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Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
Recanalization treatments in basilar artery occlusion-Systematic analysis
Perttu J Lindsberg1,2, Tiina Sairanen1, Simon Nagel3
1Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Insights
Endovascular mechanical approaches improve outcomes for basilar artery occlusion stroke compared to pharmacological thrombolysis. Careful patient selection, excluding those with extensive ischemia, is crucial for better clinical results.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Stroke Medicine
Background:
- Basilar artery occlusion (BAO) is a severe stroke type requiring revascularization.
- Current treatments include pharmacological thrombolysis and endovascular thrombectomy.
- The optimal approach and reasons for treatment futility remain unclear.
Purpose of the Study:
- To compare the effectiveness of endovascular mechanical interventions versus pharmacological thrombolysis for BAO.
- To identify predictors of futile recanalization in BAO treatment.
Main Methods:
- Systematic review and meta-analysis of 15 reports (2005 onwards) involving 803 patients.
- Analysis of a large single-center cohort (162 patients) to determine futility predictors.
Main Results:
- Mechanical approaches yielded better outcomes (35.5% vs. 24.4%) and recanalization rates (84.1% vs. 70.9%) than pharmacological thrombolysis.
- Primary thrombectomy achieved 91% recanalization and 36% good outcomes, but with a 60% futility rate (reduced to 52.8% with stentrievers).
- Extensive baseline ischemia was the strongest predictor of futile recanalization (OR 20-fold).
Conclusions:
- Endovascular mechanical methods offer superior outcomes for BAO compared to pharmacological thrombolysis.
- Improved patient selection, particularly avoiding those with extensive ischemia, is vital for enhancing clinical outcomes and reducing futility rates.
Background And Aims:
Basilar artery occlusion is a most devastating form of stroke, and the current practice is to reverse it with revascularization therapies. Pharmacological thrombolysis, intravenous or intraarterial, has been adjuncted or replaced with invasive, endovascular thrombectomy procedures. The preferred approach remains unknown and many recanalizations are futile with no clinical benefit. We sought to determine reasons for futility and weigh the existing reports to find whether endovascular mechanical interventions provide superior outcomes over pharmacological thrombolysis alone.
Methods:
After analyzing systematically the reports of outcomes produced by variable basilar artery occlusion recanalization protocols, information was retrieved and reconciled from 15 reports published from year 2005 comprising 803 patients in 17 cohorts. In the largest single-center cohort (162, Helsinki), predictors of futile recanalization (three-month modified Rankin Scale score 4 to 6) were determined.
Results:
Good outcome was reported by mechanical approaches either alone or on demand more frequently than by pharmacological, intravenous or intraarterial thrombolysis protocols (35.5% versus 24.4%, p < 0.001), accompanied by higher recanalization rates (84.1% versus 70.9%, p < 0.001). Along with superior recanalization rate at 91%, good outcome was reached by primary thrombectomy in 36% at the cost of substantial futile recanalization rate at 60%, which was lower when using modern stentrievers only (52.8%). In the Helsinki cohort, the single most significant predictor was extensive baseline ischemia, increasing the odds of futility 20-fold (95%CI 4.39-92.29, p < 0.001). Other attributes of futility were ventilation support and history of atrial fibrillation or previous stroke.
Conclusions:
Endovascular mechanical approaches have been reported to provide superior outcomes over pharmacological thrombolysis in basilar artery occlusion. Stricter patient selection, most notably to exclude victims of already extended ischemia, would assist in translating excellent recanalization rates into improved clinical outcomes and more acceptable futility rates.
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