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• W4229033899 abstract "HomeStroke: Vascular and Interventional NeurologyVol. 2, No. 3Rescue Therapy in Acute Basilar Artery Strokes: When and What? Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessEditorialPDF/EPUBRescue Therapy in Acute Basilar Artery Strokes: When and What? Deepak Khatri, MD and David Altschul, MD Deepak KhatriDeepak Khatri , Department of Neurosurgery, , Montefiore Medical Center, , New York, , NY, Search for more papers by this author and David AltschulDavid Altschul *Correspondence to: David Altschul, MD, Department of Neurosurgery, Montefiore Medical Center, 3316 Rochambeau Ave, 1st Floor Bronx, New York, NY 10467.Email: E-mail Address: [email protected] , Department of Neurosurgery, , Montefiore Medical Center, , New York, , NY, Search for more papers by this author Originally published5 May 2022https://doi.org/10.1161/SVIN.121.000363Stroke: Vascular and Interventional Neurology. 2022;2:e000363Nonstandard abbreviation and acronymBAOacute basilar artery occlusionsAcute basilar artery occlusions (BAO) are challenging lesions with a high risk of morbidity and mortality despite treatment.1, 2 Endovascular therapy in acute BAO has rapidly evolved with an aggressive approach toward successful recanalization. The clinical outcomes of thrombectomy in BAOs vary significantly and remain poorly understood.In addition to the general predictors of poor outcomes in large vessel occlusions such as higher baseline National Institutes of Health Stroke Scale score, poor collateral flow, and a low Alberta stroke program early computed tomography (CT) score, the poor prognosis in acute BAO is also attributed to a higher (23%–41%) incidence of underlying atherosclerotic lesions.1, 2 Some studies observed comparable outcomes of BAO in patients with or without underlying atherosclerotic lesions,2, 3 whereas others recognize the high risk of thrombectomy failure and early reocclusion in intracranial atherosclerosis disease‐related BAOs frequently requiring a rescue strategy for successful reperfusion.4, 5 These rescue strategies may include the direct intraarterial use of alteplase or various glycoprotein IIb/IIIa inhibitors for clot lysis locally, angioplasty via balloon or other newer devices, and intracranial stenting.Despite prolonged procedure times, the rates of successful recanalization have improved with the use of rescue therapy in acute BAO. However, no consensus presently exists regarding the timing of initiating a rescue or an “ideal” technique. Besides, the rescue treatment is largely influenced by the training and experience of the neurointerventionalist, cost, and local availability.Lun et al have retrospectively reviewed a cohort of 277 patients with acute BAO from the Endovascular Treatment in Ischemic Stroke registry who underwent mechanical thrombectomy.6 A total of 74/277 (26.7%) patients subsequently required “rescue therapy” in the form of intraarterial injection of glycoprotein IIb/IIIa inhibitors or alteplase, balloon angioplasty, or stenting for recanalization. Successful reperfusion (modified thrombolysis in cerebral infarction 2B or better), functional outcome (modified Rankin scale 0–2), and mortality at 3 months were evaluated as primary outcome measures in this study. The study demonstrates a poor survival (43.2% versus 64%) with lesser chances to gain functional independence (16.2% versus 41.4%) in patients requiring rescue therapy.These findings are in contrast with previously published data from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL‐ACT) registry, which reported a significantly lower mortality rate (18.5% versus 58.3%; P=0.006) with better functional clinical outcomes (51.9% versus 16.7%; P=0.023) in patients who received rescue therapy in the form of stenting after failed mechanical thrombectomy.7 However, the ANGEL‐ACT registry did not consider balloon angioplasty and glycoprotein IIb/IIIa inhibitors as a rescue.7 In addition, the patients with modified Rankin scale 3 were also included in the “better” functional outcome group. In another multicenter retrospective study including 212 patients with BAO, the authors resorted to “rescue treatment” in 55 patients: 31 were treated with angioplasty with or without stenting and intraarterial injection of tirofiban was performed in 24 patients.8 Successful reperfusion was observed in 49/55 (89.1%) with almost half (49.1%) achieving an independent functional outcome (modified Rankin scale 0–2) at 3 months. This study considered underlying, severe (≥70%) atherosclerotic stenosis as a deciding factor for initiating a rescue. Even though the recanalization results (77% modified thrombolysis in cerebral infarction 2B or better) in the present study are comparable, the heterogeneity in findings from these studies suggests a huge gap of knowledge in terms of patient selection and treatment decisions in acute BAO. Although the previous studies established the safety and feasibility of rescue stenting, this study used stent as a rescue measure in only 20/74 (27%) of their cases. Therefore, it indirectly reflects the effectiveness of stent as a better rescue modality as compared with intra‐arterial drugs and balloon angioplasty.The present study also highlights a higher incidence (62.2% versus 18.7%) of underlying atherosclerotic lesions in patients who required rescue either because of failure to achieve a successful recanalization (56.8%) or reocclusion after 1 or more successful passes (43.2%). It corresponds with similar findings from the BASILAR (Acute Basilar Artery Occlusion Study) study, Kang et al study, and the ANGEL‐ACT registry.7–9 Concurrently, a higher risk (10.8% versus 2.5%) of failure for final recanalization (modified thrombolysis in cerebral infarction 0) despite rescue therapy was observed.It is interesting to note that clinical outcomes at 3 months were not affected by the modified thrombolysis in cerebral infarction scores before rescue. Therefore, it may indirectly indicate the role of some other factor apart from underlying etiology in determining the final clinical outcomes.There is a lack of agreement between the number of passes versus lack of reperfusion as a determining factor in stroke thrombectomy outcomes. Some suggest the importance of successful reperfusion irrespective of multiple passes,10,11 whereas others highlight the adverse effects of each additional pass.12,13 This controversy further evolves in the setting of posterior circulation strokes because of paucity of data and lack of strong evidence.Even though, the chances of successful reperfusion decreased with additional passes. It is notable that despite successful reperfusion in the majority (77%) of the patients in the rescue therapy group, more than half of them (56.8%) died within 3 months follow‐up. Based on this discrepancy, the authors analyzed the impact of the number of passes before initiation of rescue therapy and found a significant correlation of higher mortality with each pass. Additionally, the study demonstrated an inverse relationship between good functional outcomes and the number of passes. Patients with more than 3 passes before rescue therapy had 10 times higher odds of mortality and those who survived remained functionally dependent (modified Rankin scale≥3) for life.Previous studies have demonstrated a higher risk of morbidity and mortality associated with multiple passes.14 An association with increased risk of endothelial damage with subsequent complications has been clearly established in in vitro cell studies and animal models.15 Atherosclerotic disease may be a setting in which small endothelial injury seen with thrombectomy is less well tolerated than stroke from cardioembolic origin. Even though no statistical difference was observed in the average number of attempts (3 versus 2; P=0.46) prior to stenting versus nonstenting rescue treatment options in this study, the mortality was highest (75%) in the stenting group with dismal (5%) chances of functional independence. A relatively small number of patients in this subgroup may have skewed the results. Nonetheless, the discrepancy between these poor outcomes despite significantly better (80% versus 69.2%; P=0.003) chances of achieving successful reperfusion as compared with nonstenting rescue options do require further exploration.Owing to the inherent limitations of a small, nonrandomized retrospective study, no definitive conclusions can be drawn. However, these findings support the use of rescue therapy after failed mechanical thrombectomy for acute BAO. Specifically, the study highlights the adverse impact of additional passes before the decision for rescue. Despite the discrepancy in successful recanalization and clinical outcomes, an early transition to rescue therapy is suggested. Considering these results and earlier studies, an individualized approach with a lower threshold to initiation of rescue therapy should be adopted, particularly if the underlying etiology does not appear to be cardioembolic in origin after the first pass. Future studies to develop a standardized protocol with judicious patient selection criteria may help improve the odds of functional independence.Multiple avenues in the treatment of acute BAO remain unexplored regarding the timing and choice of rescue therapy. A small incidence and lack of robust evidence at present to favor the choice of one rescue modality over another or the order of their use are the major hindrance in this direction. Therefore, a multi‐institutional prospective study to compare these techniques directly would be of potential interest.Sources of FundingNone.DisclosuresNone.AcknowledgmentsNone.Footnotes*Correspondence to: David Altschul, MD, Department of Neurosurgery, Montefiore Medical Center, 3316 Rochambeau Ave, 1st Floor Bronx, New York, NY 10467.Email: [email protected]orgThe opinions expressed in this article are not necessarily those of the American Heart Association, or the Society of Vascular and Interventional Neurology.References1 Ma G, Sun X, Tong X, Jia B, Huo X, Luo G, Wang B, Deng Y, Gao F, Song L, et al. Safety and efficacy of direct angioplasty in acute basilar artery occlusion due to atherosclerosis. Front Neurol. 2021; 12:651653. https://doi.org/10.3389/fneur.2021.651653Google Scholar2 Lee YY, Yoon W, Kim SK, Baek BH, Kim GS, Kim JT, Park MS. Acute basilar artery occlusion: differences in characteristics and outcomes after endovascular therapy between patients with and without underlying severe atherosclerotic stenosis. AJNR Am J Neuroradiol. 2017; 38:1600–1604. https://doi.org/10.3174/ajnr.A5233Google Scholar3 Zhang X, Luo G, Jia B, Mo D, Ma N, Gao F, Zhang J, Miao Z. Differences in characteristics and outcomes after endovascular therapy: a single‐center analysis of patients with vertebrobasilar occlusion due to underlying intracranial atherosclerosis disease and embolism. Interv Neuroradiol. 2019; 25:254–260. https://doi.org/10.1177/1591019918811800Google Scholar4 Siebert E, Bohner G, Zweynert S, Maus V, Mpotsaris A, Liebig T, Kabbasch C. Revascularization techniques for acute basilar artery occlusion: technical considerations and outcome in the setting of severe posterior circulation steno‐occlusive disease. Clin Neuroradiol. 2019; 29:435–443. https://doi.org/10.1007/s00062‐018‐0683‐3Google Scholar5 Kim YW, Hong JM, Park DG, Choi JW, Kang DH, Kim YS, Zaidat OO, Demchuk AM, Hwang YH, Lee JS. Effect of intracranial atherosclerotic disease on endovascular treatment for patients with acute vertebrobasilar occlusion. AJNR Am J Neuroradiol. 2016; 37:2072–2078. https://doi.org/10.3174/ajnr.A4844CrossrefMedlineGoogle Scholar6 Lun R, Walker G, Weisenburger‐Lile D, Lapergue B, Guenego A, Heran N, Siu W, Dargazanli C, Benali A, Gory B, et al. Impact of number of passes before rescue therapy in thrombectomy for basilar artery strokes. Stroke: Vasc Interv Neurol. 2022; 2:e000118. https://doi.org/10.1161/SVIN.121.000118LinkGoogle Scholar7 Luo G, Gao F, Zhang X, Jia B, Huo X, Liu R, Chi MS, Ma G, Peng G, Zhang J, et al. Intracranial stenting as rescue therapy after failure of mechanical thrombectomy for basilar artery occlusion: data from the ANGEL‐ACT registry. Front Neurol. 2021; 12:739213. https://doi.org/10.3389/fneur.2021.739213Google Scholar8 Kang DH, Jung C, Yoon W, Kim SK, Baek BH, Kim JT, Park MS, Kim YW, Hwang YH, Kim YS, et al. Endovascular thrombectomy for acute basilar artery occlusion: a multicenter retrospective observational study. J Am Heart Assoc. 2018; 7:e009419. https://doi.org/10.1161/jaha.118.009419LinkGoogle Scholar9 Zi W, Qiu Z, Wu D, Li F, Liu H, Liu W, Huang W, Shi Z, Bai Y, Liu Z, et al. Assessment of endovascular treatment for acute basilar artery occlusion via a nationwide prospective registry. JAMA Neurol. 2020; 77:561–573. https://doi.org/10.1001/jamaneurol.2020.0156Google Scholar10 Mohammaden MH, Haussen DC, Pisani L, Al‐Bayati AR, Bianchi N, Liberato B, Bhatt N, Jillella D, Frankel MR, Nogueira RG. Lack of reperfusion rather than number of passes defines futility in stroke thrombectomy: a matched case‐control study. Stroke. 2021; 52:2757–2763. https://doi.org/10.1161/strokeaha.120.033539LinkGoogle Scholar11 Tonetti DA, Desai SM, Casillo S, Stone J, Brown M, Jankowitz B, Jovin TG, Gross BA, Jadhav A. Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy. J Neurointerv Surg. 2020; 12:548–551. https://doi.org/10.1136/neurintsurg‐2019‐015330CrossrefGoogle Scholar12 García‐Tornel Á, Requena M, Rubiera M, Muchada M, Pagola J, Rodriguez‐Luna D, Deck M, Juega J, Rodríguez‐Villatoro N, Boned S, et al. When to stop. Stroke. 2019; 50:1781–1788. https://doi.org/10.1161/strokeaha.119.025088LinkGoogle Scholar13 Baek JH, Kim BM, Heo JH, Nam HS, Kim YD, Park H, Bang OY, Yoo J, Kim DJ, Jeon P, et al. Number of stent retriever passes associated with futile recanalization in acute stroke. Stroke. 2018; 49:2088–2095. https://doi.org/10.1161/strokeaha.118.021320LinkGoogle Scholar14 Cao J, Mo Y, Chen R, Shao H, Xuan J, Peng Y, Zhu X. Predictors of functional outcome and mortality in endovascular treatment for acute basilar artery occlusion: a single‐centre experience. Front Neurol. 2021; 12:731300. https://doi.org/10.3389/fneur.2021.731300Google Scholar15 Teng D, Pannell JS, Rennert RC, Li J, Li YS, Wong VW, Chien S, Khalessi AA. Endothelial trauma from mechanical thrombectomy in acute stroke: in vitro live‐cell platform with animal validation. Stroke. 2015; 46:1099–1106. https://doi.org/10.1161/strokeaha.114.007494AbstractGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2022Vol 2, Issue 3Article InformationMetrics © 2022 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.121.000363 Originally publishedMay 5, 2022 Keywordsbasilar occlusioneditorialrescuethrombectomyoutcomePDF download" @default.
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