Intra-Arterial Thrombolysis for Basilar Artery Thrombosis

Powers, William J.

doi:10.1161/01.str.0000254128.05122.a2

Cited by 13 publications

(8 citation statements)

References 26 publications

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“…Even among the BAO patients, the outcome was much better than previously assumed [22]. Furthermore, several studies based on the OCSP classification suggested the total AC infarcts had the poorest outcome [16,23,24,25,26]. As little information exists in previous studies for the long-term outcome after PCI, further comparison is limited.…”

Section: Discussionmentioning

confidence: 94%

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One-Year Case Fatality and Disability after Posterior Circulation Infarction in a Chinese Hospital-Based Stroke Study

Tao

Kong²,

Zeng³

et al. 2010

Cerebrovasc Dis

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Background and Purpose: Controversy exists as to whether posterior circulation infarction (PCI) has a poorer outcome compared to anterior circulation infarction (ACI). We aimed to investigate whether PCI had different clinical outcomes from ACI in Chinese patients with ischemic stroke. Methods: Data on ischemic stroke patients with ACI or PCI were collected including demographics, risk factors and 1-month, 3-month, and 1-year case fatality and disability (defined as modified Rankin Scale 3–5). Multivariate regression models were used to analyze predictors for death and disability. Results: Of the 1,962 enrolled cases, 433 (22.1%) had PCI. The case fatality of PCI at 1-month, 3-month and 1-year follow-up (FU) were lower than that of ACI (3.93, 5.3 and 9.7% vs. 7.26, 9.3 and 13.7%, p <0.05), and the proportion of disability was also lower in PCI at 3-month FU (19.6 vs. 29.1%, p<0.001) and 1-year FU (6.5 vs. 15.2%, p<0.001). The adjusted hazard ratio of death for PCI was 0.52 at 1 month (95% CI 0.29–0.94) and 0.52 at 3 months (95% CI 0.31–0.85), and the adjusted odds of disability in patients with PCI was 0.53 at 1 year (95% CI 0.35–0.81). Conclusions: In our cohort, patients with PCI have a lower risk of death at 1- and 3-month FU and a lower proportion of disability at 1-year FU, which needs to be verified by future studies.

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Section: Discussionmentioning

confidence: 94%

“…The poor outcome for PCI has been proposed in earlier studies [13,14,15,16,17,18,19,20]. Some were necropsy studies or involved only a small number of patients in specifically PC lesions or selected patients with more severe stroke focusing on basilar artery intraarterial thrombolysis.…”

Section: Discussionmentioning

confidence: 99%

One-Year Case Fatality and Disability after Posterior Circulation Infarction in a Chinese Hospital-Based Stroke Study

Tao

Kong²,

Zeng³

et al. 2010

Cerebrovasc Dis

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“…2 Since then, an open discussion among specialists has begun on whether to treat patients with BAO intraarterially or intravenously and whether a randomized controlled trial is feasible. [13][14][15][16][17][18][19][20][21] In a multicenter observational study it has recently been shown that the bridging concept, using combined treatment with IA rt-PA and IV platelet glycoprotein IIb/IIIa receptor inhibitors and additional percutaneous transluminal angioplasty/stenting in case of severe residual stenosis after IAT, might improve neurological outcome compared to IAT with rt-PA alone. 9 In this monocenter retrospective analysis, we compared the treatment of acute BAO with IAT alone and the combined approach of an IV glycoprotein IIb/IIIa inhibitor plus IA rt-PA treatment (bridging).…”

Section: Discussionmentioning

confidence: 99%

Therapy of Acute Basilar Artery Occlusion

Nagel

Schellinger

Hartmann

et al. 2009

Stroke

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Background and Purpose-While intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute stroke therapy within 3 hours, the optimum management of basilar artery occlusion (BAO) is still a matter of debate. We compared intraarterial thrombolysis with the combined bridging approach of intravenous abciximab and intraarterial thrombolysis with rt-PA (bridging therapy) in an observational, longitudinal, monocenter study. Methods-Between 1998 and 2006, information for 106 patients with acute BAO were prospectively entered into a local database. Patients eligible for treatment received either intraarterial thrombolysis with rt-PA alone (intraarterial thrombolysis) or were treated with intravenous abciximab and intraarterial rt-PA (bridging therapy). Outcome parameters were recanalization of the basilar artery according to Trial in Myocardial Infarction criteria, survival, and reduction of severe disability and death at 3 months. Logistic regression was used to identify independent predictors for recanalization, survival, and clinical outcome. Results-Of a total of 106 patients with confirmed BAO, 87 patients underwent subsequent angiography. Among those, 75 patients were identified who received the full treatment protocol. Patients in the bridging group had a better recanalization rate (83.7% vs 62.5%; Pϭ0.03), a higher survival rate (58.1% vs 25%; Pϭ0.01), and a better chance for an outcome with no or only mild to moderate disability (modified Rankin Scale score, 0 -3; 34.9% vs 12.5%; Pϭ0.02). Symptomatic intracerebral hemorrhage rates were comparable in both groups (14% in the bridging group vs 18.8%; Pϭ0.41). Independent predictors for recanalization were age (OR, 0.95; 95% CI, 0.91-0.99), atrial fibrillation (OR, 6.53; 95% CI, 1.14 -37.49), and bridging therapy (OR, 3.37; 95% CI, 1.02 to 11.18). Independent prognostic factors for outcome were Glasgow coma scale score at presentation (OR, 1.24; 95% CI, 1.03-1.45) and the combination of bridging therapy with successful recanalization (OR, 3.744; 95% CI, 1.04 -13.43). Conclusion-Bridging therapy for acute BAO with intravenous abciximab and intraarterial rt-PA appears to be safe and yields higher recanalization and improved survival rates, as well as an overall improved chance for a better outcome.

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“…Critics of IAT claim that procedural risks and expenses cannot currently be justified 33. Proponents suggest higher rates of recanalization with IAT and potentially lower rates of symptomatic intracranial hemorrhage 1 4 5.…”

Section: Iat Versus Ivt: Some Controversial Findingsmentioning

confidence: 99%

Endovascular therapy for acute basilar artery occlusion: a review of the literature

Mortimer

Bradley

Renowden

2011

J NeuroIntervent Surg

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Basilar artery occlusion is an infrequent form of acute stroke; clinical outcomes are heterogeneous, but the condition can be fatal. There is a lack of randomized controlled trial data in this field. Case series suggest that patients who are recanalized have much better outcomes than those who are not, and it is generally accepted that intra-arterial techniques achieve high rates of recanalization. Controversially, several studies, including a meta-analysis and registry-based investigation, that have compared intravenous thrombolysis (IVT) and intra-arterial treatment suggest similar outcomes. However, there are many potential sources of bias in each of these studies, precluding a firm conclusion. Indeed, there are many confounding factors that can influence the outcome including severity of presentation, site of occlusion, clot load, degree of collateral flow, timing of therapy, agent used for recanalization and dose of thrombolytic agent. Additionally, pretreatment infarct core imaging using diffusion-weighted imaging and the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) scoring systems have been shown to predict outcome and therefore may be useful in selecting patients for aggressive therapy. Protocols combining intravenous agents such as glycoprotein IIb/IIIa receptor antagonists or thombolytics agents with intra-arterial techniques ('bridging' therapy) have shown encouraging improvements in neurological outcome and survival. Furthermore, initial case series describing the use of mechanical clot extraction devices or aspiration catheters suggest high rates of recanalization. What would be useful is a randomized trial comparing IVT, endovascular approaches and a combined IVT/endovascular approach. However, the small numbers of patients and multiple confounding factors are barriers to the development of such a trial.

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Intra-Arterial Thrombolysis for Basilar Artery Thrombosis

Cited by 13 publications

References 26 publications

One-Year Case Fatality and Disability after Posterior Circulation Infarction in a Chinese Hospital-Based Stroke Study

One-Year Case Fatality and Disability after Posterior Circulation Infarction in a Chinese Hospital-Based Stroke Study

Therapy of Acute Basilar Artery Occlusion

Endovascular therapy for acute basilar artery occlusion: a review of the literature

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