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Observational Study
. 2019 Dec;11(12):1174-1180.
doi: 10.1136/neurintsurg-2018-014516. Epub 2019 Jun 25.

Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation

Thomas Raphael Meinel #  1 , Johannes Kaesmacher #  2 , Panagiotis Chaloulos-Iakovidis  1 , Leonidas Panos  1 , Pasquale Mordasini  3 , Pascal J Mosimann  3 , Patrik Michel  4 , Steven Hajdu  5 , Marc Ribo  6 , Manuel Requena  6 , Christian Maegerlein  7 , Benjamin Friedrich  7 , Vincent Costalat  8 , Amel Benali  8 , Laurent Pierot  9 , Matthias Gawlitza  9 , Joanna Schaafsma  10 , Vitor M Pereira  11 , Jan Gralla #  3 , Urs Fischer #  1
Affiliations
Observational Study

Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation

Thomas Raphael Meinel et al. J Neurointerv Surg. 2019 Dec.

Abstract

Background: Performing mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence-based.

Objective: To compare patients' outcome, relative merits of achieving recanalization, and predictors of futile recanalization (FR) between BAO and anterior circulation large vessel occlusion (ACLVO) MT.

Methods: In the multicenter BEYOND-SWIFT registry (NCT03496064), univariate and multivariate (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI) outcome comparisons between BAO (N=165) and ACLVO (N=1574) were performed. The primary outcome was favorable outcome at 90 days (modified Rankin Scale, mRS 0-2). Secondary outcome included mortality, symptomatic intracranial hemorrhage (sICH) and FR. The relative merits of achieving successful recanalization between ACLVO and BAO were evaluated with interaction terms.

Results: MT in BAO was more often technically effective and equally safe in regards to mortality and sICH when compared to ACLVO. When adjusting for baseline differences, there was no significant difference between BAO vs ACLVO regarding rates of favorable outcome (aOR 0.986, 95%-CI 0.553 - 1.758). However, BAO were associated with increased rates of FR (aOR 2.146, 95%-CI 1.267 - 3.633). Predictors for FR were age, stroke severity, maneuver count and intracranial stenting. No significant heterogeneity on the relative merits of achieving successful recanalization on several outcome parameters were observed when comparing BAO and ACLVO.

Conclusions: In selected patients, similar outcomes can be achieved in BAO and ACLVO patients treated with MT. Randomized controlled trials comparing patient selection and interventional strategies seem warranted to avoid FR.

Trial registration number: NCT03496064.

Keywords: angiography; intervention; stroke; thrombectomy; thrombolysis.

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Conflict of interest statement

Competing interests: UF is a consultant for Medtronic and Stryker and co-principal investigator of the SWIFT DIRECT trial (Medtronic). JG is a global principal investigator of STAR (Solitaire FR Thrombectomy for Acute Revascularisation), clinical event commitee member of the PROMISE study (European Registry on the ACE Reperfusion Catheters and the Penumbra System in the Treatment of Acute Ischemic Stroke; Penumbra), and a principal investigator and consultant for the SWIFT DIRECT study (Medtronic) and receives Swiss National Science Foundation (SNSF) grants for magnetic resonance imaging in stroke. LPi serves as a consultant for Balt, Microvention, and Penumbra. JK has received travel grants from Pfizer and Stryker. MRi serves as a consultant for Medtronic, Stryker, Anaconda, Apta Targets, and Perflow Medical and as a speaker for Neuravi. PMi has received funding for speaker honoraria from Boehringer. He has served on scientific advisory boards also for Boehringer. He has received research grants from Bristol-Myers Squibb, Boehringer, and the Swiss Heart Foundation. VMP is a consultant for Stryker (SC for DAWN trial), Penumbra (SC for PROMISE study), BALT (proctorship of products unrelated to ischemic stroke), Phenox, Rapid Medical, Neurovasc and receives research a grant from Philips. All the other authors have nothing to disclose.

Figures

Figure 1
Figure 1
Comparison of outcomes of mechanical thrombectomy (MT) in posterior versus anterior circulation. Adjusted OR of MT in basilar artery occlusion versus anterior circulation large vessel occlusion for outcome parameters in the binary multivariable logistic regression analysis, adjusting for age, National Institutes of Health Stroke Scale score on admission, systolic blood pressure, prestroke independence, known onset, diabetes, arterial hypertension, smoking, previous stroke, imaging type, intravenous thrombolysis, and time from onset to admission. mRS, modified Rankin scale; sICH, symptomatic intracranial hemorrhage; TICI, Thrombolysis in Cerebral Infarction.
Figure 2
Figure 2
Effect of successful reperfusion on outcomes stratified for posterior versus anterior circulation. Adjusted OR of achieving successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b/3) for outcome parameters stratified for patients with basilar artery occlusion versus anterior circulation. Notice the broad CIs in the posterior circulation due to the small number of patients in whom recanalization could not be achieved. Numbers indicate the p value for interaction of IV thrombolysis and successful recanalization in the binary multivariable logistic regression analysis, including age, sex, National Institutes of Health Stroke Scale score on admission, and IV thrombolysis. BAO, basilar artery occlusion; mRS, modified Rankin scale; sICH, symptomatic intracranial hemorrhage.
See this image and copyright information in PMC

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