PREMISE: Posterior Circulation Results Comparing Embolectomy to Medical Intervention in Stroke Emergencies

Chen, Patrick; Pirastehfar, Mohsen; Hailey, Lovella; Morton, Melissa; Rapp, Karen; Agrawal, Kunal; Modir, Royya; Meyer, Dawn M; Meyer, Brett C.

doi:10.7759/cureus.6000

Cited by 3 publications

(3 citation statements)

References 16 publications

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“…Our literature search is outlined in Figure S1. After removing duplicate records and three records that did not include a non‐interventionally treated comparison group (Table S1) we identified a total of five studies (two RCTs [6,7] and three observational cohort studies [8–10]), including a total of 1098 patients (Figure S1). Study and patient characteristics are summarized in Table S2.…”

Section: Resultsmentioning

confidence: 99%

Endovascular treatment for basilar artery occlusion: A systematic review and meta‐analysis

Katsanos

Safouris

Nikolakopoulos

et al. 2021

Euro J of Neurology

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Background and purpose Independent randomized controlled clinical trials (RCTs) have provided robust evidence for endovascular treatment (EVT) as the standard of care treatment for acute large vessel occlusions in the anterior circulation. We examined available studies specific to posterior cerebral circulation ischemic strokes to see if any conclusions can be drawn regarding EVT options. Methods We performed a systematic literature search to identify studies evaluating the safety and efficacy of EVT versus standard medical treatment for patients with acute basilar artery occlusion (BAO). We extracted data for outcomes of interest and presented associations between the two groups with the use of risk ratios (RRs) or odds ratios (ORs), with corresponding 95% confidence intervals (CIs). We used a random‐effects model to pool the effect estimates. Results We identified five studies (two RCTs, three observational cohorts) including a total of 1098 patients. Patients receiving EVT had a higher risk of symptomatic intracranial hemorrhage (sICH) compared to those receiving non‐interventional medical management (RR 5.42, 95% CI 2.74–10.71). Nonsignificant trends towards modified Rankin Scale (mRS) scores 0–2 (RR 1.02, 95% CI 0.74–1.41), mRS scores 0–3 (RR = 0.97, 95% CI 0.64–1.47), overall functional improvement (OR 0.93, 95% CI 0.57–1.51), and all‐cause mortality (RR 1.03, 95% CI 0.78–1.35) at 3 months were seen. Conclusion Although EVT increases the probability of sICH, the available data do not exclude the possibility of improved functional outcomes over standard therapy. As larger studies are challenged by the perceived lack of equipoise in this vulnerable patient population, results of ongoing RCTs are expected to provide substantial input for future meta‐analyses.

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Section: Resultsmentioning

confidence: 99%

Endovascular treatment for basilar artery occlusion: A systematic review and meta‐analysis

Katsanos

Safouris

Nikolakopoulos

et al. 2021

Euro J of Neurology

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“…Two studies were omitted because their participants were part of the BASILAR study 16 17. Another study conducted by Chen et al was also excluded from this meta-analysis as only three patients were recruited in the EVT group 18. A prospective and international observational study, conducted by the BASICS study group and published in 2009, was designed to compare IVT, antithrombotic treatment only, and intra-arterial therapy (IAT) for patients with BAO 19.…”

Section: Resultsmentioning

confidence: 99%

Endovascular thrombectomy versus standard medical treatment for stroke patients with acute basilar artery occlusion: a systematic review and meta-analysis

Zhao

Guo

et al. 2022

J NeuroIntervent Surg

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BackgroundWhether endovascular thrombectomy (EVT) is superior to standard medical treatment (SMT) for stroke patients with acute basilar artery occlusion (BAO) is uncertain. This systematic review and meta-analysis aimed to compare the safety and efficacy of EVT with SMT for treating BAO patients.MethodsPapers were retrieved from PubMed, Embase, and the Cochrane Library databases. The primary outcome of this meta-analysis was favorable functional outcomes at 3 months (defined as a modified Rankin Scale (mRS) score of ≤3). A random effect model was used to calculate risk ratios (RR) with 95% confidence intervals (CIs) per outcome.ResultsFive articles, including two randomized controlled trials (RCTs) and four observational cohort studies, comprising 1484 patients (1024 in the EVT group and 460 in the SMT group), were included in the meta-analysis. The pooled results demonstrated no significant differences between the EVT and SMT groups in achieving favorable functional outcomes at 3 months (RR=1.63, 95% CI 0.90, 2.96; p=0.11). However, patients in the EVT group had higher rates for symptomatic intracerebral hemorrhage (RR=6.22, 95% CI 2.06 to 18.76; p=0.001) but lower mortality at 3 months (RR=0.72, 95% CI 0.56 to 0.91; p=0.007) than patients in the SMT group.ConclusionAmong patients with BAO, EVT and SMT did not differ significantly in achieving favorable functional outcomes at 3 months, but BAO patients treated with EVT might have lower mortality at 3 months. RCTs are warranted to further assess the efficacy and safety of EVT for BAO patients.

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“…6,7 While the mTICI scoring system is mostly used to assess recanalization in the anterior circulation, recent technologic advances, such as low-profile stent retrievers and hypercompliant, atraumatic aspiration systems, have helped improve the effectiveness of mechanical thrombectomy in the posterior circulation. [8][9][10][11] Although not yet demonstrated in a randomized trial, posterior vessel thrombectomy is promising, and several trials of the efficacy and safety of thrombectomy for acute basilar artery occlusions are ongoing.…”

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confidence: 99%

Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy

Findler

Turjman²,

Raymond

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS:We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss k analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS:The overall agreement k reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients.CONCLUSIONS: Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.ABBREVIATIONS: LVO ¼ large-vessel occlusion; mTICI ¼ modified TICI T he TICI grading system is a metric developed by Higashida et al 1 to evaluate the response of thrombolytic agents in acute ischemic strokes. Following the demonstration in controlled randomized studies that mechanical thrombectomy is superior to pharmacologic management in anterior ischemic strokes, the 5-point modified TICI (mTICI) scale became instrumental in analyzing pre-and postintervention cerebral perfusion and assessing procedural effectiveness. In the anterior circulatory system, the mTICI score may be a bona fide metric, which strongly correlates with the patient's prognosis and can be effectively used as a guide for clinical decisionmaking. However, does it make sense to talk about mTICI score in basilar artery occlusions?Recent advances in endovascular therapies for stroke treatment allow rapid clot retrieval and restoration of perfusion to ischemic brain tissue. 2 While patient recovery depends on myriad factors such as the time to reperfusion, the size of the infarct, and the location of the occluded vessel, the ability to achieve rapid and complete flow restoration to ischemic tissues is currently the primary goal of stroke treatment. The assessment of vessel patency not only guides the physician's operative plan, namely deciding on additional attempts at extracting clot versus ending the procedure, but is also a metric u...

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PREMISE: Posterior Circulation Results Comparing Embolectomy to Medical Intervention in Stroke Emergencies

Cited by 3 publications

References 16 publications

Endovascular treatment for basilar artery occlusion: A systematic review and meta‐analysis

Endovascular treatment for basilar artery occlusion: A systematic review and meta‐analysis

Endovascular thrombectomy versus standard medical treatment for stroke patients with acute basilar artery occlusion: a systematic review and meta-analysis

Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy

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