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

Early diagnosis and rapid thrombectomy with stent placement in distal vertebral artery stenosis (Mori Type C) with mild symptoms

Background: Vertebrobasilar artery occlusion (VBAO) is a life-threatening condition with often nonspecific symptoms, making early diagnosis challenging. Timely intervention is crucial, especially in cases involving distal vertebral artery stenosis. Case Report: A 65-year-old male presented with acute vertigo, dizziness, and visual disturbances, along with ipsilateral sixth cranial nerve palsy. His medical history included a treated abdominal aortic aneurysm, hypercholesterolemia, and hypertension. CT angiography (CTA) revealed an occlusion in the V4 segment of the right vertebral artery. CT perfusion imaging showed minimal perfusion delay in the right brainstem. The patient received intravenous thrombolysis (IVT) with tenecteplase, followed by mechanical thrombectomy (MT), partial recanalization was achieved. However, digital subtraction angiography (DSA) identified a critical stenosis (>90%) responsible for the occlusion, consistent with arteriosclerotic disease. Following intravenous administration of 500 mg acetylsalicylic acid, a Biotronik Orsiro 2.25 × 9 mm drug-eluting stent was placed, achieving complete recanalization (eTICI 3). Neurologic symptoms resolved completely post-intervention, and the patient received 300 mg clopidogrel. He was discharged with an MRS score of 0 within 3 days. Conclusion: This case highlights the effectiveness of a multimodal approach (IVT, MT, and stenting) in treating distal vertebral artery occlusion (Mori Type C). Early diagnosis and timely endovascular intervention led to rapid symptom resolution and complete neurological recovery. Follow-up ultrasound at 4 months confirmed good bilateral vertebral artery perfusion without restenosis, supporting the potential long-term benefits of this multimodal treatment approach. This case underscores the importance of advanced imaging for early detection and the role of thrombectomy and stenting in optimizing patient outcomes.

Impact and determinants of door in-door out time for stroke thrombectomy transfers in a large hub-and-spoke network

INTRODUCTION

The mantra "time is brain" cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in-door out (DIDO) times for patients transferred to our hub center for EVT.

METHODS

Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO.

RESULTS

We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57-80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97-149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS (B = 0.007, 95% CI = 0.001-0.012, p = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B = 0.918, 95% CI = 0.010-1.826, p = 0.048), atrial fibrillation or heart failure (B = 0.793, 95% CI = 0.257-1.329, p = 0.004), and basilar LVO location (B = 2.528, 95% CI = 1.154-3.901, p < 0.001).

CONCLUSION

Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes.

Endovascular treatment of embolism-related acute basilar artery occlusion stroke: ADAPT versus stent retriever thrombectomy

PURPOSE

This study aimed to compare the efficacy and safety of a direct aspiration first-pass technique (ADAPT) and stent retriever thrombectomy (SRT) technique in embolism-related acute basilar artery occlusion (EMB-ABAO).

METHODS

We collected data from patients with EMB-ABAO in multiple stroke centers from January 2017 to February 2024. We defined two groups of enrolled patients, the ADAPT group and the SRT group. The primary outcome was the first attempt recanalization (FAR) rate. Secondary outcomes were the puncture to recanalization (PTR) time and the 90-day favorable functional outcome. The safety outcome was 90-day all-cause mortality rate.

RESULTS

A total of 406 patients were screened for endovascular treatment (EVT) of ABAO ischemic stroke, and 108 patients were identified with EMB-ABAO stroke. Among these, 96 patients were included in the final analysis. Among them, 58 (60.42%) were in the ADAPT group, and 38 (39.58%) were in the SRT group. Compared with the SRT group, the ADAPT group achieved FAR more frequently (60.34% versus 39.47%; p = 0.045) and a higher 90-day favorable functional outcome rate (44.83% versus 36.84%; p = 0.438). The median PTR time of the ADAPT group was significantly shorter than that of the SRT group (42 versus 105 min; p < 0.001).

CONCLUSION

In cases where EMB-ABAO is suspected, ADAPT was superior to SRT in terms of FAR rate and PTR time, but the 90-day mRS scores had no statistical significance. Given the reduced time to recanalization with ADAPT, an initial attempt at recanalization with ADAPT may be necessary before stent retriever. However, due to the study limitations, these findings should be interpreted as preliminary and require further study.

Ethical Considerations in Endovascular Thrombectomy for Stroke

INTRODUCTION

Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored.

METHODS

A narrative review with case examples was conducted.

RESULTS

We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke.

CONCLUSIONS

EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.

Influencing factors of futile recanalization after endovascular intervention in patients with acute basilar artery occlusion

OBJECTIVES

To explore the influence factors for futile recanalization following endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO).

METHODS

Clinical data of patients with acute BAO, who underwent endovascular treatment within 24 h of onset from January 2017 to November 2022, were retrospectively analyzed. The futile recanalization was defined as modified thrombolysis in cerebral infarction (mTICI) grade ≥2b or 3 after successful reperfusion, but the modified Rankin Scale score >2 at 3 months after EVT. Binary logistic regression model was used to analyze the influencing factors of futile recanalization.

RESULTS

A total of 471 patients with a median age of 68 (57, 74) years were included and 68.9% were males, among whom 298 (63.27%) experienced futile recanalization. Multivariate analysis revealed that concomitant atrial fibrillation (OR=0.456, 95%CI: 0.282-0.737, P<0.01), bridging thrombolysis (OR=0.640, 95%CI: 0.416-0.985, P<0.05), achieving mTICI grade 3 (OR=0.554, 95%CI: 0.334-0.918, P<0.05), arterial occlusive lesion (AOL) grade 3 (OR=0.521, 95%CI: 0.326-0.834, P<0.01), and early postoperative statin therapy (OR=0.509, 95%CI: 0.273-0.948, P<0.05) were protective factors for futile recanalization after EVT in acute BAO patients. High baseline National Institutes of Health Stroke Scale (NIHSS) score (OR=1.068, 95%CI: 1.049-1.087, P<0.01), coexisting hypertension (OR=1.571, 95%CI: 1.017-2.427, P<0.05), multiple retrieval attempts (OR=1.237, 95%CI: 1.029-1.488, P<0.05) and postoperative hemorrhagic transformation (OR=8.497, 95%CI: 2.879-25.076, P<0.01) were risk factors. For trial of ORG 10172 in acute stroke treatment (TOAST) classification, cardiogenic embolism (OR=0.321, 95%CI: 0.193-0.534, P<0.01) and other types (OR=0.499, 95%CI: 0.260-0.961, P<0.05) were related to lower incidence of futile recanalization.

CONCLUSIONS

The incidence of futile recanalization after EVT in patients with acute BAO is high. Bridging venous thrombolysis before operation and an early postoperative statin therapy may reduce the incidence of futile recanalization.

Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities

IMPORTANCE

Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process.

OBSERVATIONS

IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base.

CONCLUSIONS AND RELEVANCE

This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.

Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes

Objective

This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI.

Methods

The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified.

Results

PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy.

Discussion

PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy.

Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging

There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.

The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Compares Favorably to the Critical Area Perfusion Score for Prognostication Before Basilar Thrombectomy

INTRODUCTION

The Critical Area Perfusion Score (CAPS) predicts functional outcomes in vertebrobasilar thrombectomy patients based on computed tomography perfusion (CTP) hypoperfusion. We compared CAPS to the clinical-radiographic Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS).

METHODS

Acute basilar thrombosis patients from January 2017-December 2021 were included in this retrospective analysis from a health system's stroke registry. Inter-rater reliability was assessed for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict 90-day modified Rankin Scale (mRS) score 4-6. Area under the curve (AUC) analyses were performed to evaluate prognostic ability.

RESULTS

55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.5^5-24, were included. Light's kappa among 6 raters for favorable versus unfavorable CAPS was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio (OR) 1.0010, 95% CI 1.0007-1.0014, p<0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p=0.93). An overall favorable trend was observed for CLEOS (AUC 0.69, 95% CI 0.54-0.84) versus CAPS (AUC 0.49, 95% CI 0.34-0.64; p=0.051). Among 85.5% of patients with endovascular reperfusion, CLEOS had a statistically higher sensitivity than CAPS at identifying poor 90-day outcomes (71% versus 21%, p=0.003).

CONCLUSIONS

CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and in patients achieving reperfusion after basilar thrombectomy.

A DWI-based radiomics-clinical machine learning model to preoperatively predict the futile recanalization after endovascular treatment of acute basilar artery occlusion patients

OBJECTIVE

To develop an effective machine learning model to preoperatively predict the occurrence of futile recanalization (FR) of acute basilar artery occlusion (ABAO) patients with endovascular treatment (EVT).

MATERIALS AND METHODS

Data from 132 ABAO patients (109 male [82.6 %]; mean age ± standard deviation, 59.1 ± 12.5 years) were randomly divided into the training (n = 106) and test cohort (n = 26) with a ratio of 8:2. FR is defined as a poor outcome [modified Rankin Scale (mRS) 4-6] despite a successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b]. A total of 1130 radiomics features were extracted from diffusion-weighted imaging (DWI) images. The least absolute shrinkage and selection operator (LASSO) regression method was applicated to select features. Support vector machine (SVM) was applicated to construct radiomics and clinical models. Finally, a radiomics-clinical model that combined clinical with radiomics features was developed. The models were evaluated by receiver operating characteristic (ROC) curve and decision curve.

RESULTS

The area under the receiver operating characteristic (ROC) curve (AUC) of the radiomics-clinical model was 0.897 (95 % confidence interval, 0.837-0.958) in the training cohort and 0.935 (0.833-1.000) in the test cohort. The AUC of the radiomics model was 0.887 (0.824-0.951) in the training cohort and 0.840 (0.680-1.000) in the test cohort. The AUC of the clinical model was 0.746 (0.652-0.840) in the training cohort and 0.766 (0.569-0.964) in the test cohort. The AUC of the radiomics-clinical model was significantly larger than the clinical model (p = 0.016). A radiomics-clinical nomogram was developed. The decision curve analysis indicated its clinical usefulness.

CONCLUSION

The DWI-based radiomics-clinical machine learning model achieved satisfactory performance in predicting the FR of ABAO patients preoperatively.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy

BACKGROUND AND PURPOSE

The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT.

METHODS

We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS = (5 × age) + (10 × National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 × CTP cerebral blood volume index) and THRIVE (0-9 points) = age 60-79 years, 1 point; age ≥ 80 years, 2 points; NIHSS 11-20, 2 points; NIHSS ≥ 21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6.

RESULTS

Fifty-seven patients had mean age 66.6 (± 14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR] = 1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p = .008), whereas THRIVE was not (OR = 1.0326, 95% CI: 0.9478-1.1250, p = .466). CLEOS &gt; 503 best predicted poor outcomes.

CONCLUSIONS

A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.