Endovascular Therapy for stroke due to basilar-artery occlusion.

Langezaal, Lucianne C.M.; Hoeven, Erik Jrj van der; Montalverne, Francisco Jose de Arruda

doi:10.1016/j.jemermed.2021.06.003

Cited by 91 publications

(180 citation statements)

References 13 publications

(18 reference statements)

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“…Posterior circulation ischemic stroke results in severe disability in 30 to 54% and death in 36 to 86% of patients, 9,17,19,28,29 and clinical outcomes in BAO patients are typically poorer than AC‐LVO patients 9,12,13,16,30–32 . Surprisingly, the efficacy of ET in BAO patients has not been demonstrated in randomized or large prospective studies 18,19,33 . One possible explanation for the failure of these prior studies is insufficient imaging selection of ET treatment candidates, which was a limitation in prior anterior circulation stroke studies that failed to demonstrate ET efficacy 34–36 .…”

Section: Discussionmentioning

confidence: 99%

“…By contrast, randomized trials that have compared ET to medical management have failed to show a benefit for ET. 18,19 Therefore, additional knowledge as to which patients are most likely to benefit from ET is needed.…”

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confidence: 99%

“…Multiple retrospective studies suggest that ET treatment of basilar artery occlusion (BAO) is an effective therapy, 9–17 but retrospective studies are subject to bias that favors treatment. By contrast, randomized trials that have compared ET to medical management have failed to show a benefit for ET 18,19 . Therefore, additional knowledge as to which patients are most likely to benefit from ET is needed.…”

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confidence: 99%

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Perfusion Imaging Predicts Favorable Outcomes after Basilar Artery Thrombectomy

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Bianco

Mlynash

et al. 2021

Annals of Neurology

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Objective: Perfusion imaging identifies anterior circulation stroke patients who respond favorably to endovascular thrombectomy (ET), but its role in basilar artery occlusion (BAO) is unknown. We hypothesized that BAO patients with limited regions of severe hypoperfusion (time to reach maximum concentration in seconds [Tmax] > 10) would have a favorable response to ET compared to patients with more extensive regions involved. Methods: We performed a multicenter retrospective cohort study of BAO patients with perfusion imaging prior to ET. We prespecified a Critical Area Perfusion Score (CAPS; 0-6 points), which quantified severe hypoperfusion (Tmax > 10) in cerebellum (1 point/hemisphere), pons (2 points), and midbrain and/or thalamus (2 points). Patients were dichotomized into favorable (CAPS ≤ 3) and unfavorable (CAPS > 3) groups. The primary outcome was a favorable functional outcome 90 days after ET (modified Rankin Scale = 0-3). Results: One hundred three patients were included. CAPS ≤ 3 patients (87%) had a lower median National Institutes of Health Stroke Scale score (NIHSS; 12.5, interquartile range [IQR] = 7-22) compared to CAPS > 3 patients (13%; 23, IQR = 19-36; p = 0.01). Reperfusion was achieved in 84% of all patients, with no difference between CAPS groups (p = 0.42). Sixty-four percent of reperfused CAPS ≤ 3 patients had a favorable outcome compared to 8% of nonreperfused CAPS ≤ 3 patients (odds ratio [OR] = 21.0, 95% confidence interval [CI] = 2.6-170; p < 0.001). No CAPS > 3 patients had a favorable outcome, regardless of reperfusion. In a multivariate regression analysis, CAPS ≤ 3 was a robust independent predictor of favorable outcome after adjustment for reperfusion, age, and pre-ET NIHSS (OR = 39.25, 95% CI = 1.34->999, p = 0.04). Interpretation: BAO patients with limited regions of severe hypoperfusion had a favorable response to reperfusion following ET. However, patients with more extensive regions of hypoperfusion in critical brain regions did not benefit from endovascular reperfusion.

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confidence: 99%

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Perfusion Imaging Predicts Favorable Outcomes after Basilar Artery Thrombectomy

Cereda

Bianco

Mlynash

et al. 2021

Annals of Neurology

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“…However, endovascular thrombectomy benefitted patients with NIHSS score ≥10. 10 These results may lead to patients with NIHSS score <10 being less likely to receive endovascular therapy. In both these scenarios, treatment decision-making may be enhanced by an improved tool to identify patients with posterior circulation stroke presenting with lower NIHSS who nonetheless have potentially disabling symptoms and who might, therefore, benefit from thrombolysis or endovascular therapy.…”

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confidence: 99%

Posterior National Institutes of Health Stroke Scale Improves Prognostic Accuracy in Posterior Circulation Stroke

Alemseged

Rocco

Arba

et al. 2022

Stroke

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Background and Purpose: The National Institutes of Health Stroke Scale (NIHSS) underestimates clinical severity in posterior circulation stroke and patients presenting with low NIHSS may be considered ineligible for reperfusion therapies. This study aimed to develop a modified version of the NIHSS, the Posterior NIHSS (POST-NIHSS), to improve NIHSS prognostic accuracy for posterior circulation stroke patients with mild-moderate symptoms. Methods: Clinical data of consecutive posterior circulation stroke patients with mild-moderate symptoms (NIHSS <10), who were conservatively managed, were retrospectively analyzed from the Basilar Artery Treatment and Management registry. Clinical features were assessed within 24 hours of symptom onset; dysphagia was assessed by a speech therapist within 48 hours of symptom onset. Random forest classification algorithm and constrained optimization were used to develop the POST-NIHSS in the derivation cohort. The POST-NIHSS was then validated in a prospective cohort. Poor outcome was defined as modified Rankin Scale score ≥3 at 3 months. Results: We included 202 patients (mean [SD] age 63 [14] years, median NIHSS 3 [interquartile range, 1–5]) in the derivation cohort and 65 patients (mean [SD] age 63 [16] years, median NIHSS 2 [interquartile range, 1–4]) in the validation cohort. In the derivation cohort, age, NIHSS, abnormal cough, dysphagia and gait/truncal ataxia were ranked as the most important predictors of functional outcome. POST-NIHSS was calculated by adding 5 points for abnormal cough, 4 points for dysphagia, and 3 points for gait/truncal ataxia to the baseline NIHSS. In receiver operating characteristic analysis adjusted for age, POST-NIHSS area under receiver operating characteristic curve was 0.80 (95% CI, 0.73–0.87) versus NIHSS area under receiver operating characteristic curve, 0.73 (95% CI, 0.64–0.83), P =0.03. In the validation cohort, POST-NIHSS area under receiver operating characteristic curve was 0.82 (95% CI, 0.69–0.94) versus NIHSS area under receiver operating characteristic curve 0.73 (95% CI, 0.58–0.87), P =0.04. Conclusions: POST-NIHSS showed higher prognostic accuracy than NIHSS and may be useful to identify posterior circulation stroke patients with NIHSS <10 at higher risk of poor outcome.

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“…In light of the need for effective therapy for BSO, Dr Heit states that there are likely parallels between failed BSO thrombectomy studies and failed early anterior circulation thrombectomy trials, such as insufficient imaging selection of patients prior to thrombectomy treatment. 3,4 There are fundamental limitations to computed tomographic imaging of structures in the posterior circulation, such as streak artifact at the skull base, that make ischemic core identification difficult. Also, physicians have garnered a certain level of proficiency in interpreting perfusion imaging in the anterior circulation, but whether the same parameters are interpreted in a similar manner in BSO patients remains uncertain.…”

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confidence: 99%