Endovascular Treatment in Acute Basilar Artery Occlusion “Experience in Indian Patients”

Background: To assess the efficacy and feasibility of endovascular treatment in acute basilar artery occlusion. Method(s): Total 90 patients who underwent treatment with low-dose intraarterial alteplase combined with mechanical clot disruption for basilar artery occlusion were studied over period of ten years. All patients undergone either cerebral CT/MR with cerebral angiography followed by intraarterial treatment. We did not use intravenous route in all patients. After diagnosis of an occlusion on diagnostic angiography, an end-hole microcatheter over a microguide wire was advanced through 6-f guide catheter into occlusion site. The microcatheter tip was placed into the thrombus, and then a 20 mg bolus of alteplase was manually infused over 3 to 5 minutes. Mechanical clot disruption by multiple passes of the microwire with microcather through the clot was done after 20 mg bolus of alteplase. Followed by withdrawal of the microwire from the microcatheter, an additional 10 mg was manually infused for 3 to 5 minutes through microcatheter at the site of the remaining thrombus. Mechanical clot disruption using microcatheter and microwire was performed in remaining thrombus. Patients in whom distal migration of thrombus into posterior cerebral artery was additionally infused the 10 mg of alteplase through microcatheter. Percutaneous angioplasty or/and stent insertion performed in patients who were not achieved the complete recanalization. Recanalization status was classified according to the thrombolysis in cerebral ischemia (TICI) scale and recanalization was defined as TICI grades II or III. Variable parameters like age, sex, time to treatment, alteplase dose, duration of the procedure, recanalization, and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed on admision and at discharge of national institutes of health stroke scale (NIHSS) score, at 3 months after treatment modified rankin score (mRS). Result(s): 90 patients with acute basilar artery occlusion (32 women, 58 men) with a median age of 69 years (range, 44 -85 years). The median NIHSS score was 14.4 (range, 2-33) on admission and median time from symptom onset to intraarterial alteplase therapy was 320 minutes (range, 160-820 minute). The median intraarterial alteplase treatment duration was 20 minute (range, 10-25) and the alteplase dose was 20- 50 mg (median, 35 mg). Of these patients, sixteen patients were performed the additional injection of alteplase due to distal migration of thrombus into the posterior cerebral artery. Five patients were the severe stenosis of basilar artery after alteplase infusion and mechanical clot disruption with microcatheter and microwire. Of these patients, three patients were performed the stent placement after angioplasty and two patients were performed the angioplasty. Recanalization (TICI grade II or III) was achieved in 85 patients (94.44%). TICI grade III was occurred in 43 patients (47.78%) include, and TICI grade II was achieved in 42 patients (46.67%). Five patients (5.55%) was failed the recanalization of posterior circulation. Of these failed treatment patients, three patients had a massive thrombus into the vertebrobasilar artery, one was stopped the treatment due to procedure-related subarachnoid hemorrhage, and one had a diffuse and long segmental stenosis of basilar artery. There was symptomatic hemorrhage in four patients. Two patients were occurred the procedure-related hemorrhage. Eight patients (8.89%) died within one-week after procedure. At discharge, the median NIHSS score was 7.2 (range, 0-27). The NIHSS score of 55 patients was improved. In 30 patients, the NIHSS score was increased. At the 3-month follow-up, the functional outcome was favorable (MRS, 0-2) in 50 (55.56%) of the 90 patients. Unfavorable (MRS, 3-6) in 40 (44.44%) patients. Conclusion(s): We concluded from the study that low-dose intraarterial thrombolytics with mechanical clot disruption is feasible, safe and effective treatment for the acute basilar artery occlusion. A high rate of recanalization, high rate of survival rate and good functional outcome can be achieved.

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Artikel online veröffentlicht:
11. Mai 2021