The treatment of acute intracranial vertebrobasilar artery occlusion (VBO) has been described but often with poor results. The authors of this study set out to evaluate their institution's outcomes following multimodal treatment of VBO.
They retrospectively reviewed their endovascular database for all patients treated for acute intracranial VBO between December 2004 and June 2010. Twenty-four patients were identified. Two patients were excluded from evaluation—one because of incomplete medical records and one because the etiology was basilar stenosis and not stroke. Occlusion location, hypercoagulable causes, time to endovascular treatment, time to revascularization, comorbidities, devices used, procedural anticoagulation, and outcomes were analyzed.
Among the 22 eligible study patients, the mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15.3. The mean time from presentation to initiation of the endovascular procedure was 4.77 hours. The mean time for recanalization from the start of angiography was 1.63 hours. In 16 patients (73%), revascularization was successful (Thrombolysis in Myocardial Infarction [TIMI] score of 2 or 3). Thirteen (59%) of the 22 patients were discharged to home or a rehabilitation facility. One patient was transferred to a chronic care facility. The overall survival rate was 64%. The average NIHSS score for the 14 surviving patients at discharge was 3.9. At the follow-up (average 14.5 months, range 1–58 months), 10 patients (71%) had achieved good outcomes (modified Rankin Scale [mRS] score ≤ 2) and 4 (29%) had poor outcomes (mRS Score 3–6).
Published case series have historically shown poor outcomes and high mortality rates in association with the treatment of acute VBO, prompting surgeons to be less aggressive in the treatment of this disease than they might be otherwise. Data in this series show that the revascularization of posterior circulation occlusions is feasible and that good outcomes and lower mortality rates with newer endovascular technologies are possible, and thus more prompt and aggressive treatment of this disease may be warranted.
Abbreviations used in this paper:MERCI = Mechanical Embolus Removal in Cerebral Ischemia; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; PROACT = Prolyse in Acute Cerebral Thromboembolism; TIMI = Thrombolysis in Myocardial Infarction; VBO = vertebrobasilar artery occlusion.
ArnoldMNedeltchevKSchrothGBaumgartnerRWRemondaLLoherTJ: Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. J Neurol Neurosurg Psychiatry75:857–8622004
EckertBKochCThomallaGKucinskiTGrzyskaURoetherJ: Aggressive therapy with intravenous abciximab and intra-arterial rtPA and additional PTA/stenting improves clinical outcome in acute vertebrobasilar occlusion: combined local fibrinolysis and intravenous abciximab in acute vertebrobasilar stroke treatment (FAST): results of a multicenter study. Stroke36:1160–11652005
FurlanAHigashidaRWechslerLGentMRowleyHKaseC: Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial Prolyse in Acute Cerebral Thromboembolism. JAMA282:2003– 20111999
KashiwagiJKiyosueHHoriYOkaharaMTanoueSSagaraY: Endovascular recanalization of acute intracranial vertebrobasilar artery occlusion using local fibrinolysis and additional balloon angioplasty. Neuroradiology52:361–3702010
MathewsMSSharmaJSnyderKVNatarajanSKSiddiquiAHHopkinsLN: Safety, effectiveness, and practicality of endovascular therapy within the first 3 hours of acute ischemic stroke onset. Neurosurgery65:860–8652009
MoccoJHanelRASharmaJHauckEFSnyderKVNatarajanSK: Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods. Clinical article. J Neurosurg112:557–5622010
NoufalMSchmidleyJWErdemEKeyrouzSG: Basilar artery occlusion treated with mechanical thrombectomy beyond eight hours with successful recanalization and good functional outcomes. Cerebrovasc Dis27:614–6152009