Analysis of Treatment Outcome After Endovascular Treatment in Different Pathological Subtypes of Basilar Artery Occlusion: a Single Center Experience

Predictors and outcomes of angioplasty and stenting in acute intracranial atherosclerosis-related vertebrobasilar artery occlusion

Objective

This study aimed to investigate clinical outcomes and predictors of favorable functional outcomes after endovascular treatment, including emergent angioplasty and stenting, in patients with intracranial atherosclerotic stenosis (ICAS)-related occlusions in vertebrobasilar arteries.

Materials and methods

This retrospective case series included 46 patients with acute occlusions of vertebrobasilar arteries, due to underlying ICAS. All patients underwent a thrombectomy, followed by angioplasty and/or stenting. We performed logistic regression analyses to identify independent predictors of favorable outcomes. A favorable outcome was defined as a score of 0-3 on the 90-day modified Rankin Scale.

Results

Overall, successful reperfusion was achieved in 44/46 (95.7%) patients and 90-day favorable outcomes were achieved in 21/46 patients (45.7%). The 90-day mortality rate was 23.9% (11/46). In a multivariate binary logistic analysis, independent predictors of favorable outcome were hyperlipidemia (OR = 7.866, 95% CI: 1.093-56.590, p = 0.040), admission hyperglycemia (OR = 0.144, 95% CI: 0.023-0.914, p = 0.040), basilar artery occlusion (OR = 0.086, 95% CI: 0.008-0.907, p = 0.041), and treatment with angioplasty alone (OR = 9.779, 95% CI: 1.022-93.525, p = 0.048).

Conclusion

Our findings suggested that emergent angioplasty and/or stenting could yield high rates of successful reperfusion and favorable outcomes in patients with ICAS-related occlusions in vertebrobasilar arteries. Our study also demonstrated that hyperlipidemia and treatment with angioplasty alone were associated with favorable outcomes, in contrast, admission hyperglycemia and basilar artery occlusion were associated with unfavorable outcomes in these patients.

Effect of Stroke Etiology on Endovascular Treatment for Acute Basilar-Artery Occlusion: A Post Hoc Analysis of the ATTENTION Randomized Trial

BACKGROUND

Stroke etiology could influence the outcomes in patients with basilar-artery occlusion (BAO). This study aimed to evaluate the differences in efficacy and safety of best medical treatment (BMT) plus endovascular treatment (EVT) versus BMT alone in acute BAO across different stroke etiologies.

METHODS

The study was a post hoc analysis of the ATTENTION trial (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute BAO were classified into 3 groups according to stroke etiology (large-artery atherosclerosis [LAA], cardioembolism, and undetermined cause/other determined cause [UC/ODC]). The primary outcome was a favorable outcome (modified Rankin Scale score of 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS

A total of 340 patients with BAO were included, 150 (44.1%) had LAA, 72 (21.2%) had cardioembolism, and 118 (34.7%) had UC/ODC. For patients treated with BMT plus EVT and BMT alone, respectively, the rate of favorable outcome at 90 days was 49.1% and 23.8% in the LAA group (odds ratio, 3.08 [95% CI, 1.38-6.89]); 52.2% and 30.8% in the cardioembolism group (odds ratio, 2.45 [95% CI, 0.89-6.77]); and 37.5% and 17.4% in the UC/ODC group (odds ratio, 2.85 [95% CI, 1.16-7.01]), with P=0.89 for the stroke etiology×treatment interaction. The rate of symptomatic intracranial hemorrhage in EVT-treated patients with LAA, cardioembolism, and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the BMT-treated patients. Lower 90-day mortality was observed in patients with EVT compared with BMT alone across 3 etiology groups.

CONCLUSIONS

Among patients with acute BAO, EVT compared with BMT alone might be associated with favorable outcomes and lower 90-day mortality, regardless of cardioembolism, LAA, or UC/ODC etiologies. The influence of stroke etiology on the benefit of EVT should be explored by further trials.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04751708.

Effect of endovascular treatment on patients with basilar artery occlusion presenting with different pathologic mechanisms: a systematic review and meta-analysis

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.

Outcomes Following Mechanical Thrombectomy in Different Etiological Subtypes of Acute Basilar Artery Occlusion : Stroke Etiology and Outcome after EVT in BAO

BACKGROUND AND PURPOSE

Vertebrobasilar occlusion stroke (VBOS) is innately associated with high morbimortality despite advances in endovascular thrombectomy (EVT). Nonetheless, notable outcome dissimilarities exist between angiographically categorized stroke subtypes. We aim to evaluate potential differences concerning clinical angiographic outcomes among etiological subtypes of VBOS based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

METHODS

We retrospectively reviewed prospective EVT databases at two tertiary care stroke centers for consecutive patients with VBOS who had preinterventional MRI and underwent EVT from January 2015 to December 2019. We identified three groups: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and embolic stroke of undetermined source (ESUS). The primary endpoints were the rates of poor outcome (identified as 90-day modified Rankin scale score of 3-6) and mortality, while the secondary endpoint included the rates of incomplete reperfusion (identified as modified treatment in cerebral infarction scale mTICI 0-2b), and periprocedural symptomatic intracranial hemorrhage. We evaluated the association between the etiology and clinical angiographic outcomes through stepwise logistic regression analysis.

RESULTS

Out of 1823 patients, 139 (91 men; median age, 69 (61-76) years) with VBOS were qualified for the final analysis with incidence as follows: LAA (41%, n = 57), CES (35%, n = 48), and ESUS (24%, n = 34). Overall, incomplete reperfusion was realized in 41% (57/139) of the patients, a poor outcome in 65% (90/139), and mortality in 40% (55/139). Longer puncture to reperfusion interval (aOR 1.0182 [95% CI: 1.008-1.029]; p < 0.001) and utilization of combined aspiration-retriever technique (aOR 0.1998 [95% CI: 0.066-0.604]; p = 0.004) were associated with a greater likelihood of incomplete reperfusion (mTICI 0-2b) irrespective of the stroke etiology. After adjustment for confounding factors in the regression analysis, ESUS was an independent predictor of poor outcome (aOR 5.315 [95% CI: 1.646-17.163]; p = 0.005) and mortality (aOR 4.667 [95% CI: 1.883-11.564]; p < 0.001) at 90 days following EVT.

CONCLUSION

The functional outcome following EVT for VBOS might depend on stroke etiology. According to our results, ESUS seems to be associated with the worst outcome, which needs further investigation to tailor the appropriate therapeutic plan.

Endovascular treatment for acute basilar artery occlusion due to different stroke etiologies of large artery atherosclerosis and cardioembolism

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.

Revascularization of vertebrobasilar tandem occlusions: a meta-analysis

PURPOSE

To investigate the difference in mechanical thrombectomy (MT) outcomes between vertebrobasilar tandem occlusion (VBTO) and isolated basilar artery (BA) occlusion (non-VBTO) and the difference in rates of successful recanalization between the clean-road and dirty-road pathways, in VBTO.

METHODS

We conducted a meta-analysis after searching PubMed, EMBASE, and Google Scholar databases as of April 2021. We only included adult patients who underwent MT to treat acute ischemic stroke (AIS) due to VBTO, and the following outcomes should be reported: successful recanalization, functional outcome at 90 days, and symptomatic intracerebral hemorrhage (sICH). The main effect size measures were odds ratio and risk difference, and the software used was RevMan 5.4.

RESULTS

The analysis included 81 VBTO and 324 non-VBTO patients (seven studies). We found no significant difference regarding 3 m functional independence [4 studies: OR = 1.71 (95% CI, 0.54, 5.43), I² = 75%], 3 m mortality [4 studies: OR = 1.62 (95% CI, 0.62, 4.25), I² = 66%], sICH [4 studies: OR = 1.71 (95% CI, 0.67, 4.39), I² = 0%], and successful recanalization [3 studies: OR = 0.81 (95% CI, 0.12, 5.57), I² = 80%]. A subgroup analysis of 118 VBTO patients (five studies) showed no significant difference in successful recanalization between clean-road and dirty-road pathways [RD = 0.07 (95% CI, - 0.09, 0.24), I² = 40%].

CONCLUSION

The results of this meta-analysis support the use of MT for AIS patients with VBTO. In VBTO patients, none of the clean-road or dirty-road pathways proved to be superior to the other.