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.

Predictors of flow diverter stent in large and giant unruptured intracranial aneurysms, single-center experience

Background

Flow diversion with or without coiling has been established as the treatment of choice for large unruptured aneurysms. This study aims to assess possible predictors for radiological and clinical outcome such as location of the aneurysm (anterior or posterior circulation), complexity by a branching artery, bifurcation, and adjuvant coiling.

Methods

This study was conducted on 65 consecutive patients with 65 large, unruptured intracranial aneurysms (size ≥ 10 mm) treated with flow diverters. Follow-up angiography was done for 60 patients (92.3%) at 12 ± 8.6 months range from 3 to 36 months.

Results

Complete occlusion was achieved in 50 from 60 aneurysms (83.4%), while 8 aneurysms (13.3%) had neck remnant, and another two aneurysms (3.3%) remained with aneurysmal remnant. Periprocedural complications were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). In a multivariate logistic regression, anterior versus posterior location was less likely associated with worse outcome; adjusted OR (95% CI) of 0.16 (0.07–0.01), p = 0.006. Complete occlusion in complex aneurysms with branching artery was 60% versus 88% in simple aneurysms without branching artery (p-value = 0.04).

Conclusions

Flow diverter deployment of a large, unruptured aneurysm in the anterior circulation might have a better outcome than one in the posterior circulation. Flow diverter of aneurysms with branching artery or at bifurcation might be associated with aneurysm persistence and complications respectively.

Unassisted and multiple microcatheter coiling of distal basilar aneurysms: Outcomes and literature review

PURPOSE

The best treatment for distal basilar artery aneurysms is controversial. We aimed to review our single-centre experience with coil embolisation of aneurysms at this location and compare it with the surgical and endovascular literature.

METHODS

Forty-two aneurysms in a distal basilar location in 42 consecutive patients (15 ruptured and 27 unruptured) were treated endovascularly from 2010 to 2015. Unassisted single and multiple microcatheter coil embolisation alone was used in all cases. We studied our immediate and long-term anatomical results, operative complications, and outcome.

RESULTS

The immediate angiographic results showed complete occlusion in 34 (81%), a neck remnant in seven (16.6%) and a residual aneurysm in one patient (2.4%). There were two thromboembolic events (4.7%) without clinical sequelae; therefore, the operative morbidity and mortality were zero.Three patients with ruptured aneurysms (7.1%) died due to complicated vasospasm. Thirty-nine patients (93%) had clinical and MR imaging follow-up (mean 32.3 months ± 18.6, range from 12 to 66 months). There was recanalization in 30.8% with a retreatment rate of 15.3% and no new bleedings. The aneurysm size was the most important predictor of early anatomical outcome and recurrence.

CONCLUSION

Unassisted and multiple microcatheter coiling is a safe treatment for distal basilar aneurysms. Early anatomical results and recurrence depend on the aneurysm size. Morbidity and mortality are lower and recurrence rates are higher in comparison with clipping or other adjunctive endovascular techniques.