Vertebrobasilar recanalization modalities before the placement of stent-retrievers: Reopening is not synonymous with good outcome

Acosta, Fernando; Góméz, Elena; Rodríguez, F. de Asís Bravo; Fernández, R. Oteros; Sepúlveda, J.J. Ochoa

doi:10.1016/j.rxeng.2014.02.002

Cited by 4 publications

(3 citation statements)

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“…Delgado et al. 22 described four haemorrhagic transformations in their series of 27 patients with BAO (14.8%), three parenchymal haematomas (11.1%) and one haemorrhagic infarct (3.7%). One patient with parenchymal haematoma was considered symptomatic because of the presence of a mass effect.…”

Section: Discussionmentioning

confidence: 99%

“…Regarding good functional outcome and mortality rate, results ranged from 22.2% to 57% and 12% to 59.2%, respectively. 10–12,14,15,19–23 Singer et al. 23 recently achieved successful recanalisation in 111 patients out of a total of 141 (79%) in the largest series of BAO with endovascular treatment published until now as part of the ENDOSTROKE study, and reported good clinical outcomes in 34% of patients, with a mortality rate of 35%.…”

Section: Discussionmentioning

confidence: 99%

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Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study

et al. 2016

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Objectives The objective of this study was to add more evidence about the efficacy and safety of mechanical thrombectomy in patients with basilar artery occlusion and secondarily to identify prognostic factors. Methods Twenty-two consecutive patients (mean age 60.5 years, 15 men) with basilar artery occlusion treated with mechanical thrombectomy were included. Clinical, procedure and radiological data were collected. Primary outcomes were the modified Rankin scale score with a good outcome defined by a modified Rankin scale score of 0–2 and mortality rate at three months. Results The median National Institutes of Health stroke scale at admission was 24 (interquartile range 11.5–31.25). Twelve patients (54.5%) required tracheal intubation due to a decreased level of consciousness. Successful recanalisation (modified treatment in cerebral ischaemia scale 2b–3) was achieved in 20 patients (90.9%). A favourable clinical outcome (modified Rankin scale score 0–2) was observed in nine patients (40.9%) and the overall mortality rate was 40.9% (nine patients). Haemorrhagic events were observed in three patients (13.63%). A decreased level of consciousness requiring intubation in the acute setting was more frequent in patients with poor outcomes (84.6%) than in patients with favourable outcomes (11.1%), and in patients who died (100%) compared with those who survived (23.1%), with a statistically significant difference ( P = 0.002 and P = 0.001, respectively). Conclusion Mechanical thrombectomy is feasible and effective in patients with acute basilar artery occlusion. A decreased level of consciousness requiring tracheal intubation seems to be a prognostic factor and is associated with a poor clinical outcome and higher mortality rate. These initial results must be confirmed by further prospective studies with a larger number of patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study

et al. 2016

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“…The procedural success in our cohort is in line with that in previous studies evaluating modern devices in the treatment of acute BAO, reporting recanalization rates be-tween 64% and 100%. [11][12][13][14][15][16][17][18][19][20][21] Optimal recanalization was previously demonstrated to impact mortality and disability in these patients in a previous meta-analysis. 22 Our findings correspond with such results, as incomplete recanalization was the only predictor of mortality in our cohort.…”

Section: Discussionmentioning

confidence: 99%

Comparison of effectiveness and outcomes among different thrombectomy techniques in acute basilar artery occlusion: a dual-center experience

Monteiro¹,

Cortez

Waqas

et al. 2021

Neurosurgical Focus

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OBJECTIVE Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever–assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort. METHODS A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis. RESULTS Eighty-three patients (median age 67 years [IQR 58–76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10–21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5–363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0–2) was not significantly different among the three techniques. Poor outcome (mRS score 3–6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97–0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18–2.39; p = 0.005). CONCLUSIONS The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

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Stent Retrievers for Treating Anterior Circulation Acute Ischemic Stroke

2016

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To the Editor Touma et al 1 reported a comprehensive systematic review and meta-analysis of 5 randomized clinical trials evaluating the benefits and risks of stent retrievers in addition to recombinant tissue plasminogen activator (rtPA) for the treatment of acute ischemic stroke (AIS). The main conclusion of the study was that "the use of stent retrievers in conjunction with rtPA vs rtPA alone is associated with significant improvement of functional independence 90 days after AIS." 1 However, as pointed out by the authors, all studies included in their meta-analysis selected only patients with anterior circulation acute ischemic strokes. Nevertheless, about 20% of all strokes and transient ischemic attacks occur in the posterior circulation arterial territory. 2 Posterior circulation arterial territories have proper characteristics that differ from anterior circulatory territories. 2 While the use of stents in anterior arterial territories has been showing more consistent benefits to patients, 1 the use of stents in posterior arterial territories remains more problematic. 3 Despite a few studies showing that patients with vascular posterior strokes might benefit from stent therapy, the studies published so far might be insufficient for recommendations that could be broadly used. 3-5 Thus, extending recommendations for the use of stent retrievers in anterior territory arteries to posterior territory arteries is not possible, as it is remains to be elucidated by prospective studies whether stents are safe and superior to standard treatments in patients with critical stenosis or acute ischemic stroke of the posterior vascular territory. The main strength of evidence-based medicine is sometimes also its major problem. Evidence-based medicine recommendations need to be based in evidence. Thus, perhaps the main conclusion of the Touma et al 1 study needs to be more accurate, better specifying for what clinical situations stent retrievers showed benefits, and a more generalized conclusion should be avoided. In this venue, a more appropriate conclusion would have been that the use of stent retrievers in conjunction with rtPA can be associated with significant improvement of functional independence after AIS of the anterior vascular territories. It is possible that this review and metaanalysis will endorse future guidelines for stent retrievers for treatment of acute ischemic stroke in the near future. However, at this point, more studies are necessary before we can generalize its conclusions and also recommend this therapeutic option for patients with posterior vascular territory strokes. Stroke neurologists must be aware of this aspect.

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Vertebrobasilar recanalization modalities before the placement of stent-retrievers: Reopening is not synonymous with good outcome

Cited by 4 publications

References 14 publications

Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study

Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study

Comparison of effectiveness and outcomes among different thrombectomy techniques in acute basilar artery occlusion: a dual-center experience

Stent Retrievers for Treating Anterior Circulation Acute Ischemic Stroke

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