Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

Abstract

BackgroundEndovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the incidence and predictors of poor clinical outcome despite successful reperfusion in current clinical practice.MethodsWe used data from the ETIS (Endovascular Treatment in Ischemic Stroke) registry, a prospective multicenter observational registry of stroke treated with EVT in France. Patients undergoing EVT for acute BAO from January 2014 to May 2019 successfully treated within 8 hours from onset were included. Predictors of 90-day poor outcome (modified Rankin Scale (mRS) 4–6) were researched within patients with successful (modified Thrombolysis In Cerebral Infarction (mTICI 2b-3)) and excellent (mTICI 2c-3) reperfusion.ResultsAmong 242 patients treated within 8 hours, successful reperfusion was achieved in 195 (80.5%) and excellent reperfusion in 120 (49.5%). Poor outcome was observed in 107 (54.8%) and 60 (50%) patients, respectively. In patients with successful early reperfusion, age, higher initial National Institutes of Health Stroke Scale (NIHSS) score, lower posterior circulation Alberta Stroke Programme Early CT Score (pc-ASPECTS), and absence of prior intravenous thrombolysis were independent predictors of poor outcome. The only treatment factor with an independent predictive value was first-pass mTICI 2b-3 reperfusion (adjusted OR 0.13, 95% CI 0.05 to 0.37, p<0.001). In patients with excellent early reperfusion, independent predictors were age, initial NIHSS score, first-pass mTICI 2c-3 reperfusion, and hemorrhagic transformation on post-interventional imaging.ConclusionsEarly successful reperfusion with EVT occurred in 80.5% of patients, and the only treatment-related factor predictive of clinical outcome was first pass mTICI 2b-3 reperfusion. Further research is warranted to identify the optimal techniques and devices associated with first pass reperfusion in the posterior circulation.

First-pass effect in patients with acute vertebrobasilar artery occlusion undergoing thrombectomy: insights from the PERSIST registry

“…Therefore, future studies should pay more attention to how to provide fast, complete, and safe reperfusion during EVT in VBAO patients. 13 …”

“…Therefore, future studies should pay more attention to how to provide fast, complete, and safe reperfusion during EVT in VBAO patients. 13 With such a question, we investigated the possible predictors that influence the achievement of FPE in patients with VBAO. We found that stroke etiology, the site of occlusion, collateral status, and EVT strategies were important predictors for FPE.…”

“… 12 Therefore, it is important to identify the predictors associated with first-pass reperfusion in the posterior circulation stroke. 13 …”

“…12 Therefore, it is important to identify the predictors associated with first-pass reperfusion in the posterior circulation stroke. 13 To address this question, we conducted a study comparing the baseline characteristics and clinical outcomes of patients with FPE with those of the remainder of the cohort. The aim was to identify factors that may influence the achievement of FPE in EVT patients with VBAO and the relationship between FPE and prognosis.…”

Effective Mechanical Thrombectomy for Posterior Circulation Ischemia Using Magnetic Resonance Imaging-based Arterial Structures

“…6) Because successful recanalization in anterior circulation stroke with a single thrombectomy device pass is associated with a good functional outcome, there is increasing interest in the efficacy of the first-pass effect for basilar artery occlusion. 14) An accurate understanding of the stroke mechanism and precise endovascular recanalization therapy is required to achieve a first-pass effect. There are numerous anatomical variations in the posterior circulation.…”