Thrombectomy in patients with basilar artery thrombosis

Introduction. This article is devoted to the discussion of a life-threatening condition - basilar artery thrombosis (BAT). The article presents the results of a comparative analysis of two groups of patients with angiographically confirmed BAT: with and without reperfusion therapy.

Relevance. Basilar artery thrombosis is a life-threatening condition in which mortality can reach 95%, and severe neurological deficits and dependence in everyday life on others (modified Ran-kin Scale (mRS), score 4–5) are observed in 65% of surviving patients. Ischemic stroke (IS) due to BAT is diagnosed in 1–4% of patients with acute cerebrovascular event (ACVE). Currently, reperfusion therapy (RT) in the form of systemic thrombolytic therapy (sTLT) with rt-PA and/or thrombectomy (TE) is the only effective and safe method for treating patients with IS. In randomized trials, it was found that RT, whether it is sTLT, TE or a combination of these techniques, despite the best degree of functional recovery in patients by day 90 from the onset of the disease, does not lead to a statistically significant decrease in mortality. Nevertheless, the results of 10 prospective studies of the use of endovascular treatment in patients with IS in the posterior circulation system indicate that this type of therapy leads to a decrease in 90-day mortality from 95% to 16–47% in case of successful recanalization (mTICI (modified Thrombolysis in Cerebral Infarction), 2–b–3).

Aim of study. To assess the safety and efficacy of TE in patients with BAT.

Material and methods. This study included 15 patients with IS, admitted within the 6-hour therapeutic window, and confirmed BAT by CT and/or MRangiography. The baseline level of wakefulness was assessed using the Glasgow Coma Scale (GCS), and the severity of neurological deficit was assessed by the National Institutes of Health Stroke Scale (NIHSS).

Results. Basilar artery thrombectomy was performed in 7 patients (endovascular treatment group), 8 patients received no endovascular treatment (standard therapy group). Good clinical outcomes by day 90 from the onset of the disease (mRS, score 0–2) were observed in 57.1% of patients in the endovascular treatment group and in 12.5% of patients in the standard therapy group. However, these differences were not statistically significant (p>0.05). There were also no differences between the two groups in functional outcomes and Rivermead mobility index (RMI) by day 90 from the onset of the disease (Barthel Index of Activities of Daily Living (BI) score 97±5.0 and 100, RMI score 14.0±0.0 and 15 in the endovascular treatment group and standard therapy group, respectively). Mortality by day 90 in the endovascular treatment group was 42.9% (3 patients), in the standard therapy group — 87.5% (7 patients). In the subgroup of patients with GCS score at admission no more than score 8, there was a statistically significant strong two-way negative correlation between TE performance and mortality (r=-1.0; p=0.000), as well as a positive correlation between TE and a Rankine score by day 90 (r=0.956; p=0.003). Mortality was statistically significantly lower in the endovascular treatment group compared to the standard therapy group (0% versus 100%, respectively, p=0.025). Clinical outcomes of the disease by day 90 were statistically significantly better in the endovascular treatment group: mRS, score 0–2 in 100% of cases versus 0% in the standard treatment group (p=0.028).

Conclusion. Currently, the only effective treatment for basilar artery thrombosis is thrombectomy. The possibility of performing thromboectomy in these cases should be considered in all patients, regardless of the severity of the stroke and the decrease in the level of wakefulness, since endovascular treatment in this case is a life-saving procedure. The symptom of a hyperdense basilar artery can be used as a diagnostic tool for suspected basilar artery thrombosis, but should not rule out angiography. In our series of observations, the mortality rate in patients who underwent thrombectomy was 42.9%. Good functional outcomes (mRS, score 0–2) and the absence mobility limitation (RMI, score 14) were observed in 57.1% of patients by day 90 after thrombectomy.

1. Lohse A, Preul C, Witte OW, Isenmann S. Clinical Diagnostics, Therapy and Outcome After Basilar Artery Thrombosis. Open Crit Care Med J. 2011;4(1):28–34. https://doi.org/10.2174/1874828701104010028

2. Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry. 2005;76(9):1238–1241. PMID: 16107358 https://doi.org/10.1136/jnnp.2004.049924

3. Demel SL, Broderick JP. Basilar Occlusion Syndromes: An Update. Neurohospitalist. 2015;5(3):142–150. PMID: 26288672 https://doi.org/10.1177/1941874415583847

4. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–1587. PMID: 7477192 https://doi.org/10.1056/NEJM199512143332401

5. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. N Engl J Med. 2008;359(13):1317–1329. PMID: 18815396 https://doi.org/10.1056/NEJMoa0804656

6. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med. 2015;372(11):1019–1030. PMID: 25671798 https://doi.org/10.1056/NEJMoa1414905

7. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med. 2015;372(11):1009–1018. PMID: 25671797 https://doi.org/10.1056/NEJMoa1414792

8. Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. 2015;372(1):11–20. PMID: 25517348 https://doi.org/10.1056/NEJMoa1411587

9. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A Trial of Imaging Selection and Endovascular Treatment for Ischemic Stroke. N Engl J Med. 2013;368(11):914–923. PMID: 23394476 https://doi.org/10.1056/NEJMoa1212793

10. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. N Engl J Med. 2015;372(24):2296–2306. PMID: 25882510 https://doi.org/10.1056/NEJMoa1503780

11. Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. N Engl J Med. 2015;372(24):2285–2295. PMID: 25882376 https://doi.org/10.1056/NEJMoa1415061

12. Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomized controlled trial. Lancet Neurol. 2016;15(11):1138-1147. PMID: 2756723 https://doi.org/10.1016/S1474-4422(16)30177-6

13. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–e418. PMID: 31662037 https://doi.org/10.1161/STR.0000000000000211

14. Baik SH, Park HJ, Kim J-H, Jang CKi, Kim BM, Kim DJ. Mechanical Thrombectomy in Subtypes of Basilar Artery Occlusion: Relationship to Recanalization Rate and Clinical Outcome. Radiology. 2019;291(3):730–737. PMID: 30912720 https://doi.org/10.1148/radiol.2019181924

15. Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring H-P, Trenkler J, et al. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol. 2015;77(3):415–424. PMID: 25516154 https://doi.org/10.1002/ana.24336

16. Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–1731. PMID: 26898852 https://doi.org/10.1016/S0140-6736(16)00163-X

17. Mokin M, Sonig A, Sivakanthan S, Ren Z, Elijovich L, Arthur A, et al. Clinical and procedural predictors of outcomes from the endovascular treatment of posterior circulation strokes. Stroke. 2016;47(3):782–788. PMID: 26888533 https://doi.org/10.1161/STROKEAHA.115.011598

18. Bouslama M, Haussen DC, Aghaebrahim A, Grossberg JA, Walker G, Rangaraju S, et al. Predictors of good outcome after endovascular therapy for vertebrobasilar occlusion stroke. Stroke. 2017;48(12):3252–3257. PMID: 29089457 https://doi.org/10.1161/STROKEAHA.117.018270

19. Weber R, Minnerup J, Nordmeyer H, Eyding J, Krogias C, Hadisurya J, et al. Thrombectomy in posterior circulation stroke: differences in procedures and outcome compared to anterior circulation stroke in the prospective multicentre REVASK registry. Eur J Neurol. 2019;26(2):299–305. PMID: 30218610 https://doi.org/10.1111/ene.13809

20. Kang DH, Jung C, Yoon W, Kee KS, Baek BH, Kim JT, et al. Endovascular thrombectomy for acute basilar artery occlusion: a multicenter retrospective observational study. J Am Heart Assoc. 2018;7(14): e009419. PMID: 29982231 https://doi.org/10.1161/JAHA.118.009419

21. Gory B, Mazighi M, Blanc R, Labreuche J, Piotin M, Turjman F, et al. Mechanical thrombectomy in basilar artery occlusion: influence of reperfusion on clinical outcome and impact of the first-line strategy (ADAPT vs stent retriever). J Neurosurg. 2018;129(6):1482–1491. PMID: 29327997 https://doi.org/10.3171/2017.7.JNS171043

22. Rentzos A, Karlsson JE, Lundqvist C, Rosengren L, Hellström M, Wikholm G. Endovascular treatment of acute ischemic stroke in the posterior circulation. Interv Neuroradiol. 2018;24(4):405–411. PMID: 29562859 https://doi.org/10.1177/1591019918762320

23. Raymond S, Rost NS, Schaefer PW, Thabele L-M, Hirsch JA, Gonzalez RG, et al. Patient selection for mechanical thrombectomy in posterior circulation emergent large-vessel occlusion. Interv Neuroradiol. 2018;24(3):309–316. PMID:29231792 https://doi.org/10.1177/1591019917747253

24. Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke. 1993;24(1):35–41. PMID: 7678184 https://doi.org/10.1161/01.str.24.1.35

25. Finsterer J. Management of cryptogenic stroke. Acta Neurol Belg. 2010;110(2):135–147. PMID: 20873443

26. Castillo M. The Core Curriculum: Neuroradiology. Lippincott Williams & Wilkins; 2002.

27. Pope TL, Harris JHJr. (ed.) Harris & Harris’ Radiology of Emergency Medicine. 5th ed. Lippincott Williams & Wilkins; 2012.

28. Nagel S. [Stroke due to acute occlusion of the basilar artery: Diagnosis and treatment]. Med Klin Intensivmed Notfmed. 2017;112(8):679–686. PMID: 28905077 https://doi.org/10.1007/s00063-017-0347-0

29. Johnson TM, Romero CS, Smith AT. Locked-in syndrome responding to thrombolytic therapy. Am J Emerg Med. 2018;36(10):1928.5–1928. PMID: 29983216 https://doi.org/10.1016/j.ajem.2018.07.003

30. Reid M, Famuyide AO, Forkert ND, Talai AS, Evans JW, Sitaram A, et al. Correction to: Accuracy and Reliability of Multiphase CTA Perfusion for Identifying Ischemic Core. Clin Neuroradiol. 2019;29(3):553. PMID:31161342 https://doi.org/10.1007/s00062-019-00803-2

31. Kadoya Y, Zen K, Oda Y, Matoba S. Successful Endovascular Treatment for Aortic Thrombosis Due to Primary Antiphospholipid Syndrome: A Case Report and Literature Review. Vasc Endovascular Surg. 2019;53(1):51–57. PMID: 30092725 https://doi.org/10.1177/1538574418791355

32. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011;10(11):1002–1014. PMID: 22014435 https://doi.org/10.1016/S1474-4422(11)70229-0

33. Ernst M, Romero JM, Buhk J-H, Cheng B, Herrmann J, Fiehler J, et al. Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography. PLoS One. 2015;10(10):e0141096. PMID: 26479718 https://doi.org/10.1371/journal.pone.0141096