Basilar Artery Occlusion: Clinical Management and Therapy
DOI:
https://doi.org/10.7175/cmi.v12i1.1363Keywords:
Stroke, Basilar artery occlusion, Headache disorders, Magnetic resonance image, Thrombolysis.Abstract
Basilar artery occlusion is a potentially life-threatening subset of the larger category of posterior circulation strokes, carrying > 80% fatality rate without treatment. This condition accounts for about 1% to 4% of all ischemic strokes and is generally related to local atherothrombosis or cardioembolism.
Diagnosis can be challenging because presenting symptoms are often non focal, such as headache, dizziness, and vertigo. The onset of the symptomatology can be abrupt without preceding events, abrupt with prodromal symptoms, or progressive and stuttering. Finally, the severity of clinical presentation may range from isolated cranial nerve palsies to tetraplegia, locked-in state, or coma.
If basilar artery occlusion is readily recognized and confirmed with the aid of neuroimaging, intravenous thrombolysis or endovascular treatment can be undertaken immediately in order to recanalize the occluded artery and thus reduce mortality and improve outcome.
References
Markus HS, van der Worp HB, Rothwell PM. Posterior circulation ischaemic stroke and transient ischaemic attack: diagnosis, investigation, and secondary prevention. Lancet Neurol 2013; 12: 989-98; https://doi.org/10.1016/S1474-4422(13)70211-4
Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol 2014; 5: 1-16; https://doi.org/10.3389/fneur.2014.00030
Mattle HP, Arnold M, Lindsberg PJ, et al. Basilar artery occlusion. Lancet Neurol 2011; 10: 1002-14; https://doi.org/10.1016/S1474-4422(11)70229-0
Caplan LR, Amarenco P, Rosengart A, et al. Embolism from vertebral artery origin occlusive disease. Neurology 1992; 42: 1505-12
Meyding-Lamadé U, Rieke K, Krieger D, et al. Rare diseases mimicking acute vertebrobasilar artery thrombosis. J Neurol 1995; 242: 335-43
Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005; 352: 2618-26; https://doi.org/10.1056/NEJMra041544
Sparaco M, Feleppa M. Reversible stenosis of the basilar artery due to transient hemoconcentration: a case report. Neurol Disord Therap 2018; 2; https://doi.org/10.15761/NDT.1000127
Ferbert A, Bruckmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke 1990; 21: 1135-42
Demel LD, Broderick JP. Basilar artery occlusion: un update. Neurohospitalist 2015; 5: 142-50; https://doi.org/10.1177/1941874415583847
Schneider JI, Olshaker JS. Vertigo, vertebrobasilar disease, and posterior circulation ischemic stroke. Emerg Med Clin North Am 2012; 30: 681-93; https://doi.org/10.1016/j.emc.2012.06.004.
Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40: 3504-10; https://doi.org/10.1161/STROKEAHA.109.551234
Vestergaard K, Andersen G, Nielsen MI, et al. Headache in stroke. Stroke 1993; 24: 1621-4
Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke 2006; 37: 922-8; https://doi.org/10.1161/01.STR.0000202582.29510.6b
Caplan LR. “Top of the basilar” syndrome. Neurology 1980; 30: 72-9
Mehler MF. The rostral basilar artery syndrome: diagnosis, etiology, prognosis. Neurology 1989; 39: 9-16
Von Campe G, Regli F, Bogousslavsky J. Heralding manifestations of basilar artery occlusion with lethal or severe stroke J Neurol Neurosurg Psychiatry 2003; 74: 1621-6; https://doi.org/10.1136/jnnp.74.12.1621
Ropper AH. ‘Convulsions’ in basilar artery occlusion. Neurology 1988; 38: 1500-1
Kirchmann M, Thomsen LL, Olesen J. Basilar-type migraine: clinical, epidemiologic, and genetic features. Neurology 2006; 66: 880-6; https://doi.org/10.1212/01.wnl.0000203647.48422.dd
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33: 629-808; https://doi.org/10.1177/0333102413485658
Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 2008; 39: 2485-90; https://doi.org/10.1161/STROKEAHA.107.511162
Hwang DY, Silva GS, Furie KL, et al. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med 2012; 42: 559-65; https://doi.org/10.1016/j.jemermed.2011.05.101
van der Hoeven EJ, McVerry F, Vos JA, et al. Collateral flow predicts outcome after basilar artery occlusion: the posterior circulation collateral score. Int J Stroke 2016; 11: 768-75; https://doi.org/10.1177/1747493016641951
Alemseged F, Shah DG, Diomedi M, et al. The Basilar Artery on Computed Tomography Angiography Prognostic Score for Basilar Artery Occlusion. Stroke 2017; 48: 631-7; https://doi.org/10.1161/STROKEAHA.116.015492
van Seeters T, Biessels GJ, van der Schaaf IC, et al. Prediction of outcome in patients with suspected acute ischaemic stroke with CT perfusion and CT angiography: the Dutch acute stroke trial (DUST) study protocol. BMC Neurol 2014; 14: 37; https://doi.org/10.1186/1471-2377-14-37
Saver JL, Goyal M, Bonafe A, et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. N Engl J Med 2015; 372: 2285-95; https://doi.org/10.1056/NEJMoa1415061
Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med 2015; 372: 1009-18; https://doi.org/10.1056/NEJMoa1414792
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 2018; 378: 11-21; https://doi.org/10.1056/NEJMoa1706442
van der Hoeven EJ, Dankbaar JW, Algra A, et al. Additional Diagnostic Value of Computed Tomography Perfusion for Detection of Acute Ischemic Stroke in the Posterior Circulation. Stroke 2015; 46: 1113-5; https://doi.org/10.1161/STROKEAHA.115.008718
Sporns P, Schmidt R, Minnerup J, et al. Computed tomography perfusion improves diagnostic accuracy in acute posterior circulation stroke. Cerebrovasc Dis 2016; 41: 242-7; https://doi.org/10.1159/000443618
Schulz UG, Fischer U. Posterior circulation cerebrovascular syndromes: diagnosis and management. J Neurol Neurosurg Psychiatry 2016; 0: 1-9; https://doi.org/10.1136/jnnp-2015-311299
Yoo AJ, Hakimelahi R, Rost NS, et al. Diffusion weighted imaging reversibility in the brainstem following successful recanalization of acute basilar artery occlusion. J Neurointerv Surg 2010; 2: 195-7; https://doi.org/10.1136/jnis.2009.002048
Kumar G, Shahripour RB, Alexandrov AV. Recanalization of acute basilar artery occlusion improves outcomes: a meta-analysis. J Neurointervent Surg 2014; 0: 1-7; https://doi.org/10.1136/neurintsurg-2014-011418
Vergouwen MD, Algra A, Pfefferkorn T, et al. Basilar Artery International Cooperation Study (BASICS) Study Group. Time is brain(stem) in basilar artery occlusion. Stroke 2012; 43: 3003-6; https://doi.org/10.1161/STROKEAHA.112.666867
Ferbert A, Brückmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke 1990; 21: 1135-42
Baird TA, Muir KW, Bone I. Basilar artery occlusion. Neurocrit Care 2004; 3: 319-30; https://doi.org/10.1385/NCC:1:3:319
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-7; https://doi.org/10.1056/NEJM199512143332401
Hacke W, Kaste M, Fieschi C, et al.; for the ECASS-study group. Safety and efficacy of i.v. thrombolysis with a recombinant tissue plasminogen activator in the treatment of acute hemispheric stroke. JAMA 1995; 274: 1017-25
Hacke W, KasteM, Fieschi C, et al. Randomised double-blind placebocontrolled trial of thrombolytic therapy with i.v. alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian acute stroke study investigators. Lancet 1998; 352: 1245-51
Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase thrombolysis for acute non interventional therapy in ischemic stroke. JAMA 1999; 282: 2019-26
Wahlgren N, Ahmed N, Dávalos A, et al. SITS-MOST investigators Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITSMOST): an observational study. Lancet 2007; 369: 275-82; https://doi.org/10.1016/S0140-6736(07)60149-4
Hacke W, Kaste M, Bluhmki E, et al., for the European Cooperative Acute Stroke Study (ECASS) investigators. Alteplase compared with placebo within 3 to 4•5 hours for acute ischemic stroke. N Engl J Med 2008; 359: 1317-29; https://doi.org/10.1056/NEJMoa0804656
The IST-3 collaborative group. The benefits and harms of i.v. thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379: 2352-63; https://doi.org/10.1016/S0140-6736(12)60768-5
Sairanen T, Strbian D, Soinne L, et al, for the Helsinki Stroke Thrombolysis Registry (HSTR) Group. Intravenous thrombolysis of basilar artery occlusion: predictors of recanalization and outcome. Stroke 2011; 42: 2175-9; https://doi.org/10.1161/STROKEAHA.110.605584
Strbian D, Sairanen T, Silvennoinen H, et al. Thrombolysis of basilar artery occlusion: impact of baseline ischemia and time. Ann Neurol 2013; 73: 688-94; https://doi.org/10.1002/ana.23904
Rha J-H, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38: 967-73; https://doi.org/10.1161/01.STR.0000258112.14918.24
Schonewille WJ, Wijman CAC, Michel P, et al. On behalf of the BASICS study group. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 2009; 8: 724-30; https://doi.org/10.1016/S1474-4422(09)70173-5
Knap D, Kirmes T, Honkowicz M, et al. Treatment of basilar artery occlusion using various techniques of interventional radiology. Vasc Med Surg 2016; 4: 1; https://doi.org/10.4172/2329-6925.1000241
Singer OC, Berkefeld J, Nolte CH, et al. Mechanical recanalization in basilar artery occlusion: The ENDOSTROKE study. Ann Neurol 2015; 77: 415-24; https://doi.org/10.1002/ana.24336
Gory B, Eldesouky I, Sivan-Hoffmann R, et al. Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review. J Neurol Neurosurg Psychiatry 2016; 87: 520-5; https://doi.org/10.1136/jnnp-2014-310250
Phan K, Zhao DF, Phan S, et al. Endovascular therapy including thrombectomy for acute ischemic stroke: A systematic review and meta-analysis with trial sequential analysis. J Clin Neurosci 2016; 29: 38-45; https://doi.org/10.1016/j.jocn.2015.12.025
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49: e46-e99; https://doi.org/10.1161/STR.0000000000000158
Lindsberg PJ, Pekkola J, Strbian D, et al. Time window for recanalization in basilar artery occlusion: Speculative synthesis. Neurology 2015; 85: 1806-15; https://doi.org/10.1212/WNL.0000000000002129
Lindsberg PJ, Sairanen T, Nagel S, et al. Recanalization treatments in basilar artery occlusion—Systematic analysis. European Stroke Journal 2016; 1: 41-50; https://doi.org/10.1177/2396987316629889
Rothwell PM, Howard SC, Spence D. Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke 2003; 34: 2583-90; https://doi.org/10.1161/01.STR.0000094424.38761.56
The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee. Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Cerebrovasc Dis 2008; 25: 457-507; https://doi.org/10.1159/000131083
Published
Issue
Section
License
Authors who publish with this journal agree to the following terms:- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution Non-Commercial 4.0 Licence that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal. The Publication Agreement can be downloaded here, and should be signed by the Authors and sent to the Publisher when the article has been accepted for publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
- Authors are permitted to post their work online after publication (the article must link to publisher version, in html format)