Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques

Abstract

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy

“…Median CLEOS score (IQR) for the entire cohort was 508 (426-584) and median THRIVE score (IQR) was 4 (3)(4)(5)(6). Characteristics in the good (mRS 0-2) and poor (mRS 3-6) outcome groups are shown in Table 1.…”

“…Notably, the natural history of patients presenting with an acute BAO who do not receive reperfusion therapy is poor, 2 though randomized EVT trials have not universally demonstrated a benefit for thrombectomy. 3 Despite this, EVT remains the standard of care for BAO patients presenting with a disabling neurological deficit in the absence of a large core infarction on initial imaging studies, 3 considering the excellent reperfusion rates with EVT and good outcomes in over 40% of patients reported in meta-analyses. 4,5 Similar to CLEOS, the Totaled Health Risks in Vascular Events (THRIVE) score predicts outcomes for patients presenting with anterior circulation large vessel occlusion (LVO) strokes and was originally derived from the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi-MERCI clinical trials.…”

“…Basilar artery occlusion (BAO) thrombectomy patients were not included in the original CLEOS derivation study. Notably, the natural history of patients presenting with an acute BAO who do not receive reperfusion therapy is poor, 2 though randomized EVT trials have not universally demonstrated a benefit for thrombectomy 3 . Despite this, EVT remains the standard of care for BAO patients presenting with a disabling neurological deficit in the absence of a large core infarction on initial imaging studies, 3 considering the excellent reperfusion rates with EVT and good outcomes in over 40% of patients reported in meta‐analyses 4,5 …”

Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes

“…Poor outcomes among patients treated with endovascular therapy has been reported in patients with BATMAN <7 [18] . Generalization of these scores is challenging given the retrospective nature of the studies, variable outcome definitions, and small sample sizes [31] . In theory, MRI studies could be used to identify the absolute validity of scores before spending time and effort optimizing issues with beam-hardening and other artifacts which limit posterior fossa gray-white resolution on CT.…”

Influencing factors of futile recanalization after endovascular intervention in patients with acute basilar artery occlusion

“…急性基底动脉闭塞是急性缺血性脑卒中的严重亚型之一，占颅内大血管闭塞的5%~10%，患者病死率和严重残疾率高达70% ［ 1 - 3 ］ 。最近两项有关急性基底动脉闭塞血管内治疗的随机对照试验——BAOCHE（Basilar Artery Occlusion Chinese Endovascular）试验 ［ 4 ］ 和ATTENTION（Endovascular Treatment for Acute Basilar-Artery Occlusion）试验 ［ 5 ］ 结果显示，中重度急性基底动脉闭塞所致缺血性脑卒中患者机械取栓相比标准药物治疗可以更多获益。《急性缺血性卒中血管内治疗中国指南2023》建议，对发病24 h内的急性后循环大血管闭塞患者，经过临床及影像筛选后，推荐血管内取栓治疗（Ⅰ类推荐，A级证据） ［ 6 ］ 。可以预见，血管内机械取栓将成为急性基底动脉闭塞患者急性期治疗的一个重要方法。然而，尽管80%~90%在起病24 h内接受血管内治疗的急性基底动脉闭塞患者可以获得血管成功再通（mTICI分级2b~3级），其中仍有超过一半的患者在90 h内临床神经功能结局不良，即发生血管无效再通 ［ 7 - 8 ］ 。因此，深入研究急性基底动脉闭塞患者血管内治疗后无效再通的发生机制和预测因素，有助于在临床中识别风险因素和保护因素，找到个性化的治疗靶点，减少无效再通发生率，从而改善患者的临床结局。…”