Mechanical thrombectomy in basilar artery occlusion: influence of reperfusion on clinical outcome and impact of the first-line strategy (ADAPT vs stent retriever)

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Several randomized trials have been focused on patients with anterior circulation stroke, whereas few data on posterior circulation stroke are available. Thus, new mechanical thrombectomy (MT) strategies, including a direct-aspiration first-pass technique (ADAPT), remain to be evaluated in basilar artery occlusion (BAO) patients. The authors here assessed the influence of reperfusion on outcome in BAO patients and examined whether ADAPT improves the reperfusion rate compared with stent retriever devices.


Three comprehensive stroke centers prospectively collected individual data from BAO patients treated with MT. Baseline characteristics as well as radiographic and clinical outcomes were compared between the 2 MT strategies. The primary outcome measure was the rate of successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b–3. Favorable outcome was defined as a 90-day modified Rankin Scale score of 0–2.


Among the 100 adult patients included in the study, 46 were treated with first-line ADAPT (median age 61 years, IQR 53–71 years; stent-retriever rescue therapy was secondarily used in 12 [26.1%]) and 54 were treated with a primary stent retriever (median age 67 years, IQR 53–78 years). There was no difference in baseline characteristics between the 2 treatment groups, except for the rate of diabetes (19.6% vs 5.7%, respectively, p = 0.035). Successful reperfusion was achieved in 79% of the overall study sample. Overall, the rate of favorable outcome was 36.8% and 90-day all-cause mortality was 44.2%. Successful reperfusion positively impacted favorable outcome (OR 4.57, 95% CI 1.24–16.87, p = 0.023). A nonsignificant trend toward a higher successful reperfusion rate (unadjusted OR 2.56, 95% CI 0.90–7.29, p = 0.071) and a significantly higher rate of complete reperfusion (mTICI grade 3; unadjusted OR 2.59, 95% CI 1.14–5.86, p = 0.021) was found in the ADAPT group. The procedure duration was also significantly lower in the ADAPT group (median 45 minutes, IQR 34 to 62 minutes vs 56 minutes, IQR 40 to 90 minutes; p = 0.05), as was the rate of periprocedural complications (4.3% vs 25.9%, p = 0.003). Symptomatic intracranial hemorrhage (0.0% vs 4.0%, p = 0.51) and 90-day all-cause mortality (46.7% vs 42.0%, p = 0.65) were similar in the 2 groups.


Among BAO patients, successful reperfusion is a strong predictor of a 90-day favorable outcome, and the choice of ADAPT as the first-line strategy achieves a significantly higher rate of complete reperfusion with a shorter procedure duration.

ABBREVIATIONS ADAPT = a direct-aspiration first-pass technique; ASPECTS = Alberta Stroke Programme Early CT Score; BAO = basilar artery occlusion; mRS = modified Rankin Scale; MT = mechanical thrombectomy; mTICI = modified Thrombolysis in Cerebral Ischemia; NIHSS = National Institutes of Health Stroke Scale.

Article Information

Correspondence Benjamin Gory: CHRU Nancy, Hôpital Central, Nancy, France.

INCLUDE WHEN CITING Published online January 12, 2018; DOI: 10.3171/2017.7.JNS171043.

Disclosures Dr. Mazighi has been a consultant for Medtronic. Dr. Turjman has been a consultant for Codman, Balt, and Medtronic.

© AANS, except where prohibited by US copyright law.



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    Demonstration of ADAPT and a stent retriever thrombectomy in BAO. Pretreatment anterior angiograms (A and B) showing a complete BAO (arrows). Anterior native images showing the large-bore aspiration catheter (arrow, C) and stent retriever device (arrow, D) in the BA during the procedure. Postthrombectomy anterior angiograms (E and F) showing complete recanalization of the BA.

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    Flowchart of patient selection. ET = endovascular treatment.

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    Distribution of mTICI grade at the end of procedure (A) and the mRS score at 90 days (B), according to the first-line endovascular approach used.



Adams HP JrBendixen BHKappelle LJBiller JLove BBGordon DL: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35411993


Bracard SDucrocq XMas JLSoudant MOppenheim CMoulin T: Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:113811472016


Buuren SGroothuis-Oudshoorn K: mice: Multivariate imputation by chained equations in R. J Stat Softw 45:i032011


Chueh JYPuri ASWakhloo AKGounis MJ: Risk of distal embolization with stent retriever thrombectomy and ADAPT. J Neurointerv Surg 8:1972022016


Conover WJIman RL: Analysis of covariance using the rank transformation. Biometrics 38:7157241982


Dargazanli CConsoli ABarral MLabreuche JRedjem HCiccio G: Impact of modified TICI 3 versus modified TICI 2b reperfusion score to predict good outcome following endovascular therapy. AJNR Am J Neuroradiol 38:90962017


Dennis MMead GDoubal FGraham C: Determining the modified Rankin score after stroke by postal and telephone questionnaires. Stroke 43:8518532012


Efron BTibshirani RJ: An Introduction to the Bootstrap. New York: Chapman & Hall1993


Gerber JCDaubner DKaiser DEngellandt KHaedrich KMueller A: Efficacy and safety of direct aspiration first pass technique versus stent-retriever thrombectomy in acute basilar artery occlusion—a retrospective single center experience. Neuroradiology 59:2973042017


Gilberti NGamba MPremi ECosta AVergani VDelrio I: Endovascular mechanical thrombectomy in basilar artery occlusion: variables affecting recanalization and outcome. J Neurol 263:7077132016


Gory BEldesouky ISivan-Hoffmann RRabilloud MOng ERiva R: Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review. J Neurol Neurosurg Psychiatry 87:5205252016


Goyal MMenon BKvan Zwam WHDippel DWMitchell PJDemchuk AM: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:172317312016


Hacke WKaste MFieschi Cvon Kummer RDavalos AMeier D: Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 352:124512511998


Jung CYoon WAhn SJChoi BSKim JHSuh SH: The revascularization scales dilemma: is it right to apply the treatment in cerebral ischemia scale in posterior circulation stroke? AJNR Am J Neuroradiol 37:2852892016


Lapergue BBlanc RGory BLabreuche JDuhamel AMarnat G: Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA 318:4434522017


Lapergue BBlanc RGuedin PDecroix JPLabreuche JPreda C: A direct aspiration, first pass technique (ADAPT) versus stent retrievers for acute stroke therapy: an observational comparative study. AJNR Am J Neuroradiol [epub ahead of print]2016


Liu XXu GLiu YZhu WMa MXiong Y: Acute basilar artery occlusion: Endovascular Interventions versus Standard Medical Treatment (BEST) Trial-Design and protocol for a randomized, controlled, multicenter study. Int J Stroke 12:7797852017


Matsumoto HNishiyama HTetsuo YTakemoto HNakao N: Initial clinical experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter for acute ischemic stroke of the anterior circulation. J Neurointerv Surg [epub ahead of print]2016


Mokin MSonig ASivakanthan SRen ZElijovich LArthur A: Clinical and procedural predictors of outcomes from the endovascular treatment of posterior circulation strokes. Stroke 47:7827882016


Nagel SHerweh CKöhrmann MHuttner HBPoli SHartmann M: MRI in patients with acute basilar artery occlusion – DWI lesion scoring is an independent predictor of outcome. Int J Stroke 7:2822882012


Nguyen TNMalisch TCastonguay ACGupta RSun CHMartin CO: Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke 45:1411452014


Nogueira RGLutsep HLGupta RJovin TGAlbers GWWalker GA: Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380:123112402012


Rubin DB: Multiple Imputation for Nonresponse in Surveys. New York: Wiley1987


Saver JLJahan RLevy EIJovin TGBaxter BNogueira RG: Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:124112492012


Schonewille WJWijman CACMichel PRueckert CMWeimar CMattle HP: Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 8:7247302009


Schulz UGFischer U: Posterior circulation cerebrovascular syndromes: diagnosis and management. J Neurol Neurosurg Psychiatry 88:45532017


Singer OCBerkefeld JNolte CHBohner GHaring HPTrenkler J: Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol 77:4154242015


Son SChoi DSOh MKHong JKim SKKang H: Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion. J Neurointerv Surg 8:13182016


Strbian DSairanen TSilvennoinen HSalonen OKaste MLindsberg PJ: Thrombolysis of basilar artery occlusion: impact of baseline ischemia and time. Ann Neurol 73:6886942013


Turk ASSpiotta AFrei DMocco JBaxter BFiorella D: Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointerv Surg 6:2312372014


van der Hoeven EJSchonewille WJVos JAAlgra AAudebert HJBerge E: The Basilar Artery International Cooperation Study (BASICS): study protocol for a randomised controlled trial. Trials 14:2002013


van Houwelingen RCLuijckx GJMazuri ABokkers RPEshghi OSUyttenboogaart M: Safety and outcome of intra-arterial treatment for basilar artery occlusion. JAMA Neurol 73:122512302016


Zaidat OOYoo AJKhatri PTomsick TAvon Kummer RSaver JL: Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 44:265026632013


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