Thrombolysis and adjunct anticoagulation in patients with acute basilar artery occlusion

Ritvonen, Juhani; Strbian, Daniel; Silvennoinen, Heli; Virtanen, Pekka; Salonen, Oili; Lindsberg, Perttu J.; Sairanen, Tiina

doi:10.1111/ene.13781

Cited by 12 publications

(17 citation statements)

References 30 publications

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“…Limitations of the present study include the relatively small sample size in our long‐term analysis and the absence of data from EVT‐treated patients, for whom long‐term follow‐up is not yet available. Strengths of the present study include a longer follow‐up time than has ever been described and a previously well‐established and prospectively collected single‐center IVT‐treated BAO cohort [14,18,24,32]…”

Section: Discussionmentioning

confidence: 99%

Outcomes and long‐term mortality after basilar artery occlusion—A cohort with up to 20 years’ follow‐up

Ritvonen

Sairanen

Silvennoinen

et al. 2020

Euro J of Neurology

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Background The data on long‐term outcome after basilar artery occlusion (BAO) are scarce. Little is known about BAO survivors´ outcome over decades. Aim We set out to investigate long‐term survival and causes of death in BAO patients with up to two decades of follow‐up. We also evaluated differences in outcome trends. Methods Two hundred and seven BAO patients treated with intravenous thrombolysis (IVT) at the Department of Neurology, Helsinki University Hospital, between 1995 and 2016, were analyzed. Short‐term outcome was assessed by modified Rankin Scale (mRS) at 3 months. Long‐term cumulative survival rate was analyzed using Kaplan−Meier analysis. Factors associated with mortality were analyzed with Cox regression. Results Moderate outcome (mRS 0–3) was achieved in 41.1% and good outcome (mRS 0–2) in 30.4% of patients at 3 months. Three‐month mortality was 39.6%, of which 89% died within the first month. The median follow‐up time in 3‐month survivors was 8.9 years (maximum 21.8 years). Total mortality during follow‐up was 52.2%. Cumulative mortality rate was 25.7%. Older age, coronary artery disease and more extensive ischemic changes on admission brain imaging were independently associated with long‐term mortality. After the acute phase, the rate of other vascular causes of death increased in relation to stroke. Conclusions The described evolution of a large, single‐center BAO cohort shows a trend towards a higher rate of good and/or moderate outcome during later years in IVT‐treated patients. Survivors showed relative longevity, and the rate of cardiac and other vascular causes of death increased in relation to stroke sequelae over the long term.

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Section: Discussionmentioning

confidence: 99%

Outcomes and long‐term mortality after basilar artery occlusion—A cohort with up to 20 years’ follow‐up

Ritvonen

Sairanen

Silvennoinen

et al. 2020

Euro J of Neurology

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“…Intravenous thrombolysis is the standard care in patients with basilar artery occlusion (BAO) and other large vessel occlusions of the posterior circulation. Yet, intravenous thrombolysis yields insufficient reperfusion rates and poor outcomes in patients with BAO 7,8) , and MT appears to increase recanalization and to be more promising to help patients with posterior circulation occlusion (PCO) to improve clinical outcomes.…”

Section: Data Synthesis and Analysismentioning

confidence: 99%

Mechanical Thrombectomy for Posterior Circulation Occlusion: A Comparison of Outcomes with the Anterior Circulation Occlusion – A Meta-Analysis

Wang

et al. 2020

JAT

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There is no randomized controlled trial to compare the effectiveness and safety of mechanical thrombectomy (MT) to intravenous thrombolysis in patients with posterior circulation occlusion (PCO). Hence, we firstly performed a meta-analysis to investigate the outcomes of MT in PCO and then compared these outcomes to anterior circulation occlusion (ACO) to provide fundamental data to further studies. Methods: We searched the PubMed, EMBASE, and Cochrane Library from dates of inception to June 2019 for relevant studies. Outcomes including functional independence at 90 days, successful recanalization, mortality, symptomatic intracranial hemorrhage (sICH), and futile recanalization were extracted. Results: Seven studies involving 474 patients with PCO thrombectomy were analyzed. There was a lower rate of functional independence at 90 days and a higher rate of mortality after thrombectomy in PCO versus ACO (odds ratios (OR) 0.72; 95% confidence interval (CI) 0.57-0.90; OR 2.03; 95% CI 1.30-3.18). Recanalization rates were comparable (OR 1.01; 95% CI 0.62-1.65), but a higher futile recanalization rate was found in basilar artery occlusion (BAO) (OR 1.75; 95% CI 1.30-2.37). There was a lower rate of sICH in MT for patients with PCO versus ACO (OR 0.54; 95% CI 0.29-0.99). Conclusions: We found that the outcomes of MT for patients with PCO were poorer than with ACO. On the other hand, MT appears to have lower rates of sICH and to increase successful recanalization. Given the high recanalization rate, MT may serve as an adjunct to standard treatment. The key point to improve outcomes is recognizing reliable factors associated with futile recanalization and optimizing the results of MT. But in view of the different characteristics of posterior circulation stroke and anterior circulation stroke, the results are far from robust. acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the new generations of mechanical thrombectomy (MT) devices compared to intravenous thrombolysis 2-6) , grounded on which American Heart Association/American Stroke Association guidelines Copyright©2020 Japan Atherosclerosis Society This article is distributed under the terms of the latest version of CC BY-NC-SA defined by the Creative Commons Attribution License.

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“…(von Kummer & Hacke, 1992) From 1998 to 2013, two single‐arm cohorts compared with historical controls and a single‐center case–control study demonstrated that thrombolysis followed by anticoagulation with IVH did not increase the risk of sICH. (Amaro et al., 2013; Grond et al., 1998; Schmülling et al., 2003) As for patients with acute basilar artery stroke, one study showed a higher rate of sICH and a shift toward worse outcome in thrombolyzed patients treated with IVH as compared to subcutaneous low‐molecular weight heparin,(Ritvonen et al., 2019) while another study did not find that sICH after thrombolysis was related to adjuvant anticoagulation with IVH. (Sairanen et al., 2015) These observational case series showed conflicting results largely because of inhomogeneous selection of patients and different dosage of heparin for the study.…”

Section: Discussionmentioning

confidence: 99%

Benefit and risk of early intravenous heparin after thrombolysis in patients with acute ischemic stroke

et al. 2020

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Thrombolysis and adjunct anticoagulation in patients with acute basilar artery occlusion

Abstract: Our study showed a lower rate of sICH and a shift towards improved outcome in thrombolysed patients with BAO treated with LMWH as compared with UFH.

Cited by 12 publications

References 30 publications

Outcomes and long‐term mortality after basilar artery occlusion—A cohort with up to 20 years’ follow‐up

Outcomes and long‐term mortality after basilar artery occlusion—A cohort with up to 20 years’ follow‐up

Mechanical Thrombectomy for Posterior Circulation Occlusion: A Comparison of Outcomes with the Anterior Circulation Occlusion – A Meta-Analysis

Benefit and risk of early intravenous heparin after thrombolysis in patients with acute ischemic stroke

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