Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease.

Abstract

In this retrospective analysis we report our treatment experience in 65 consecutive patients with clinical signs of severe brainstem ischemia with angiographically demonstrated thrombotic vertebrobasilar artery occlusions who received either local intra-arterial thrombolytic therapy (urokinase or streptokinase) (43 patients) or conventional therapy (antiplatelet agents or anticoagulants) (22 patients). We analyzed the data with respect to cerebral artery occlusion patterns, posttreatment arterial recanalization, and the clinical categories of favorable/unfavorable outcome and survival/death. In subgroup analyses, recanalization in patients who received thrombolytic therapy correlated significantly with clinical outcome; in 19 of 43 patients, recanalization was demonstrated angiographically, while in 24 patients the occlusion persisted. All patients without recanalization died, but 14 of the 19 patients displaying recanalization survived (p = 0.000007), 10 with a favorable clinical outcome. Only three of the 22 patients who received conventional therapy survived, all with a moderate clinical deficit. When we compared the treatment groups, highly significant differences in both outcome quality (p = 0.017) and survival (p = 0.0005) were found to depend on establishing recanalization. Our data support the concept that technically successful thrombolysis of vertebrobasilar artery occlusions is associated with beneficial clinical outcome.

Mechanical Thrombectomy in Basilar Artery Thrombosis: Technical Advances and Safety in a 10-Year Experience

“…To our best knowledge, systematic data on safety of MT devices comparing different generations of recanalization devices and techniques are not available yet. In our study, reflecting ''real-world'' experience, we could show that modern stent retriever and suction thrombectomy In previous studies on intra-arterial fibrinolysis, recanalization rates of approximately 50-60 % for complete recanalization, and B70 % when combining partial and complete recanalization, were reported in acute BAO [1][2][3][4][5][6]. Until now, only anecdotal reports and small singlecenter studies on MT in BAO have reported promising recanalization rates of 72-100 % [7,11,17,18].…”

“…Although the standard therapy, local intra-arterial fibrinolysis, has decreased mortality rates in acute true basilar artery occlusion (BAO) from 80 to 90 % to approximately 60 %, acute basilar artery embolism is still a devastating life-threatening disease [1][2][3][4]. Furthermore, intra-arterial fibrinolysis has some limitations (e.g., low efficiency in cases of large thrombus load, frequent distal embolization, extensive time to recanalization) and potential intrinsic complications (i.e., intracranial bleeding) [3,5,6].…”

“…MT seems to be a more effective and probably less hazardous endovascular technique than intra-arterial fibrinolysis to achieve rapid and complete restoration of the blood flow, which is crucial for a favourable prognosis in patients with BAO [2][3][4]6]. The recent MERCI [9,10] and Penumbra [8] studies presented promising recanalization rates in the anterior and posterior circulation.…”

Intra-arterial Thrombolysis

“…It is associated with a mortality between 50% and 90% in patients treated conventionally (antiplatelets or heparin) or not at all. 2,3 If survived, the consequence frequently is a locked-in syndrome, the most gruelsome outcome thinkable. Different patterns include caudal vertebrobasilar, mid-basilar and top-of-the-basilar thrombosis, the former mostly being of atherothrombotic and the latter of embolic origin.…”

“…6,7 Most studies suffered from small numbers: Ͻ10 patients with only a few in the range of 40 to 50 patients. 2,8,9 All had an open, retrospective or partly prospective design with differing treatment regimens, mostly IA thrombolytic drugs formally rendering level III evidence at best.…”