the asymmetric group. Compared with the symmetric group, the asymmetric group had significantly larger BAT diameter (mean 3.5±1.0 mm vs 4.3±1.1 mm, P=0.001) and basilar artery tip/trunk ratio (1.2±0.2 vs 1.7±0.2, P<0.001). The asymmetric group showed a significantly lower rate of complete reperfusion (71.2% vs 40.5%, P=0.002) and first pass effect (FPE) (51.5% vs 21.4%, P=0.002) than the symmetric group. The BAT asymmetry was an independent predictor of failed FPE (OR 0.299, 95% CI 0.098 to 0.918, P=0.035) and failed complete reperfusion (OR 0.275, 95% CI 0.087 to 0.873, P=0.029).

CONCLUSIONS

The efficacy of MT for dBAO differs according to the anatomic morphology of the BAT. The asymmetric BAT was frequently encountered in dBAO patients and was independently associated with a reduced likelihood of complete reperfusion and FPE.

Superior cerebellar artery occlusion remaining after thrombectomy for acute basilar artery occlusion

To investigate the incidence and impact of superior cerebellar artery (SCA) occlusion remaining after thrombectomy for acute basilar artery occlusion (BAO). We retrospectively analyzed data from 116 patients who underwent thrombectomy for BAO. The patency of SCA was assessed on final angiograms. Clinical and radiologic data of the patients were retrieved from a prospectively collected database and analyzed. All patients underwent pretreatment and follow-up DWI to detect new infarctions in SCA territory. Ten patients (8.6%) had SCA occlusions on final angiograms. Of these, two patients had bilateral occlusions. A new infarction with a diameter ranged from 4 to 11 mm in corresponding SCA territory occurred in 5 of 10 patients. No patients with SCA occlusions experienced symptomatic cerebellar hemorrhage or malignant cerebellar infarction. Nine of 12 SCA occlusions showed spontaneous recanalization on follow-up CT angiography. Four of 10 patients showed 90-day favorable outcome (mRS 0-3) and 90-day mortality occurred in one patient. SCA occlusions remaining after thrombectomy for acute BAO had a benign clinical course. Most of these lesions recanalized spontaneously. Our study suggests that attempts to recanalize remnant SCA occlusion may be unnecessary after basilar artery thrombectomy.

Endovascular Embolization of Basilar Artery Fenestration Aneurysms: A 21-Year Institutional Case Series

BACKGROUND AND OBJECTIVES

Basilar artery fenestration is a rare phenomenon sometimes associated with basilar artery fenestration aneurysms (BAFAs). This review investigates the natural history and management outcomes of BAFAs and describes the outcomes of BAFAs treated with embolization.

METHODS

A single-center database was queried for all cases of endovascular BAFA treatment. Data on complications, clinical and angiographic outcomes, and retreatment rates were collected.

RESULTS

Seventeen aneurysms across 17 patients were treated. The mean (SD) age was 56 (13) years, and 15 (88%) patients were women. Among 15 aneurysms with data available, 2 arose from the fenestration limbs and 13 from both limbs and the vertebral artery. Of 16 aneurysmal projections available, 7 projected anteriorly, 7 posteriorly, and 2 superiorly. Among 17 patients, balloon-assisted coiling was the most common treatment (n = 10), followed by primary coiling (n = 3), stent-assisted coiling (n = 2), coiling with flow diversion (n = 1), and balloon-assisted coiling and flow diversion (n = 1). Complications noted in 5 patients included hemorrhage, thromboembolism, paresthesias, vasospasm, and transient hemiparesis. Among 16 patients with postoperative results available, 12 showed favorable clinical outcomes, 3 were disabled, and 1 died. The rates of postoperative complete (Raymond-Roy Occlusion Classification 1) and incomplete (Raymond-Roy Occlusion Classification 2 and 3) occlusion among 15 patients with available data were 6 and 9, respectively.

CONCLUSION

Endovascular management of these rare aneurysms is feasible and safe, with high rates of favorable radiographic and clinical outcomes. This series reflects a general preference toward coiling and stent-assisted coiling, although flow diversion may be considered in select cases.

Outcome prediction value of critical area perfusion score for acute basilar artery occlusion

PURPOSE

To investigate the performance of the Critical Area Perfusion Score (CAPS), based on computed tomography perfusion (CTP) time to maximum (Tmax) > 10s maps, to predict the outcome in acute basilar artery occlusion (BAO) in patients undergoing endovascular treatment (EVT).

METHODS

We perform a retrospective analysis of a prospectively collected database of acute BAO treated with EVT in a comprehensive stroke center. The favorable outcome was defined as the 90-day modified Rankin Scale (mRS) ≤ 3. We performed the logistic regression analysis to find the independent predictors of the favorable outcome. Then, we used receiver operating characteristic analyses to assess the predictive value of the imaging parameters, including CAPS, Posterior Circulation Alberta Stroke Program Early CT Score (PC-ASPECTS), pons midbrain index (PMI), posterior circulation computed tomography angiography (PC-CTA) score, Basilar Artery on Computed Tomography Angiography (BATMAN) score, and CTP parameters. Finally, the Delong test was used to compare the area under the curve (AUC) of CAPS against the other imaging parameters.

RESULTS

Of the 65 enrolled patients, the incidence of the favorable outcome was 44.6% (29/65). Low CAPS (per 1- point increased odds ratio [OR], 0.43; 95% confidence interval [CI], 0.22-0.86; P = 0.017) and admission National Institutes of Health Stroke Scale (NIHSS) (per 1- point increased OR, 0.80; 95% CI, 0.70-0.91; P = 0.001) were independently associated with favorable outcome. The AUC of CAPS was 0.83 (95% CI, 0.74-0.93; P < 0.001) with ≤ 3 cut-off value, 89.66% sensitivity, 77.22% specificity, and 80.00% accuracy, which was greater than the other imaging parameters (All P for Delong test < 0.05).

CONCLUSIONS

CAPS was the most accurate imaging-based outcome predictor in acute BAO patients. Future large prospective multicenter studies are needed to verify these results.

Anatomic Variants in the Anterior Inferior Cerebellar Artery Encountered During Resection of Vestibular Schwannomas

BACKGROUND AND OBJECTIVES

Vestibular schwannomas (VS) are often phenotypically benign lesions that may be technically challenging to resect because of involvement of neurovascular structures. The anterior inferior cerebellar artery (AICA) is commonly identified near VS, with variable position in relation to the tumor; however, little published literature describes anatomic and pathologic variants of AICA observed during VS resection.

METHODS

A prospectively maintained cohort of surgically managed VS with available operative reports and clinical/radiographic follow-up was queried and reviewed for noted aberrations.

RESULTS

We identified 66 cases with noted AICA abnormalities among 880 reviewer cases, including 20 loops extending into the internal auditory canal (2.3%), 18 arteries embedded in dura (2.0%), 15 AICA branches directly within VS (1.7%), 8 main trunk arteries coursing between cranial nerves 7 and 8 (0.9%), 3 arteries embedded in temporal bone (0.2%), 1 aneurysm (0.1%), and 1 artery bifurcating cranial nerve 6 (0.1%). The median age of AICA-variant patients was 55 years (range 19-74), and 29 were female (45%). Compared with the other AICA variants, tumors embedded with AICA tended to be larger lesions on maximal axial diameter (2.9 vs 1.6 cm; P = .006), they more commonly underwent less than total resection (73% vs 28%; P = .0001), and they had higher rates postoperative House-Brackmann scores >2 (47% vs 20%; P = .005). Two patients had radiographic and symptomatic postoperative cerebral ischemia or hemorrhage-1 from a bone-encased AICA and 1 from a dural embedded variant.

CONCLUSION

Anatomic variants of AICA occur in approximately 7% of VS operations. Most aberrations do not affect surgical or clinical outcomes, and the rate of major vascular injury was low. However, certain types variably add operative time and in the case of AICA encasement in the tumor, likely indicate a more aggressive tumor phenotype with lower rates of gross total resection and high incidences of facial nerve weakness.

Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.

Dynamic and visual nomograms to online predict unfavorable outcome of mechanical thrombectomy for acute basilar artery occlusion

BACKGROUND

The evidence of mechanical thrombectomy (MT) in basilar artery occlusion (BAO) was limited. This study aimed to develop dynamic and visual nomogram models to predict the unfavorable outcome of MT in BAO online.

METHODS

BAO patients treated with MT were screened. Preoperative and postoperative nomogram models were developed based on clinical parameters and imaging features. An independent dataset was collected to perform external validation. Web-based calculators were constructed to provide convenient access.

RESULTS

A total of 127 patients were included in the study, and 117 of them were eventually included in the analysis. The nomogram models showed robust discrimination, with an area under the receiver operating characteristic (ROC) of 0.841 (preoperative) and 0.916 (postoperative). The calibration curves showed good agreement. The preoperative predictors of an unfavorable outcome were previous stroke, the National Institutes of Health Stroke Scale (NIHSS) at admission, and the posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS). The postoperative predictors were previous stroke, NIHSS at 24 h, and pc-ASPECTS.

CONCLUSION

Dynamic and visual nomograms were constructed and validated for the first time for BAO patients treated with MT, which provided precise predictions for the risk of an unfavorable outcome. The preoperative model may assist clinicians in selecting eligible patients, and the postoperative model may facilitate individualized poststroke management.

Trapping and side-to-end superior cerebellar artery to superior cerebellar artery bypass for treatment of fusiform superior cerebellar artery aneurysm

We describe the technical nuances of in-situ bypass for treatment of a fusiform superior cerebellar artery (SCA) aneurysm via surgical trapping and a side-to-end in-situ bypass between duplicated SCAs. Our patient is a 40-year-old male who presented with an incidental aneurysm of the proximal right superior cerebellar artery (SCA). Formal angiography was performed that demonstrated a fusiform morphology of the aneurysm, as well as a duplicated SCA on that side. After extensive counseling, the patient elected to undergo surgical clip reconstruction with possible bypass. A large frontotemporal craniotomy was performed and a combined transsylvian-subtemporal approach to the ventral anterolateral brainstem was performed. After identifying the aneurysm, the tentorium was incised posterior to the insertion of the trochlear nerve to widen the operative field. An end-to-side anastomosis between the duplicated SCAs was performed, followed by trapping of the diseased arterial segment. The patient had an oculomotor nerve palsy post-operatively, however this resolved by his six-month follow-up. In-situ bypass is a viable technique for revascularizing the SCA territory during clip reconstruction of fusiform aneurysms. A duplicated SCA allows for an SCA to SCA bypass. Incising the tentorium can increase visualization of donor and recipient vessels and facilitate performance of the anastomosis.

Effect of collateral status on the outcomes of endovascular treatment of acute basilar artery occlusion due to large-artery atherosclerosis

OBJECTIVE

Authors of this study aimed to evaluate the effects of collateral status on the prognostic value of endovascular treatment (EVT) in patients with basilar artery occlusion (BAO) due to large-artery atherosclerosis (LAA).

METHODS

The study included 312 patients from the BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion Study) registry who had undergone EVT for acute BAO due to LAA and whose composite collateral scores were available. The effects of collateral status on EVT were assessed based on the composite collateral score (0-2 vs 3-5). The primary outcome was a favorable outcome (modified Rankin Scale score of 0-3) at 90 days.

RESULTS

The composite collateral score was 0-2 in 130 patients and 3-5 in 182. A good collateral status (composite collateral score 3-5) was associated with a favorable outcome (66/182 [36.3%] vs 31/130 [23.8%], adjusted odds ratio [aOR] 2.21, 95% CI 1.18-4.14, p = 0.014). A lower baseline National Institutes of Health Stroke Scale (NIHSS) score was an independent predictor of a favorable outcome in the poor collateral status group (aOR 0.91, 95% CI 0.87-0.96, p = 0.001). In the good collateral status group, there was a significant correlation between favorable outcomes and a younger age (aOR 0.96, 95% CI 0.92-0.99, p = 0.016), lower baseline NIHSS score (aOR 0.89, 95% CI 0.85-0.93, p < 0.001), lower proportion of diabetes mellitus (aOR 0.31, 95% CI 0.13-0.75, p = 0.009), and shorter procedure time (aOR 0.99, 95% CI 0.98-1.00, p = 0.003).

CONCLUSIONS

A good collateral status was a strong prognostic factor after EVT in patients with BAO underlying LAA. A shorter procedure time was associated with favorable outcomes in patients with a good collateral status.

Atrial myxoma embolization of the basilar artery presenting with a convulsive seizure: Case report

BACKGROUND

Basilar artery occlusion (BAO) is a rare cause of convulsive seizure. Such patients who are treated for epilepsy will miss the optimal time for treatment. Atrial myxoma is a rare cause of stroke and should be surgically removed as soon as possible after diagnosis.

CASE SUMMARY

We report a patient who presented with convulsions as the initial symptom and was diagnosed with BAO by computed tomographic angiography. After transthoracic echocardiogram, the cause of the disease was diagnosed as atrial myxoma. The patient recovered well after endovascular treatment and resection of the atrial myxoma.

CONCLUSION

A small number of patients with BAO present with convulsive seizures. It is very important to make a timely diagnosis. Direct thrombaspiration may be the best choice for basilar artery cardioembolization, and thrombectomy for distal moderate vascular occlusion in posterior circulation is feasible. Atrial myxoma is a rare cause of cardioembolic stroke and should be resected as soon as possible to prevent further embolic complications.

Effect of the anastomosis between the posterior inferior cerebellar artery and the superior cerebellar artery on outcomes of acute basilar artery occlusion after endovascular treatment

BACKGROUND

The effects of secondary collateral compensation on outcomes remain unclear in patients with acute basilar artery occlusion (BAO) after endovascular treatment (EVT). This study aimed to evaluate the benefits of the anastomosis between the posterior inferior cerebellar artery (PICA) and the superior cerebellar artery (SCA) in BAO after EVT.

METHODS

This cohort study was conducted using data from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry. Patients with acute BAO and treated with EVT were included. The primary outcome was a modified Rankin Scale score of 0-2 at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (SICH) and 90-day mortality.

RESULTS

Of the 646 patients included in the study, 196 (30.3%) patients had a PICA-SCA anastomosis. The PICA-SCA anastomosis was significantly associated with independent functional outcome at 90 days (67/196 (34.2%) vs 109/450 (24.2%), adjusted OR (aOR) 1.80 (95% CI 1.13 to 2.86), p=0.01) and was significantly associated with a decreased rate of SICH (40/442 (9.0%) vs 5/193 (2.6%), aOR 0.29 (95% CI 0.11 to 0.76), p=0.01). No significant difference was found between PICA-SCA anastomosis and 90-day mortality (219/450 (48.7%) vs 80/196 (40.8%), aOR 0.72 (95% CI 0.48 to 1.08), p=0.11). Subgroup analysis showed that the association between independent functional outcome and PICA-SCA anastomosis was strongest in patients with middle BAO (27/77 (35.1%) vs 22/118 (18.6%), aOR 2.64 (95% CI 1.13 to 6.15), p=0.03).

CONCLUSIONS

The PICA-SCA anastomosis is significantly associated with better functional outcomes in patients with acute BAO after EVT, especially in those with middle BAO.

Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial

BACKGROUND

The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study).

METHODS

BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days.

RESULTS

Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P=0.033) if adjusted for early intubation.

CONCLUSIONS

In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.

Evolution of endovascular therapy trials for basilar artery occlusion

Basilar artery occlusion (BAO) is an uncommon event, and leads to poor outcome in an estimated 60 to 80% of patients. Two early randomized trials, BASICS and BEST demonstrated equivocal benefit of endovascular therapy (EVT) compared to medical management. These trials helped in forming the design, sample size and eligibility criteria for the subsequent two trials, ATTENTION and BAOCHE which demonstrated superiority of EVT over medical management. In this commentary, we look at the evolution of how early BAO studies formed the building blocks for successive BAO trials, review lessons learned, and opportunities for future research.

How I do it: neuromonitoring-guided clipping of high-riding basilar tip aneurysm

BACKGROUND

Clipping of basilar tip aneurysms presents unique challenges due to the risk of perforator compromise and subsequent disabling stroke.

METHOD

Herein, we describe the correct trajectory of the clip applier to clip basilar tip aneurysms through an orbitozygomatic approach to prevent perforator injury and discuss management of intraoperative neuromonitoring changes.

CONCLUSION

We anticipate that this video and illustration will aid surgeons as they treat complex wide-necked basilar tip aneurysms with microsurgical clipping.

How I do it? Basilar bifurcation and left anterior choroidal artery aneurysms clipping

BACKGROUND

Despite advancements in endovascular techniques, microsurgical treatment for posterior circulation aneurysms remains challenging.

METHOD

This report highlights the successful clipping surgery of a 17-year-old female patient with an aneurysm located at the basilar artery (BA) bifurcation and left anterior choroidal artery (AChoA). To improve exposure, the posterior communicating artery was transected. A straight fenestrated clip was then placed to repair the BA bifurcation aneurysm, followed by a curved mini clip for the AChoA aneurysm.

CONCLUSION

This report demonstrates the nuances of microsurgery in the treatment of select complex cases, which can benefit from microsurgery to achieve optimal treatment outcomes.

[Incidence and predictors of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion]

Objective: To investigate the incidence and predictors of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion. Methods: Patients were selected from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry, which was a prospective, multicenter registry study between June 2015 and December 2017. The demographic characteristics, past history, personal history, vital signs, National Institutes of Health Stroke Scale (NIHSS) score, imaging examination, onset/admission/puncture/end of operation, operation-related variables, medication during operation, patency of occluded blood vessels after operation, etiology classification, and 90-day modified Rankin scale (mRS) score were collected. Successful endovascular treatment was defined as modified thrombolysis in cerebral infarction (mTICI) 2b-3. Poor outcome was defined as 90-day mRS 4-6. Multivariate logistic regression analysis was performed to analyze the predictors of poor clinical outcome after successful endovascular treatment. Results: A total of 170 (128 males and 42 females) acute basilar artery occlusion patients undergoing successful endovascular treatment were included in the analysis, with the median age of [M (Q1, Q3)] of 64 (55, 70) years. Poor clinical outcome occurred in 72 patients (42.4%). Multivariate logistic regression analysis revealed that high baseline NIHSS score (OR=1.166, 95%CI: 1.109-1.225, P<0.001) and high baseline systolic blood pressure (OR=1.032, 95%CI: 1.010-1.053, P=0.003) were the independent predictors of poor clinical outcome. Conclusions: The incidence of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion is 42.4%. High baseline NIHSS score and systolic blood pressure are associated with the poor clinical outcome.

Endovascular treatment of acute basilar artery occlusion: A systematic review and meta-analysis of first-line stent retriever versus direct aspiration

BACKGROUND

The best choice between first-line aspiration and stent retriever for acute basilar artery occlusion remains controversial. This study aims to perform a systematic review and meta-analysis comparing the stent retriever and direct aspiration about reported recanalization rates and periprocedural complications.

METHOD

PubMed, Embase, Web of Science, Cochrane, and Clinical Trials were searched for the studies evaluating the efficacy and safety of first-line aspiration versus stent retriever for acute basilar artery occlusion. A standard software program (Stata Corporation) was used for end-point analyses. Statistical significance was defined as a p-value less than .05.

RESULTS

A total of 11 studies were involved in the current study, including 1014 patients. Regarding postoperative recanalization, the pooled analysis identified a significant difference in successful recanalization (odds ratio [OR] = 1.642; 95% confidence interval (95% CI): 1.099-2.453; p = .015) and complete recanalization (OR = 3.525; 95% CI: 1.306-2.872; p = .001) between the two groups in favor of the first-line aspiration. Concerning the complications, the first-line aspiration could achieve a lower rate of total complication (OR = .359; 95% CI: .229-.563; p < .001) and hemorrhagic complication (OR = .446, 95% CI: .259-.769; p = .004) than stent retriever. No significant difference was observed in postoperative mortality (OR = .966; p = .880), subarachnoid hematoma (OR = .171; p = .094), and parenchymal hematoma (OR = .799; p = .720). In addition, the pooled results revealed a significant difference in procedure duration between the two groups in favor of aspiration (WMD = -27.630, 95% CI: -50.958 to -4.302; p = .020). However, there was no significant difference in favorable outcome (OR = 1.149; p = .352) and rescue therapy (OR = 1.440; p = .409) between the two groups.

CONCLUSION

Given that the first-line aspiration was associated with a higher rate of postoperative recanalization, a lower risk of postoperative complication, and a faster duration of the procedure, these findings support the aspiration may be more secure than a stent retriever.

Endovascular thrombectomy for basilar artery occlusion: translating research findings into clinical practice

BACKGROUND

Basilar artery occlusion is a rare and severe condition. The effectiveness of endovascular thrombectomy in patients with basilar artery occlusion was unclear until recently, because these patients were excluded from most trials of endovascular thrombectomy for large-vessel occlusion ischaemic stroke.

RECENT DEVELOPMENTS

The Basilar Artery International Cooperation Study (BASICS) and the Basilar Artery Occlusion Endovascular Intervention versus Standard Medical Treatment (BEST) trials, specifically designed to investigate the benefit of thrombectomy in patients with basilar artery occlusion, did not find significant evidence of a benefit of endovascular thrombectomy in terms of disability outcomes at 3 months after stroke. However, these trials suggested a potential benefit of endovascular thrombectomy in patients presenting with moderate-to-severe symptoms. Subsequently, the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) and the Basilar Artery Occlusion Chinese Endovascular (BAOCHE) trials, which compared endovascular thrombectomy versus medical therapy within 24 h of onset, showed clear benefit of endovascular thrombectomy in reducing disability and mortality, particularly in patients with moderate-to-severe symptoms. The risk of intracranial haemorrhage with endovascular thrombectomy was similar to the risk in anterior circulation stroke. Thrombectomy was beneficial regardless of age, baseline characteristics, the presence of intracranial atherosclerotic disease, and time from symptom onset to randomisation. Therefore, the question of whether endovascular thrombectomy is beneficial in basilar artery occlusion now appears to be settled in patients with moderate-to-severe symptoms, and endovascular thrombectomy should be offered to eligible patients. WHERE NEXT?: Key outstanding issues are the potential benefits of endovascular thrombectomy in patients with mild symptoms, the use of intravenous thrombolysis in an extended time window (ie, after 4·5 h of symptom onset), and the optimal endovascular technique for thrombectomy. Dedicated training programmes and automated software to assist with the assessment of imaging prognostic markers could be useful in the selection of patients who might benefit from endovascular thrombectomy. Large international research networks should be built to address knowledge gaps in this field and allow the conduct of clinical trials with fast and consecutive enrolment and a diverse ethnic representation.

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.

Effective Mechanical Thrombectomy for Posterior Circulation Ischemia Using Magnetic Resonance Imaging-based Arterial Structures

To improve the success of mechanical thrombectomy, three-dimensional turbo spin-echo (3D-TSE) sequences on T2WI can be employed to estimate the vascular structure of the posterior circulation. In addition to the short imaging time of 3D-TSE T2WI (33 sec), it can visualize the outer diameter of the main cerebral artery, including the occluded vessels. However, to date, the efficacy of mechanical thrombectomy in the posterior circulation remains unclear, and safer and more efficient mechanical thrombectomy procedures are required. Assessment of the anatomical variations in the posterior circulation using 3D-TSE T2WI is valuable for access decisions, device selection, and safe device guidance and retrieval techniques to the target vessel. Herein, we present representative cases of basilar artery and posterior cerebral artery occlusions in our institute and describe the utility of preoperative 3D-TSE T2WI in these patients.

Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion

BACKGROUND

The effects and risks of endovascular thrombectomy 6 to 24 hours after stroke onset due to basilar-artery occlusion have not been extensively studied.

METHODS

In a trial conducted over a 5-year period in China, we randomly assigned, in a 1:1 ratio, patients with basilar-artery stroke who presented between 6 to 24 hours after symptom onset to receive either medical therapy plus thrombectomy or medical therapy only (control). The original primary outcome, a score of 0 to 4 on the modified Rankin scale (range, 0 to 6, with a score of 0 indicating no disability, 4 moderately severe disability, and 6 death) at 90 days, was changed to a good functional status (a modified Rankin scale score of 0 to 3, with a score of 3 indicating moderate disability). Primary safety outcomes were symptomatic intracranial hemorrhage at 24 hours and 90-day mortality.

RESULTS

A total of 217 patients (110 in the thrombectomy group and 107 in the control group) were included in the analysis; randomization occurred at a median of 663 minutes after symptom onset. Enrollment was halted at a prespecified interim analysis because of the superiority of thrombectomy. Thrombolysis was used in 14% of the patients in the thrombectomy group and in 21% of those in the control group. A modified Rankin scale score of 0 to 3 (primary outcome) occurred in 51 patients (46%) in the thrombectomy group and in 26 (24%) in the control group (adjusted rate ratio, 1.81; 95% confidence interval [CI], 1.26 to 2.60; P<0.001). The results for the original primary outcome of a modified Rankin scale score of 0 to 4 were 55% and 43%, respectively (adjusted rate ratio, 1.21; 95% CI, 0.95 to 1.54). Symptomatic intracranial hemorrhage occurred in 6 of 102 patients (6%) in the thrombectomy group and in 1 of 88 (1%) in the control group (risk ratio, 5.18; 95% CI, 0.64 to 42.18). Mortality at 90 days was 31% in the thrombectomy group and 42% in the control group (adjusted risk ratio, 0.75; 95% CI, 0.54 to 1.04). Procedural complications occurred in 11% of the patients who underwent thrombectomy.

CONCLUSIONS

Among patients with stroke due to basilar-artery occlusion who presented 6 to 24 hours after symptom onset, thrombectomy led to a higher percentage with good functional status at 90 days than medical therapy but was associated with procedural complications and more cerebral hemorrhages. (Funded by the Chinese National Ministry of Science and Technology; BAOCHE ClinicalTrials.gov number, NCT02737189.).

Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion

BACKGROUND

Data from trials investigating the effects and risks of endovascular thrombectomy for the treatment of stroke due to basilar-artery occlusion are limited.

METHODS

We conducted a multicenter, prospective, randomized, controlled trial of endovascular thrombectomy for basilar-artery occlusion at 36 centers in China. Patients were assigned, in a 2:1 ratio, within 12 hours after the estimated time of basilar-artery occlusion to receive endovascular thrombectomy or best medical care (control). The primary outcome was good functional status, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]), at 90 days. Secondary outcomes included a modified Rankin scale score of 0 to 2, distribution across the modified Rankin scale score categories, and quality of life. Safety outcomes included symptomatic intracranial hemorrhage at 24 to 72 hours, 90-day mortality, and procedural complications.

RESULTS

Of the 507 patients who underwent screening, 340 were in the intention-to-treat population, with 226 assigned to the thrombectomy group and 114 to the control group. Intravenous thrombolysis was used in 31% of the patients in the thrombectomy group and in 34% of those in the control group. Good functional status at 90 days occurred in 104 patients (46%) in the thrombectomy group and in 26 (23%) in the control group (adjusted rate ratio, 2.06; 95% confidence interval [CI], 1.46 to 2.91, P<0.001). Symptomatic intracranial hemorrhage occurred in 12 patients (5%) in the thrombectomy group and in none in the control group. Results for the secondary clinical and imaging outcomes were generally in the same direction as those for the primary outcome. Mortality at 90 days was 37% in the thrombectomy group and 55% in the control group (adjusted risk ratio, 0.66; 95% CI, 0.52 to 0.82). Procedural complications occurred in 14% of the patients in the thrombectomy group, including one death due to arterial perforation.

CONCLUSIONS

In a trial involving Chinese patients with basilar-artery occlusion, approximately one third of whom received intravenous thrombolysis, endovascular thrombectomy within 12 hours after stroke onset led to better functional outcomes at 90 days than best medical care but was associated with procedural complications and intracerebral hemorrhage. (Funded by the Program for Innovative Research Team of the First Affiliated Hospital of USTC and others; ATTENTION ClinicalTrials.gov number, NCT04751708.).

Stent retriever thrombectomy in the treatment of basal artery stent thrombosis: Two case reports

RATIONALE

Stent thrombosis is a rare but serious complication that requires timely treatment. Catheter thrombectomy is the first-line therapy for this condition; however, it may be challenging for patients with in-stent emboli located in the basilar artery.

PATIENT CONCERNS

Herein, we reported 2 cases with stent thrombosis in the vertebrobasilar artery, including their imaging and clinical findings. Both patients were successfully treated with stent retriever thrombectomy.

DIAGNOSIS

The presence of cerebral infarction was diagnosed by magnetic resonance. Cranial computed tomography excluded cerebral hemorrhage, and basilar artery occlusion was considered in combination with the medical history.

INTERVENTIONS

After cerebral angiography confirmed basilar artery occlusion, the stent thrombectomy was used to remove the thrombus.

OUTCOMES

The emboli were removed from the stent, and the angiography confirmed that the blood flow in the posterior cerebral circulation was recovered to TICI level 3. Moreover, all symptoms disappeared.

LESSONS

Cerebral vascular stent thrombectomy is a feasible approach for treating cerebral vascular stent thrombosis.

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.

Microvascular decompression for trigeminal neuralgia caused by persistent trigeminal artery associated with craniosynostosis: a case report

BACKGROUND

Persistent trigeminal artery (PTA) is a rare arterial anastomosis between the basilar artery (BA) and internal carotid artery (ICA). It plays an indispensable role in a number of neurological disorders, including trigeminal neuralgia (TN).

CASE PRESENTATION

We report a unique case of a 58-year-old Han female patient with TN caused by PTA associated with craniosynostosis. Preoperative three-dimensional time-of-flight (3D-TOF) magnetic resonance (MR) and 3D constructive inference in steady state (3D-CISS) imaging showed that the PTA run though Meckel's cave. Complete pain relief was immediately achieved after microvascular decompression (MVD), without facial numbness and other complications. No recurrence was recorded at the 1-year follow up.

CONCLUSIONS

Microvascular decompression is a feasible option for the treatment of complex TN combined with other abnormalities. For patients deemed suitable for percutaneous balloon compression, PTA should be ruled out. Preoperative 3D-TOF and 3D-CISS MR imaging were essential to identify PTA neurovascular conflicts.

How I do it: two-step transposition technique during endoscopic microvascular decompression for trigeminal neuralgia

BACKGROUND

Endoscopic microvascular decompression (eMVD) provides excellent visualization and minimally invasive surgical treatment of trigeminal neuralgia (TN). The transposition technique is desirable for long-term outcomes of TN.

METHOD

A two-step transposition technique is performed during eMVD for TN due to the arch-shaped superior cerebellar artery (SCA). First, the cerebellomesencephalic segment of the SCA is pulled out using oxycellulose balls. Second, the retracted lateral pontomesencephalic segment of the SCA is detached from the trigeminal nerve and is transposed for fixation at the tentorium cerebelli.

CONCLUSION

The two-step transposition technique offers simple, reliable decompression for TN due to the arch-shaped SCA.

Endovascular treatment for acute basilar artery occlusion via persistent primitive hypoglossal artery: A case report

INTRODUCTION

Although their effectiveness and safety have not yet been established, endovascular treatments have recently been applied in the treatment of acute basilar artery occlusion. If not identified, persistent primitive hypoglossal artery, a rare variant of the posterior circulation, could be a barrier to the successful treatment of basilar artery occlusion.

PATIENT CONCERNS

An 83-year-old woman, who had been undergoing treatment for hypertension for 20 years, visited our hospital 3 hours after the onset of acute unresponsive mental deterioration. The patient was unresponsive to painful stimuli, and the pupils were equal and miotic.

DIAGNOSIS

Brain computed tomography angiography confirmed complete occlusion of the distal basilar artery and revealed a dilated branch arising from the right internal carotid artery at the C2 vertebral level.

INTERVENTIONS

Endovascular thrombectomy was performed directly via the right femoral artery. Complete recanalization was achieved via manual aspiration thrombectomy.

OUTCOMES

Brain magnetic resonance imaging revealed multifocal cerebral infarctions in the bilateral thalamus, midbrain, and cerebellar vermis. The patient's neurological symptoms gradually improved.

CONCLUSIONS

This is a rare case of basilar artery occlusion that was successfully treated with mechanical thrombectomy through persistent primitive hypoglossal artery. It is important to consider the potential clinical implications of this rare vascular variant.

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.

Endovascular therapy for acute basilar artery occlusion caused by vertebral artery dissection: Case report

RATIONALE

The best endovascular therapy revascularization strategies for acute ischemic stroke caused by vertebral artery dissection (VAD) are unclear. We describes a case of basilar artery (BA) occlusion caused by extracranial VAD, in which we used a stent-retriever to achieve thrombectomy in the BA through the contralateral vertebral artery (VA).

PATIENT CONCERNS

A 32-year-old male presented with a sudden-onset headache accompanied by articulation disorder, left-sided weakness, and tinnitus in the left ear.

DIAGNOSIS

Digital subtraction angiography showed the V1 to V2 segment dissection of the left VA and occlusion of the BA.

INTERVENTIONS

Thrombectomy was performed through the thinner right VA with three passes of the Solitaire FR device 4 × 20 mm in the BA, and angiograms showed modified treatment in cerebral ischemia 3 reperfusion of BA and left VA V4 segment still occluded.

OUTCOMES

The patient had a modified Rankin Scale of 2 at 90 days, and re-established blood flow of the left VA and BA.

LESSONS

When extracranial VAD complicated with BA occlusion, choosing the clean-road path to perform a BA thrombectomy may be a fast and effective treatment strategy.

Endovascular embolization versus surgical clipping in a single surgeon series of basilar artery aneurysms: a complementary approach in the endovascular era

Background

Currently, most basilar artery aneurysms (BAAs) are treated endovascularly. Surgery remains an appropriate therapy for a subset of all intracranial aneurysms. Whether open microsurgery would be required or utilized, and to what extent, for BAAs treated by a surgeon who performs both endovascular and open procedures has not been reported.

Methods

Retrospective analysis of prospectively maintained, single-surgeon series of BAAs treated with endovascular or open surgery from the first 5 years of practice.

Results

Forty-two procedures were performed in 34 patients to treat BAAs—including aneurysms arising from basilar artery apex, trunk, and perforators. Unruptured BAAs accounted for 35/42 cases (83.3%), and the mean aneurysm diameter was 8.4 ± 5.4 mm. Endovascular coiling—including stent-assisted coiling—accounted for 26/42 (61.9%) treatments and led to complete obliteration in 76.9% of cases. Four patients in the endovascular cohort required re-treatment. Surgical clip reconstruction accounted for 16/42 (38.1%) treatments and led to complete obliteration in 88.5% of cases. Good neurologic outcome (mRS ≤ 2) was achieved in 88.5% and 75.0% of patients in endovascular and open surgical cohorts, respectively (p = 0.40). Univariate logistic regression analysis demonstrated that advanced age (OR 1.11[95% CI 1.01–1.23]) or peri-procedural adverse event (OR 85.0 [95% CI 6.5–118.9]), but not treatment modality (OR 0.39[95% CI 0.08–2.04]), was the predictor of poor neurologic outcome.

Conclusions

Complementary implementation of both endovascular and open surgery facilitates individualized treatment planning of BAAs. By leveraging strengths of both techniques, equivalent clinical outcomes and technical proficiency may be achieved with both modalities.

Microvascular decompression for trigeminal neuralgia attributable to the vertebrobasilar artery: decompression technique and significance of separation from the nerve root

BACKGROUND

Separation of the vertebrobasilar artery (VBA) from the trigeminal nerve root in microvascular decompression (MVD) is technically challenging. This study aimed to review the clinical features of VBA involvement in trigeminal neuralgia and evaluate surgical decompression techniques in the long term.

METHODS

We retrospectively reviewed the surgical outcomes of 26 patients (4.4%) with VBA involvement in 585 consecutive MVDs for TGN using a Teflon roll for repositioning the VBA. The final operative status of the nerve decompression was categorized into two groups: the separation group and the contact group. Separation of the VBA from the nerve root was completed in 13 patients in the separation group, and slight vascular contact remained in the remaining 13 patients of the contact group. The clinical features of VBA-related TGN were investigated and the operative results were analyzed.

RESULTS

Multiple arteries are involved in neurovascular compression (NVC) in most cases. The anterior inferior cerebellar artery was the most common concomitant artery (69%). The site of the NVC varies from the root entry zone to the distal portion of the root. All patients were pain-free immediately after surgery and maintained medication-free status during the follow-up period, except for one patient (3.8%) who had recurrent facial pain 8 years after surgery. Postoperative facial numbness was observed in six patients (23%). Of these, one patient showed improvement within 3 months and the other five patients had persistent facial numbness (19.2%). Other neurological deficits include one dry eye, one diplopia due to trochlear nerve palsy, two decreased hearing (< 50 db), two facial weaknesses, and two cerebellar ataxia. Although most of them were transient, one dry eye, two hearing impairments, and one cerebellar ataxia became persistent deficits. Statistical analyses revealed no difference in surgical efficacy or complications in the long term between the two groups.

CONCLUSIONS

Slightly remaining vascular contact does not affect pain relief in the long term. Our study indicated that once the tense trigeminal nerve is loosened, further attempts to mobilize the VBA are not necessary.