Supplementingand activating blood circulation method to treat vertebrobasilar dolichoectasia with posterior circulatory watershed infarction: a case report of two patients.

Vertebrobasilar dolichoectasia (VBD), a rare posterior circulation vascular variant disease, is an important risk factor for many acute cerebrovascular diseases. An insufficient understanding of VBD often leads to misdiagnose. Two cases of VBD that were initially diagnosed as posterior circulation watershed infarction are reported here. Absence of common causes of stroke including hypoperfusion, blood system diseases, carotid and aortic dissection, and eosinophil elevation, the symptoms of the 2 patients met the diagnostic criteria of VBD. Both patients displayed symptoms that were in line with the Traditional Chinese Medicine (TCM) syndrome pattern of "deficiency and blood stasis". Accordingly, they were comprehensively treated with Supplementingand activating blood circulation method. The clinical manifestations of the 2 patients were remarkably improved and no recurrence of watershed infarction was found in a 1-year follow-up. A detailed medical history and laboratory examination are capable of improving diagnostic accuracy of VBD. TCM treatment based on syndrome identification might be a promising candidate for VBD management.

CT chest-cerebral angiography for basilar artery occlusion caused by pulmonary arteriovenous malformation.

Early diagnosis of basilar artery occlusion (BAO) based only on clinical findings is challenging. We present a fully recovered case of BAO caused by pulmonary arteriovenous malformation (PAVM) that was diagnosed early using a protocol for CT angiography (CTA) and promptly treated with endovascular therapy (EVT). A woman in her 50s complained of vertigo with normal level of consciousness (LOC). On arrival, her LOC decreased to a Grass Coma Scale score of 12, and we performed a CT chest-cerebral angiography protocol. Head CTA showed BAO, and an intravenous tissue plasminogen activator was administered, followed by EVT. Chest contrast-enhanced CT showed PAVM in segment 10 of the left lung, which was treated with coil embolisation. For patients with a complaint of vertigo, BAO should be suspected, even if they have an initially normal LOC. A CT chest-cerebral angiography protocol is useful for prompt diagnosis and treatment of BAO and can reveal undetermined causes.

Symptomatic vertebrobasilar artery stenosis treated with enoxaparin.

Nil.

Dolichoectasia: a brain arterial disease with an elusive treatment.

INTRODUCTION: Dolichoectasia is a form of brain large artery disease associated with a high risk of mortality and morbidity. Progressive enlargement of arterial size is a predictor of mortality, but there are no specific treatments for arresting or slowing down dilatation. Additionally, dilated brain arteries can cause flow stagnation, which can trigger thrombosis and cause stroke. Pathology and genetic studies indicate a possible role for increased matrix metalloproteinase activation in arterial dilatation and thus in the pathophysiology of dolichoectasia. Therefore, therapeutic interventions aimed at slowing down arterial dilatation and preventing thrombosis could hypothetically play a role in treating patients with dolichoectasia. METHODS: We present four patients with dolichoectasia that exemplify therapeutic challenges worth discussing in the context of the current literature. Two patients were treated off-label with doxycycline (based on its antiMMP properties) and with apixaban, one patient was put on warfarin and later switched to aspirin, and the fourth patient underwent endovascular treatment. RESULTS: We report four cases, all men 50 years or older. Of the two patients treated with doxycycline, we noted a slowdown of the basilar artery (BA) growth, but the BA continued to grow in the other patient. Of the two patients who received apixaban, none had a subsequent stroke in 5 and 4 years of follow-up, respectively. One patient was admitted with a fatal BA thrombosis and rupture, and pathological examination of the brain arteries demonstrated advanced arterial wall degeneration but no atherosclerosis. DISCUSSION: These cases exemplify the challenges of treating people with dolichoectasia and highlight the need for better evidence regarding the best possible treatment for this population.

Reversible cerebral vasoconstriction syndrome with basilar artery stenosis: A case report.

INTRODUCTION: Acute severe headaches in young patients may be associated with fatal neurological complications that necessitate imaging examinations. Among acute severe headaches, a thunderclap headache may indicate the rupture of a cerebral aneurysm or the onset of reversible cerebral vasoconstriction syndrome for which emergent evaluation is required. PATIENT CONCERNS: We report the case of a 36-year-old man who presented to our hospital with an acute severe headache after excessive exercise the previous day. He was prescribed a pain reliever and discharged under the suspicion of vestibular migraine but returned to the emergency room after 4 hours due to right hemiparesis, right facial palsy, severe dysarthria, and a mild drowsy mental status. DIAGNOSIS: After cerebral angiography, we diagnosed basilar artery stenosis with acute infarction in the posterior circulation due to reversible cerebral vasoconstriction syndrome. INTERVENTIONS: Brain computed tomography angiography revealed complete occlusion of the vertebrobasilar artery. Transfemoral cerebral angiography showed spontaneous improvement in the occlusion before thrombectomy. OUTCOMES: Ten months later, high-resolution vessel wall magnetic resonance angiography showed persisting severe stenosis of the basilar artery. CONCLUSIONS: A headache in young patients with risk factors of atherosclerosis, such as smoking history, uncontrolled hypertension, and dyslipidemia may be caused by reversible cerebral vasoconstriction syndrome or ischemic stroke, which has fatal neurological complications. Therefore, reversible cerebral vasoconstriction syndrome or ischemic stroke should be suspected and appropriately evaluated in such patients, even if the headache is not the thunderclap type.

[Collateral circulation pathway in patients with basilar artery occlusion/severe stenosis: a single-center case series].

Objective: To investigate the collateral circulation compensation model in patients with favorable prognosis of basilar artery occlusion/severe stenosis treated with drugs or endovascular therapy. Methods: Clinical data of patients with basilar artery occlusion/severe stenosis and good clinical outcome were retrospectively collected in the Department of Neurology, Sixth Medical Center of PLA General Hospital from January 2019 to January 2020. They were divided into intensive drug therapy group and combined endovascular therapy group. The number and ways of collateral compensation pathway described by digital substraction angiography (DSA) were analyzed, and the characteristics of the collateral compensation model were summarized. SPSS22.0 software was used for statistical analysis, and the constituent ratio (%) was used for statistical description of the enumeration data. Results: A total of 32 eligible patients were included, including 27 males and 5 females, with an average age 45-76 (59±10) years. The compensation model included posterior communicating artery-posterior cerebral artery (13 cases, 40.6%), posterior communicating artery-posterior cerebral artery-basilar artery (10 cases, 31.2%), cerebellar artery-anastomotic branches of superior cerebellar artery (8 cases, 25.0%), anterior choroid artery-anastomotic branches of posterior choroid artery (2 cases, 6.2%), collateral circulation not established (11 cases, 34.4%).In drug treatment group, collateral compensation was found in the majority (14/15), with mainly posterior communicating artery (10/14).Most patients in combined treatment group did not develop collateral compensation (10/17), anastomotic branches of PICA-SCA were the main routes (6/7). Conclusion: In patients with basilar artery occlusion/severe stenosis, favorable clinical outcome can be achieved in both groups of patients treated with intensive drug therapy or endovascular therapy.

Bridging versus direct endovascular therapy in basilar artery occlusion.

BACKGROUND: We evaluated safety and efficacy of intravenous recombinant tissue Plasminogen Activator plus endovascular (bridging) therapy compared with direct endovascular therapy in patients with ischaemic stroke due to basilar artery occlusion (BAO). METHODS: From a national prospective registry of endovascular therapy in acute ischaemic stroke, we selected patients with BAO. We compared bridging and direct endovascular therapy evaluating vessel recanalisation, haemorrhagic transformation at 24-36 hours; procedural complications; and functional outcome at 3 months according to the modified Rankin Scale. We ran logistic and ordinal regression models adjusting for age, sex, National Institutes of Health Stroke Scale (NIHSS), onset-to-groin-puncture time. RESULTS: We included 464 patients, mean(±SD) age 67.7 (±13.3) years, 279 (63%) males, median (IQR) NIHSS=18 (10-30); 166 (35%) received bridging and 298 (65%) direct endovascular therapy. Recanalisation rates and symptomatic intracerebral haemorrhage were similar in both groups (83% and 3%, respectively), whereas distal embolisation was more frequent in patients treated with direct endovascular therapy (9% vs 3%; p=0.009). In the whole population, there was no difference between bridging and direct endovascular therapy regarding functional outcome at 3 months (OR=0.79; 95% CI=0.55 to 1.13). However, in patients with onset-to-groin-puncture time ≤6 hours, bridging therapy was associated with lower mortality (OR=0.53; 95% CI=0.30 to 0.97) and a shift towards better functional outcome in ordinal analysis (OR=0.65; 95% CI=0.42 to 0.98). CONCLUSIONS: In ischaemic stroke due to BAO, when endovascular therapy is initiated within 6 hours from symptoms onset, bridging therapy resulted in lower mortality and better functional outcome compared with direct endovascular therapy.

Free-floating and spinning thrombus of the basilar artery: A case report.

RATIONALE: Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.. PATIENT CONCERNS: A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis. DIAGNOSES: Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis. INTERVENTIONS: We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days. OUTCOMES: No thrombus was observed on the third follow-up digital subtraction angiography. LESSONS: No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.

Ischemic Cerebellar Stroke in a 4-Year-Old Boy After Chickenpox: An Atypical Vascular Involvement.

Cerebrovascular events in pediatric population are very rare. Up to 30% may result from varicella zoster (VZV) arteriopathy, usually as a delayed complication of varicella primary infection. The most typical pattern includes involvement of anterior brain circulation arteries, probably by VZV migration from the trigeminal ganglia. Strokes related with VZV usually have a good prognosis, but risk of recurrence is greater when compared to other stroke etiologies in this age group. We report the case of a 4-year-old boy, immunocompetent, who presented a basilar artery stenosis and a cerebellar stroke, an extremely rare presentation of VZV arteriopathy. The investigation workup and treatment are detailed, as the clinical and imaging follow-up after one year.

Tenecteplase vs Alteplase Before Endovascular Therapy in Basilar Artery Occlusion.

OBJECTIVE: To investigate the efficacy of tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, prior to endovascular thrombectomy (EVT) in patients with basilar artery occlusion (BAO). METHODS: To determine whether TNK is associated with better reperfusion rates than alteplase prior to EVT in BAO, clinical and procedural data of consecutive patients with BAO from the Basilar Artery Treatment and Management (BATMAN) registry and the Tenecteplase vs Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial were retrospectively analyzed. Reperfusion >50% or absence of retrievable thrombus at the time of the initial angiogram was evaluated. RESULTS: We included 110 patients with BAO treated with IV thrombolysis prior to EVT (mean age 69 [SD 14] years; median NIH Stroke Scale score 16 [interquartile range (IQR) 7-32]). Nineteen patients were thrombolysed with TNK (0.25 mg/kg or 0.40 mg/kg) and 91 with alteplase (0.9 mg/kg). Reperfusion >50% occurred in 26% (n = 5/19) of patients thrombolysed with TNK vs 7% (n = 6/91) thrombolysed with alteplase (risk ratio 4.0, 95% confidence interval 1.3-12; p = 0.02), despite shorter thrombolysis to arterial puncture time in the TNK-treated patients (48 [IQR 40-71] minutes) vs alteplase-treated patients (110 [IQR 51-185] minutes; p = 0.004). No difference in symptomatic intracranial hemorrhage was observed (0/19 [0%] TNK, 1/91 [1%] alteplase; p = 0.9). CONCLUSIONS: TNK may be associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare TNK with alteplase in patients with BAO are warranted. CLINICALTRIALSGOV IDENTIFIERS: NCT02388061 and NCT03340493. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that TNK leads to higher reperfusion rates in comparison with alteplase prior to EVT in patients with BAO.

Outcomes and long-term mortality after basilar artery occlusion-A cohort with up to 20 years' follow-up.

BACKGROUND: The data on long-term outcome after basilar artery occlusion (BAO) are scarce. Little is known about BAO survivors´ outcome over decades. AIM: We set out to investigate long-term survival and causes of death in BAO patients with up to two decades of follow-up. We also evaluated differences in outcome trends. METHODS: Two hundred and seven BAO patients treated with intravenous thrombolysis (IVT) at the Department of Neurology, Helsinki University Hospital, between 1995 and 2016, were analyzed. Short-term outcome was assessed by modified Rankin Scale (mRS) at 3 months. Long-term cumulative survival rate was analyzed using Kaplan-Meier analysis. Factors associated with mortality were analyzed with Cox regression. RESULTS: Moderate outcome (mRS 0-3) was achieved in 41.1% and good outcome (mRS 0-2) in 30.4% of patients at 3 months. Three-month mortality was 39.6%, of which 89% died within the first month. The median follow-up time in 3-month survivors was 8.9 years (maximum 21.8 years). Total mortality during follow-up was 52.2%. Cumulative mortality rate was 25.7%. Older age, coronary artery disease and more extensive ischemic changes on admission brain imaging were independently associated with long-term mortality. After the acute phase, the rate of other vascular causes of death increased in relation to stroke. CONCLUSIONS: The described evolution of a large, single-center BAO cohort shows a trend towards a higher rate of good and/or moderate outcome during later years in IVT-treated patients. Survivors showed relative longevity, and the rate of cardiac and other vascular causes of death increased in relation to stroke sequelae over the long term.

Clinical outcomes of mechanical thrombectomy following intravenous administration of recombinant tissue-type plasminogen activator for basilar artery occlusion.

OBJECTIVE: Mechanical thrombectomy (MT) following intravenous administration of recombinant tissue-type plasminogen activator (IV-rt-PA) is considered an effective treatment for the occlusion of the internal carotid artery or the M1 segment of the middle cerebral artery. However, its efficacy in treating basilar artery (BA) occlusion is still unclear. In order to evaluate the efficacy of MT in treating BA occlusion, we aimed to analyzed the clinical outcomes of those patients who had undergone MT following IV-rt-PA administration. PATIENTS AND METHODS: We retrospectively analyzed the clinical outcomes of 11 patients with BA occlusion who had undergone MT following IV-rt-PA administration between January 1, 2015, and March 31, 2019. RESULTS: The patients consisted of 8 men and 3 women. The mean (±standard deviation) age was 73 ±â€¯9.4 years. Stroke subtypes were found to be atherothrombosis in 2 patients, cardiogenic embolism in 6, arterial dissection in 1, and an unknown cause in 2. The median pretreatment scores were 9 on the Glasgow Coma Scale (GCS) and 25 on the National Institutes of Health Stroke Scale. The time elapsed from onset of the stroke to reperfusion was 281 min. Successful reperfusion, characterized by a modified Thrombolysis in Cerebral Infarction grade ≥ 2b, was achieved in all patients. The 3-month outcomes were good [modified Rankin Scale (mRS) 0-2] in 5 patients and poor (mRS 3-6) in 6 patients. The pretreatment median GCS scores were significantly higher in patients with a good outcome compared to that in those with a poor outcome with scores of 11 and 7.5, respectively (P =  0.044). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off score on the GCS was 9.5 [area under the curve (AUC), 0.867; sensitivity, 0.8; specificity, 1.0]. Complications occurred in 1 patient with arterial dissection who had developed a subarachnoid hemorrhage and later died. CONCLUSION: The results of the present study suggests that the pretreatment GCS score might affect the clinical outcomes in patients with BA occlusion who underwent MT following IV-rt-PA therapy.

Comparative effectiveness of Ginkgo injections for treating vertebrobasilar insufficiency: A systematic review and network meta-analysis.

WHAT IS KNOWN AND OBJECTIVE: This study sought to assess the clinical effectiveness of Ginkgo injections (GIs) combined with conventional drugs for vertebrobasilar insufficiency (VBI). METHODS: Randomized controlled trials (RCTs) that assessed the adjunctive effects of GIs for patients with VBI were retrieved from several English and Chinese databases from inception to December 2018. The Cochrane risk of bias method was used to evaluate the methodological quality of the eligible trials. The data were analysed by Stata 13.0 and WinBUGS 1.4.3 software. RESULTS: A total of 20 RCTs that included 1710 patients were included. All RCTs had an unclear risk of bias or a high risk of bias. The network meta-analysis (NMA) showed that the use of four kinds of GIs, especially Ginkgo leaf extract and dipyridamole injections (GDs), as adjunctive therapies with drugs for VBI increased the total effectiveness rate. Ginkgo biloba leaf extract injections (EGbs) combined with conventional drugs were more effective than only conventional drugs for improving the results of transcranial Doppler ultrasonography (TCD). Shuxuening injections (SXNs) seemed superior for improving blood viscosity-related indicators. Adverse events were mentioned in nine trials, and there was no difference between the GI group and the control group for the incidence rate of adverse events. WHAT IS NEW AND CONCLUSIONS: GIs showed significant benefits as an add-on therapy for VBI, as GIs increased the total effectiveness rate and improved the results of TCD examinations. Due to the limited sample size and quality of the included trials, the results of this review still need to be tested in larger, rigorous studies in the future.

Polyethylene glycol-conjugated human adrenomedullin as a possible treatment for vascular dementia.

Adrenomedullin (AM) is a multifunctional bioactive peptide. Recent studies have shown that AM has protective effects against ischemic brain damage. We recently prepared a long-acting human AM derivative that was conjugated with a 60 kDa polyethylene glycol (PEG-AM), which had an effect similar to that of native AM. In this study, we examined the effect of PEG-AM on four-vessel occlusion model rats, which exhibit vascular dementia. From day 10 to day 14 after surgery, the learning and memory abilities of the rats were examined using a Morris water maze. The rats were treated with a single subcutaneous injection of 1.0 or 10.0 nmol/kg of PEG-AM. PEG-AM treatment reduced the escape latency in the hidden platform test. Furthermore, the treatment increased the time spent in the platform quadrant in the probe test. The data showed that PEG-AM injection prevented memory loss and learning disorders in dose-dependent manner. On day 14, the immunoreactive AM concentration in plasma was 9.749 ±â€¯2.167 pM in the high-dose group (10.0 nmol/kg) and 0.334 ±â€¯0.073 pM in the low-dose group (1.0 nmol/kg). However, even in the low-dose group, a significant effect was observed in both tests. The present data indicate that PEG-AM is a possible therapeutic agent for the treatment of ischemic brain injury or vascular dementia.

Rare cause of Bow Hunter's syndrome due to an aberrant course of a vertebral artery.

Bow Hunter's syndrome (BHS) is a rare cause of vertebrobasilar insufficiency and is reported to most commonly be caused by vertebral artery impingement on cervical vertebrae osteophytes. We report a case in a 56-year-old male patient who on investigation of recurrent posterior circulation ischaemic strokes was found to have BHS. The aetiology of the syndrome in this patient is due to a particularly unusual aberrancy in the path of the atlantoaxial portion of the culprit left vertebral artery. Aberrancy of the distal portion of the vertebral artery is in itself a rare entity, and there are few reports of it in relation to BHS. The patient in this case was successfully treated with endovascular sacrifice of the vertebral artery with no further dynamic occlusive symptoms.

Extracranial-to-Intracranial Bypass for Refractory Vertebrobasilar Insufficiency.

BACKGROUND: Vertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset. METHODS: A multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded. RESULTS: Five patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter. CONCLUSIONS: Refractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.

Recurrent Acute Ischemic Stroke Associated with Dolichoectatic Aneurysm of the Internal Carotid Artery.

BACKGROUND: Cranial artery dolichoectasia is characterized by dilated, elongated, and tortuous cranial arteries. Dolichoectasia and dolichoectatic aneurysm-particularly of the internal carotid arteries (ICAs)-are rare but can lead to stroke. We report a case of suspected recurrent acute cerebral infarction and dolichoectatic aneurysm of the left ICA combined with right dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation. CASE DESCRIPTION: An 80-year-old man experienced 3 days of recurrent aphasia episodes. He had a history of atrial fibrillation and hypertension. Neurologic findings indicated Wernicke aphasia. Magnetic resonance imaging showed acute cerebral infarction in the left temporal and parietal lobes. Magnetic resonance angiography and cerebral angiography showed dolichoectatic aneurysms in the C1-2 portion of the bilateral ICAs and vertebrobasilar dolichoectasia. Possible diagnoses included convulsion, cardioembolic infarction, atherothrombotic cerebral infarction, and acute ischemic stroke associated with the dolichoectatic aneurysm of the left ICA. Oral antiplatelet drugs, direct oral anticoagulants, and anticonvulsants were administered. Nine months after initial hospitalization, the patient had a recurrence of acute ischemic stroke and was rehospitalized. He was treated with a new direct oral anticoagulant, clopidogrel, statins, and ethyl icosapentate. At 2 years after initial hospitalization, he has had no recurrence of stroke, has a modified Rankin Scale score of 2, and is currently being followed as an outpatient. CONCLUSIONS: A direct oral anticoagulant (edoxaban) and clopidogrel were effective for suspected recurrent acute ischemic stroke associated with dolichoectatic aneurysm of the ICA combined with contralateral dolichoectatic aneurysm, vertebrobasilar dolichoectasia, and atrial fibrillation.

Catastrophic Secondary Infarctions with Onset Seizure Following Tissue Plasminogen Activator Therapy.

Fatalities following intravenous recombinant tissue-type plasminogen activator therapy have been reported. Major fatal complications following intravenous recombinant tissue-type plasminogen activator therapy include intracranial hemorrhage, aortic dissection, and extracranial bleeding. However, the possibility that intravenous recombinant tissue-type plasminogen activator therapy itself paradoxically induces synchronized multiple cerebral novel infarctions has never been considered. We herein report the first case of bilateral internal carotid artery infarction with onset seizure following intravenous recombinant tissue-type plasminogen activator therapy for a vertebral-basilar artery infarction. A 75-year-old man was transferred to our hospital and diagnosed with acute ischemic stroke in the basilar artery. His National Institute of Health Stroke Scale score was 4. The intravenous recombinant tissue-type plasminogen activator therapy was initiated 234 minutes after stroke onset because no contraindications were present. Almost 2 hours after the intravenous recombinant tissue-type plasminogen activator therapy, the patient suddenly fell into a deep coma with generalized convulsions. A huge secondary infarction was found in the bilateral anterior circulation territories, and he died 7 days after stroke onset. This case alerts clinicians to the possibility of synchronized multiple cerebral infarctions following intravenous recombinant tissue-type plasminogen activator therapy as a dangerous complication in patients with multiple severe stenoses in the cerebral arteries.

Thrombolysis and adjunct anticoagulation in patients with acute basilar artery occlusion.

BACKGROUND AND PURPOSE: Patients suffering from basilar artery occlusion (BAO) and treated with intravenous thrombolysis are, in some centers, started on adjunct anticoagulation in hyperacute settings. We aimed to assess the outcome of such patients and to compare low-molecular weight heparin (LMWH) and unfractionated heparin (UFH) in this context. METHODS: We examined 211 patients with angiography-proven BAO treated with intravenous thrombolysis and either adjunct UFH or LMWH. Main outcome variables were rate of symptomatic intracranial hemorrhage (sICH) according to European Cooperative Acute Stroke Study II criteria and modified Rankin Scale (mRS) at 3 months. RESULTS: The overall rate of sICH was 11.4% and driven by the UFH group (13.3%). None of the LMWH group developed sICH. Recanalization rate did not significantly differ between the LMWH and UFH groups. An additional propensity analysis was made to balance anticoagulation groups regarding baseline characteristics. Propensity analysis showed a significant difference in sICH rate (0.0% vs. 14.8%, P = 0.044) in favor of LMWH. Independent outcome (mRS score 0-2) was achieved in a total of 31.0% and in 44.8% and 29.1% in the LMWH and UFH group, respectively (P = 0.09). Propensity analysis showed a significant difference in the risk of ending up bedridden or dead (mRS score 5-6; 34.5% vs. 63.0%, P = 0.033) in favor of LMWH. CONCLUSIONS: Our study showed a lower rate of sICH and a shift towards improved outcome in thrombolysed patients with BAO treated with LMWH as compared with UFH.