Outcome of Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Patients with Intracranial Atherosclerotic Disease.

INTRODUCTION: Intracranial atherosclerotic disease (ICAD) has been identified as a major cause of acute basilar artery occlusion (BAO).This study compared the characteristics and treatment outcomes in acute BAO patients with and without ICAD. METHODS: A prospective cohort study was conducted at 115 People's Hospital, Ho Chi Minh city, Vietnam from August 2021 to June 2023. Patients with acute BAO who underwent endovascular treatment within 24 h from symptom onset were included (thrombectomy alone or bridging with intravenous alteplase). The baseline characteristics and outcomes were analyzed and compared between patients with and without ICAD. Good functional outcome was defined as mRS ≤3 at 90 days. RESULTS: Among the 208 patients enrolled, 112 (53.8%) patients were categorized in the ICAD group, and 96 (46.2%) in the non-ICAD group. Occlusion in the proximal segment of the basilar artery was more common in patients with ICAD (55.4% vs. 21.9%, p < 0.001), whereas the distal segment was the most common location in the non-ICAD group (58.3% vs. 10.7%, p < 0.001). Patients in the ICAD group were more likely to undergo treatment in the late window, with a higher mean onset-to-treatment time compared to the non-ICAD group (11.6 vs. 9.5 h, p = 0.01). In multivariable logistic regression analysis, distal segment BAO was negatively associated with ICAD (aOR 0.13, 95% CI: 0.05-0.32, p < 0.001), while dyslipidemia showed a positive association (aOR 2.44, 95% CI: 1.15-5.17, p = 0.02). There was a higher rate for rescue stenting in the ICAD compared to non-ICAD group (15.2% vs. 0%, p < 0.001). However, no significant differences were found between the two groups in terms of good outcome (45.5% vs. 44.8%, p = 0.91), symptomatic hemorrhage rates (4.5% vs. 8.3%, p = 0.25), and mortality (42% vs. 50%, p = 0.25). CONCLUSION: ICAD was a common etiology in patients with BAO. The location segment of BAO and dyslipidemia were associated with ICAD in patients with BAO. There was no difference in 90-day outcomes between BAO patients with and without ICAD undergoing endovascular therapy.

Endovascular treatment for acute ischemic stroke beyond the 24-h time window: Selection by target mismatch profile.

INTRODUCTION: Endovascular treatment for acute ischemic stroke patients with large vessel occlusion (LVO) has been established as a promising clinical intervention within a late time window of 6-24 h after symptom onset. Patients with slow progression, however, may still benefit from endovascular treatment beyond the 24-h time window (very late window). AIM: The aim of this study is to report insight into the potential clinical benefits of endovascular treatment for acute ischemic stroke beyond 24 h from symptom onset. METHODS: A retrospective analysis was performed on consecutive patients undergoing endovascular treatment for acute anterior circulation LVO ischemic stroke beyond 24 h. Participants were recruited between July 2019 and November 2020. Patients were selected based on the DAWN/DEFUSE 3 criteria (Perfusion-RAPID, iSchemaView) and patients receiving treatment beyond 24 h were compared to a group of patients receiving endovascular treatment between 6 and 24 h after symptom onset. The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were shift modified Rankin Scale (mRS) analysis and successful reperfusion was defined by thrombolysis in cerebral infarction (TICI) 2b-3 on the final procedure. Safety outcomes were symptomatic intracranial hemorrhage and death at the 90-day follow-up. Propensity score (PS)-matched analyses were employed to rectify the imbalanced baseline characteristics between the two groups. RESULTS: A total of 166 patients were recruited with a median age of 63.0 (56.0-69.0) and 28.9% of all patients were females. Patients in the beyond 24-h group had a longer onset-to-groin time (median = 27.2 vs 14.3 h, p < 0.001) than those in the 6- to 24-h group. There were no statistically significant differences between the two groups in National Institutes of Health Stroke Scale (NIHSS) (median = 12.0 vs 15.0, p = 0.37), perfusion imaging characteristics (core: median = 11.0 vs 9.0 mL, p = 0.86; mismatch volume: median = 106.0 vs 96.0, p = 0.44; mismatch ratio = 6.46 vs 7.24, p = 0.91), and perfusion-to-groin time (median = 72.5 vs 76.0 min, p = 0.77). No significant differences were noted among patients between the two groups in the primary endpoint functional independence analysis (50.0% vs 46.6%, p = 0.77) and in the safety endpoint analysis: mortality (15.0% vs 11.0%, p = 0.71) or symptomatic hemorrhage (0% vs 3.42%, p > 0.999). In PS-matched analyses, there were no significant differences among patients between the two groups in functional independence (50.0% vs 54.8%, p = 0.74), mortality (16.7% vs 9.68%, p = 0.50), or symptomatic hemorrhage (0% vs 6.45%, p = 0.53). CONCLUSION: Endovascular treatment can be performed safely and effectively in LVO patients beyond 24 h from symptom onset when selected by target mismatch profile. The clinical outcome of these patients was comparable to those treated in the 6- to 24-h window. Larger studies are needed to confirm these findings.

A Case of Successful Intravenous Thrombolysis Bridged with Repeated Endovascular Treatment in Acute Basilar Artery Occlusion.

Acute basilar artery occlusion (BAO) is a neurological emergency that has a high rate of mortality and poor functional outcome. Endovascular therapy (ET) is the gold standard therapy for large vessel occlusion stroke of the anterior circulation. Whether ET can also be effectively and safely performed in early recurrent large vessel occlusion, especially in BAO, is unclear. We describe a case of successful recanalization and independent functional outcome of a BAO patient treated with intravenous thrombolysis combined with repeated ET. The patients was a 32-year-old man with a history of heavy smoking and drinking who presented to the Emergency Department with dizziness and hypertension, and progressed over the next 13 h to left hemiparesis and mild dysarthria with an NIHSS score of 7. CT angiography demonstrated occlusion of the proximal basilar artery (BA). Intravenous alteplase was given followed by ET. The first intervention failed and over the next 8 h, the patient's NIHSS score increased to 12. A second attempt with balloon angioplasty managed to reconstitute arterial blood flow with a severe residual stenosis of the proximal BA. Subsequently, the patient progressed into deep coma with reocclusion of the BA demonstrated on transcranial Doppler. A third intervention with emergent stenting resulted in complete recanalization of the BA and excellent neurological recovery. This patient received three endovascular treatments within 24 h due to reocclusion of the BA and achieved good outcomes. In conclusion, repeated ET for early recurrent BAO is feasible in carefully selected patients.

Perfusion-Based Decision-Making for Mechanical Thrombectomy in a Transient Ischemic Attack Patient with Middle Cerebral Artery Occlusion.

A significant proportion of patients with large-vessel occlusion (LVO) initially present to the hospital with transient ischemic attack (TIA) and mild clinical manifestations such as low National Institutes of Health Stroke Scale (NIHSS) scores (≤5). However, due to the natural course of the disease, the individuals may subsequently develop worsening symptoms. To date, there is lack of evidence-based guidelines on mechanical thrombectomy (MT) among those patients. Therefore, the predicting factors associated with better or worse outcomes for acute stroke patients receiving MT compared to those not receiving the treatment are unknown. We describe a TIA case with LVO who was treated with MT; we used perfusion imaging as a decision aid. A 55-year-old male patient with a past medical history of TIA, hypertension, and hyperlipidemia was admitted to our hospital for evaluation of transient mild right hemiparesis and dysarthria lasting for 5 min 3 h before admission. He reported that he had experienced the same condition 1 day before. On admission, neurological examination showed normal function with an NIHSS score of 0. Computed tomography angiography revealed left proximal M1 occlusion. In addition, perfusion magnetic resonance imaging maps calculated by the RAPID software showed acute small lesions on the left hemisphere with core volume (0 mL) and a large ischemic penumbra (70 mL). Immediate endovascular thrombectomy was performed 5 h following symptom onset with complete recanalization and clinical recovery. The case suggests that MT in LVO patients with low NIHSS scores, even a score of 0, on presentation is potentially a safe and effective treatment. The use of perfusion imaging in the acute phase of stroke should be encouraged for the decision-making process.