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Aging and disease    2021, Vol. 12 Issue (2) : 404-414     DOI: 10.14336/AD.2020.0704
Orginal Article |
Outcomes in Endovascular Therapy for Basilar Artery Occlusion: Intracranial Atherosclerotic Disease vs. Embolism
Wu Longfei1, Rajah Gary B2,3,4, Cosky Eric E5, Wu Xiling6, Li Chuanhui7, Chen Jian8, Zhao Wenbo1, Wu Di1, Ding Yuchuan5, Ji Xunming8,*
1Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.
2Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
3Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.
4Department of Neurosurgery, Munson Healthcare, Traverse City, Michigan, USA.
5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA.
6Department of Traditional Chinese Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
7Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China.
8Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Abstract  

Acute ischemic stroke due to basilar artery occlusion (BAO) carries a very poor prognosis. Functional outcomes in BAO patients undergoing endovascular therapy (EVT) may differ according to the specific pathological mechanisms. We aimed to explore the impact of the underlying pathological mechanisms on prognosis at 90-days and long-term follow-up in BAO patients treated with EVT. We analyzed consecutive BAO patients undergoing EVT from December 2012 to December 2018 at a single center (Xuanwu Hospital). Patients were classified into either an intracranial atherosclerotic disease (ICAD) group or an embolic group according to the corresponding angiographic findings. The baseline characteristics and functional outcomes were compared between the two groups. Multivariable logistic regression analysis was performed. Among the 167 patients enrolled, 78 patients (46.7%) were in the ICAD group and 89 patients (53.3%) were assigned to the embolic group. Overall, 149 patients (89.2%) achieved successful reperfusion post-EVT. There were no significant differences in functional outcomes at 90-days and long-term follow-up between the two groups. Similarly, a Kaplan-Meier survival analysis showed similar long-term survival probabilities (P = 0.438). The pathological mechanism was not associated with functional independence (OR, 1.818; 95% CI, 0.694-4.761; P = 0.224), favorable outcome (OR, 1.476; 95% CI, 0.592-3.681; P = 0.403), or mortality (OR, 1.249; 95% CI, 0.483-3.226; P = 0.646). However, based on subgroup analysis, embolic BAO versus ICAD was significantly associated with better functional independence in those aged 60 years and younger (OR, 4.513; 95% CI, 1.138-17.902). In this study, no differences in either 90-days or long-term functional outcomes between ICAD-related BAO and embolic BAO patients undergoing EVT were observed. However, in BAO patients aged ≤ 60 years, the pathological mechanism of embolism was associated with better functional independence.

Keywords stroke      endovascular therapy      basilar artery occlusion      intracranial atherosclerotic disease      embolism     
Corresponding Authors: Ji Xunming   
About author:

These authors contributed equally to this work.

Just Accepted Date: 24 July 2020   Issue Date: 24 March 2021
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Wu Longfei
Rajah Gary B
Cosky Eric E
Wu Xiling
Li Chuanhui
Chen Jian
Zhao Wenbo
Wu Di
Ding Yuchuan
Ji Xunming
Cite this article:   
Wu Longfei,Rajah Gary B,Cosky Eric E, et al. Outcomes in Endovascular Therapy for Basilar Artery Occlusion: Intracranial Atherosclerotic Disease vs. Embolism[J]. Aging and disease, 2021, 12(2): 404-414.
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http://www.aginganddisease.org/EN/10.14336/AD.2020.0704     OR
Overall (n=167)ICAD (n=78)Embolism (n=89)P value
Patient characteristics
Age, y, mean (SD)60.0 (11.8)58.5 (9.5)61.3 (13.3)0.112
Male, n (%)138 (82.6)66 (84.6)72 (80.9)0.527
BMI, mean (SD)26.0 (3.2)26.0 (3.1)26.0 (3.3)0.897
NIHSS, median (IQR)23 (15-33)22 (15-34)24 (15-33)0.665
pc-ASPECTS, median (IQR)8 (7-10)8 (7-10)8 (7-9)0.593
GCS, median (IQR)8 (5-12)7 (5-12)8 (5-11)0.795
Intravenous alteplase, n (%)34 (20.4)14 (17.9)20 (22.5)0.469
Systolic BP, median (IQR)150 (133-170)146 (130-168)150 (139-170)0.323
Diastolic BP, median (IQR)87 (76-95)85 (75-94)88 (79-96)0.334
Comorbidities, n (%)
Hypertension131 (78.4)59 (75.6)72 (80.9)0.410
Diabetes mellitus48 (28.7)27 (34.6)21 (23.6)0.116
Hyperlipidemia41 (24.6)15 (19.2)26 (29.2)0.135
Atrial fibrillation29 (17.4)3 (3.8)26 (29.2)<0.001
Smoking77 (46.1)38 (48.7)39 (40.4)0.526
Time intervals, min
From stroke onset to groin puncture, median (IQR)557 (365-783)578 (334-782)540 (381-798)0.890
From groin puncture to reperfusion, median (IQR)60 (46-78)72 (55-85)55 (40-74)<0.001
From stroke onset to reperfusion, median (IQR)621 (424-849)654 (402-851)579 (434-844)0.655
General anesthesia, n (%)103 (61.7)45 (57.7)58 (65.2)0.321
Occlusion sites, n (%)
Intracranial VA25 (15.0)15 (19.2)10 (11.2)0.149
Proximal BA51 (30.5)46 (59.0)5 (5.6)<0.001
Middle BA22 (13.2)9 (11.5)13 (14.6)0.559
Distal BA69 (41.3)8 (10.3)61 (68.5)<0.001
Collateral status, n (%)
ASITN/SIR grade 0-2122 (73.1)47 (60.3)75 (84.3)<0.001
ASITN/SIR grade 3-445 (26.9)31 (39.7)14 (15.7)
Number of passes, median (IQR)1 (1-2)2 (1-2)1 (1-2)0.192
Interventional procedures, n (%)
Stent retriever138 (82.6)67 (85.9)71 (79.8)0.297
Aspiration47 (28.1)20 (25.6)27 (30.3)0.501
Intra-arterial thrombolysis25 (15.0)12 (15.4)13 (14.6)0.888
Stenting59 (35.3)37 (47.4)22 (24.7)0.002
Balloon angioplasty31 (18.6)22 (28.2)9 (10.1)0.003
Reperfusion, n (%)
mTICI ≥ 2b149 (89.2)66 (84.6)83 (93.3)0.072
mTICI 378 (46.7)31 (39.7)47 (52.8)0.091
Table 1  Baseline characteristics.
Overall (n=167)ICAD (n=78)Embolism (n=89)P value
Primary outcome, median (IQR)
mRS at 90 days4 (2-6)5 (2-6)4 (2-6)0.802
Secondary outcomes, clinical, n (%)
90-day follow-up
Functional independence51 (30.5)21 (26.9)30 (33.7)0.342
Favorable outcome70 (41.9)31 (39.7)39 (43.8)0.594
Mortality53 (31.7)23 (29.5)30 (33.7)0.559
Long-term follow-up
Functional independence65 (38.9)29 (37.2)36 (40.4)0.665
Favorable outcome73 (43.7)33 (42.3)40 (44.9)0.732
Mortality65 (38.9)28 (35.9)37 (41.6)0.453
Secondary outcomes, safety, n (%)
Procedure-related complications36 (21.6)17 (21.8)19 (21.3)0.944
Serious adverse events
Symptomatic intracranial hemorrhage10 (6.0)5 (6.4)5 (5.6)0.830
New ischemic stroke6 (3.6)3 (3.8)3 (3.4)1
Progression of stroke11 (6.6)7 (9.0)4 (4.5)0.244
Pneumonia46 (27.5)24 (30.8)22 (24.7)0.383
Table 2  Primary and secondary outcomes.
Figure 1.  Functional outcomes, survival probability, and subgroups analysis. (A) No significant difference was observed in the distribution of modified Rankin Scale between the ICAD and embolism groups at either 90-days (P = 0.802) or long-term follow-up (P = 0.798). (B) There was no significant survival difference between the ICAD and embolism groups at long-term follow-up (log-rank, P = 0.438). (C) A forest plot shows that, in patients aged 60 years and younger, the difference in the clinical outcomes favored the embolism group (multivariable logistic regression analysis). However, there were no significant differences between the two groups among other subgroups. The cutoff values and categories of the subgroups were based on the median values. Abbreviations: ICAD, intracranial atherosclerotic disease; CI, Confidence Interval; NIHSS, National Institutes of Health Stroke Scale; pc-ASPECTS, posterior circulation Alberta Stroke Program Early Computed Tomography Score.
Functional independenceFavorable outcomeMortality

OR95% CIP valueOR95% CIP valueOR95% CIP value
Age0.9560.923-0.9910.0140.9770.944-1.0110.1771.0210.987-1.0570.231
NIHSS0.9320.897-0.968<0.0010.9240.891-0.959<0.0011.0571.018-1.0990.004
pc-ASPECTS1.5351.121-2.1010.0081.5701.178-2.0940.0020.7200.549-0.9440.018
Atrial fibrillation1.4130.461-4.3260.5450.9450.323-2.7630.9181.8520.638-5.3790.257
Time from stroke onset to reperfusion0.9980.997-1.0000.0160.9990.997-1.0000.0881.0010.999-1.0020.229
Occlusion sites0.8860.599-1.3110.5460.9860.675-1.4390.9410.6190.415-0.9230.019
Collateral status1.4820.598-3.6730.3862.1620.886-5.2780.0900.2410.086-0.6770.007
Reperfusion condition2.7490.495-15.2680.2486.4921.186-35.5430.0310.7330.234-2.2960.594
Pathological mechanism1.8180.694-4.7610.2241.4760.592-3.6810.4031.2490.483-3.2260.646
Table 3  Predictors of functional outcomes at 90-day follow-up (multivariable analysis).
Overall
(n=85)
ICAD
(n=45)
Embolism
(n=40)
P value
Patient characteristics
Age, y, mean (SD)51.2 (7.9)52.4 (7.3)49.7 (8.4)0.115
Male, n (%)77 (90.6)40 (88.9)37 (92.5)0.569
BMI, mean (SD)25.9 (3.5)26.1 (3.2)25.6 (3.9)0.519
NIHSS, median (IQR)24 (16-35)23 (16-34)25 (15-37)0.454
pc-ASPECTS, median (IQR)8 (8-10)8 (8-10)8 (7-9)0.831
GCS, median (IQR)6 (4-12)6 (4-13)7 (4-12)0.821
Intravenous alteplase, n (%)18 (21.2)11 (24.4)7 (17.5)0.434
Systolic BP, median (IQR)150 (130-170)147 (130-169)154 (140-170)0.346
Diastolic BP, median (IQR)88 (81-100)85 (81-97)90 (81-100)0.417
Comorbidities, n (%)
Hypertension68 (80.0)35 (77.8)33 (82.5)0.587
Diabetes mellitus23 (27.1)13 (28.9)10 (25.0)0.687
Hyperlipidemia15 (17.6)5 (11.1)10 (25.0)0.094
Atrial fibrillation7 (8.2)1 (2.2)6 (15.0)0.048
Smoking58 (68.2)32 (71.1)26 (65.0)0.546
Time intervals, min
From stroke onset to groin puncture, median (IQR)510 (330-734)522 (331-731)449 (290-750)0.619
From groin puncture to reperfusion, median (IQR)60 (47-79)72 (49-83)59 (39-76)0.041
From stroke onset to reperfusion, median (IQR)580 (398-791)596 (401-791)522 (361-793)0.526
General anesthesia, n (%)51 (60.0)26 (57.8)25 (62.5)0.657
Occlusion sites, n (%)
Intracranial VA11 (12.9)8 (17.8)3 (7.5)0.159
Proximal BA28 (32.9)26 (57.8)2 (5.0)<0.001
Middle BA12 (14.1)4 (8.9)8 (20.0)0.142
Distal BA34 (40.0)7 (15.6)27 (67.5)<0.001
Collateral status, n (%)
ASITN/SIR grade 0-261 (71.8)28 (62.2)33 (82.5)0.038
ASITN/SIR grade 3-424 (28.2)17 (37.8)7 (17.5)
Interventional procedures, n (%)
Stent retriever75 (88.2)41 (91.1)34 (85.0)0.383
Aspiration25 (29.4)12 (26.7)13 (32.5)0.556
Intra-arterial thrombolysis8 (9.4)6 (13.3)2 (5.0)0.272
Stenting33 (38.8)22 (48.9)11 (27.5)0.043
Balloon angioplasty16 (18.8)12 (26.7)4 (10.0)0.050
Reperfusion, n (%)
mTICI ≥ 2b77 (90.6)39 (86.7)38 (95)0.272
mTICI 337 (43.5)18 (40.0)19 (47.5)0.486
Table 4  Baseline characteristics among patients aged 60 years and younger.
Overall (n=85)ICAD (n=45)Embolism (n=40)P value
Primary outcome, median (IQR)
mRS at 90 days4 (2-6)4 (2-5)3 (1-6)0.382
Secondary outcomes, clinical, n (%)
90-day follow-up
Functional independence30 (35.3)12 (26.7)18 (45.0)0.077
Favorable outcome38 (44.7)17 (37.8)21 (52.5)0.173
Mortality22 (25.9)10 (22.2)12 (30.0)0.414
Long-term follow-up
Functional independence38 (44.7)17 (37.8)21 (52.5)0.173
Favorable outcome41 (48.2)20 (44.4)21 (52.5)0.458
Mortality27 (31.8)14 (31.1)13 (32.5)0.891
Secondary outcomes, safety, n (%)
Procedure-related complications22 (25.9)12 (26.7)10 (25.0)0.861
Serious adverse events
Symptomatic intracranial hemorrhage6 (7.1)2 (4.4)4 (10.0)0.414
New ischemic stroke5 (5.9)2 (4.4)3 (7.5)0.663
Progression of stroke7 (8.2)4 (8.9)3 (7.5)1
Pneumonia25 (29.4)13 (28.9)12 (30.0)0.911
Table 5  Primary and secondary outcomes among patients aged 60 years and younger.
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