Basilar occlusion

The In-Time Retriever (Boston Scientific, Natick, MA) has four to six wire loops and tends to bow when opened but has no specific opening to capture the embolus. This device has been successfully used in a case of an MCA occlusion resistant to thrombolytics and balloon angioplasty, as well as in cases of basilar occlusion. The TriSpan (Boston Scientific, Natick, MA), a neck bridge device consisting of three nitinol loops originally designed to treat wide-necked aneurysms, has also been used to treat basilar occlusions. ... 

There are few data to guide intra-arterial thrombolysis in the posterior circulation. Observational studies and the one existing very small randomized controlled trial of intraarterial thrombolysis for basilar occlusion show no evidence of benefit (Arnold et al 2004, Lindsberg and Mattie 2006). However, given the poor outcome of basilar occlusion, many clinicians believe thrombolysis is justified, even many hours after the event, particularly since there is some evidence that the ischemic penumbra and thus the available window for thrombolysis may extend for many hours in the posterior circulation. 

Fig. 6.1 Basilar occlusion, (a) The T2 weighted image shows loss of the signal flow void in the basilar artery in this patient with basilar occlusion and hyperacute pontine infarct. No parenchymal abnormality is noted at this early time point, (b) Coronal MIP image from the CT angiogram demonstrates the occlusion as a filling defect (arrow)...

Smith WS (2007) Intra-arterial thrombolytic therapy for acute basilar occlusion pro. Stroke 38 701-703... 

Lindsberg and Mattle ° recently analyzed published case series reporting on the outcome of basilar artery occlusion (BAO) after lAT or IV thrombolysis. In 420 BAO patients treated with IV thrombolysis (76) and lAT (344), death or dependency was equally common 78% (59 of 76) and 76% (260 of 344). Recanalization was achieved more frequently with lAT (225 of 344 65%) than with IV thrombolysis (40 of 76 53% p = 0.05), but survival rates after IV thrombolysis (38 of 76 50%) and lAT (154 of 344 45%) were equal (p = 0.48). A total of 24% of patients treated with lAT and 22% treated with IV thrombolysis reached good outcomes (p = 0.82). Without recanalization, the likelihood of achieving a good outcome was close to nil (2%). The authors conclude that recanalization occurs in more than half of BAO patients treated with lAT or IV thrombolysis, and 45-55% of survivors regain functional independence. They advised that hospitals not equipped for lAT should consider setting up IV thrombolysis protocols for BAO since the effect of IVT did not appear to be much different from the effect of lAT. 

The MERCI trial was a prospective single-arm, multicenter trial designed to test the safety and efficacy of the MERCI clot retrieval device to restore the patency of intracranial arteries in the first 8 hours of an acute stroke. All patients were ineligible for IV rt-PA. The occlusion sites were the intracranial vertebral artery, basilar... 

A significant neurologic deficit expected to result in long-term disability, and attributable to large vessel occlusion (basilar, vertebral, internal carotid, or middle cerebral artery M1 or M2 branches). 

Stenting of an acutely occluded intracranial vessel may provide fast recanalization by entrapping the thrombus between the stent and the vessel wall. A recent study in which 19 patients with acute occlusions at the ICA terminus n = 8), M1/M2 (n = 7), or basilar artery (n = 4) were treated with balloon-expandable stents showed a TIMI 2 and 3 recanalization rate of 79% and no symptomatic intracranial hemorrhages (Fig. 4.5). ... 

The Penumbra stroke system (Penumbra Inc., San Leandro, CA) includes two different revascularization options (1) thrombus debulking and aspiration may be achieved by a reperfusion catheter that aspirates the clot while a separator device fragments it, and (2) direct thrombus extraction may be performed by a ring retriever while a balloon guide catheter is used to temporarily arrest flow. This system has been tested in a pilot trial in Europe. Twenty patients (mean NIHSS 21) with a total of 21 vessel occlusions (7 ICA, 5 MCA, and 9 Basilar) were treated up to 8 hours after symptom onset. Recanalization prior to lA lysis was achieved in all cases (48% TIMI 2 52% TIMI 3). Seven patients were also treated with lA UK or rt-PA. Good outcome at 30 days (defined as mRS < 2 or NIHSS 4-point improvement) was demonstrated in 42%. The mortality rate was 45%, but there were no device-related deaths. There was one asymptomatic SAH and three symptomatic ICHs. A prospective, single-arm, multicenter trial is being conducted in the United States and Europe currently. 

Yu W, Binder D, Foster-Barber A, Malek R, Smith WS, Higashida RT. Endovascular embolectomy of acute basilar artery occlusion. Neurology 2003 61 1421-1423. 

Lindsberg PJ, Mattie HP. Therapy of basilar artery occlusion a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke 2006 37 922-928. 

Eckert B, Koch C, Thomalla G, Roether J, Zeumer H. Acute basilar artery occlusion treated with combined intravenous Abciximab and intra-arterial tissue plasminogen activator report of 3 cases. Stroke 2002 33 1424-1427. 

Bergui M, Stura G, Daniele D, Cerrato P, Berardino M, Bradac GB. Mechanical thrombolysis in ischemic stroke attributable to basilar artery occlusion as first-line treatment. Stroke 2006 37 145-150. 

Unlabeled Uses Acute peripheral occlusive disease, basilar artery occlusion, cerebral infarction, deep vein thrombosis, femoropopliteal artery occlusion, mesenteric or subclavian vein occlusion, pleural effusion (parapneumonic)... 

Biller J, Haberland C, Toffol GJ, O Reilly D, Tentler RL. Basilar artery occlusion in an adolescent girl a risk of oral contraceptives J Child Neurol 1986 l(4) 347-50. 

In most patients with BA thrombosis, obstruction is limited to the mid portion of the basilar artery (Fig. 1.2) (Voetsch et al. 2004). Embolic occlusion rather than thrombotic occlusion mainly blocks the distal part of the BA when it divides into the PCAs. The distal BA supplies the midbrain and... 

Fisher CM (1965c) The vascular lesion in lacunae. Trans Am Neurol Assoc 90 243-5 243-245 Fisher CM (1967) A lacunar stroke. The dysarthria-clumsy hand syndrome. Neurology 17 614-617 Fisher CM (1977) Bilateral occlusion of basilar arterybranches. 

Fisher CM, Caplan LR (1971) Basilar artery branch occlusion a cause of pontine infarction. Neurology 21 900-905 Fisher CM, Curry HB (1964) Pure motor hemiplegia. Trans Am Neurol Assoc 89 94-7 94-97... 

Ostrem JL, Saver JL, Alger JR, Starkman S, Leary MC, Duck-wiler G, Jahan R, Vespa P, Villablanca JP, Gobin YP, Vin-uela F, Kidwell CS (2004) Acute basilar artery occlusion diffusion-perfusion MRI characterization of tissue salvage... 

The most feared vertebrobasilar stroke is occlusion of the basilar artery. Patients with lesions in the basilar artery are five times more likely to have a poor outcome independent of other factors (Glass et al. 2002). The importance of its early recognition is the possibility of performing intra-arterial throm-... 

Della Sala S, Francescani A, Spinnler H (2002) Gait apraxia after bilateral supplementary motor area lesion. J Neurol Neurosurg Psychiatry 72 77-85 Devuyst G, Bogousslavsky J, Meuli R et al (2002) Stroke or transient ischemic attacks with basilar artery stenosis or occlusion clinical patterns and outcome. Arch Neurol 59 567-573... 

Atheromatous medium-sized arteries at the base of the brain, particularly the vertebral and basilar arteries, may become affected by dolichoectasia. The arteries are widened, tortuous and elongated and may be visualized on MRI or, if the walls are calcified, on CT. Dolichoectasia is usually found in elderly patients with hypertension and diabetes and it may cause stroke through embolization of thrombus or by occlusion of small branch arteries. In younger patients, it should raise the possibility of Fabry s disease. 

In Japanese, moyamoya means puff of smoke and describes the characteristic radiological appearance of the fine anastomotic collaterals that develop from the perforating and pial arteries at the base of the brain, the orbital and ethmoidal branches of the external carotid artery and the leptomeningeal and transdural vessels in response to severe stenosis or occlusion of one, or both, distal internal carotid arteries (Yonekawa and Khan 2003). The circle of Willis and the proximal cerebral and basilar arteries may also be involved. 

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