Mechanical Thrombectomy in Pediatric Large Vessel Occlusions Before Cerebrovascular Maturity: A Case Report and Technical Note.

Pediatric arterial ischemic stroke is a rare but increasingly acknowledged disorder. Large vessel occlusions in this population have been treated off-label with endovascular thrombectomy. However, there is limited evidence to guide management. Small children, before the age of five when the cerebrovasculature reaches adult size, present additional challenges. We report the case of cardioembolic basilar occlusion in a two-year-old and the technical details of endovascular management, currently lacking in published literature. We employed a 5 French slender sheath, typically used for radial access, as a femoral short sheath. We accessed the dominant vertebral artery with a 5 French intermediate catheter, navigated with a typical 0.027-inch microcatheter and 0.014-inch microwire, and performed direct aspiration thrombectomy of the basilar clot. No closure device was employed. The patient had a near-complete and durable recovery. Small children present additional challenges for the endovascular management of stroke. Pre-procedural imaging can be used to design an aspiration-capable system appropriate for the child's size. Endovascular thrombectomy in children is feasible with some modifications to adult protocols.

The charlotte large artery occlusion endovascular therapy outcome score compares favorably to the critical area perfusion score for prognostication before basilar thrombectomy.

INTRODUCTION: The Critical Area Perfusion Score (CAPS) predicts functional outcomes in vertebrobasilar thrombectomy patients based on computed tomography perfusion (CTP) hypoperfusion. We compared CAPS to the clinical-radiographic Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS). METHODS: Acute basilar thrombosis patients from January 2017-December 2021 were included in this retrospective analysis from a health system's stroke registry. Inter-rater reliability was assessed for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict 90-day modified Rankin Scale (mRS) score 4-6. Area under the curve (AUC) analyses were performed to evaluate prognostic ability. RESULTS: 55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.55-24, were included. Light's kappa among 6 raters for favorable versus unfavorable CAPS was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio (OR) 1.0010, 95% CI 1.0007-1.0014, p<0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p=0.93). An overall favorable trend was observed for CLEOS (AUC 0.69, 95% CI 0.54-0.84) versus CAPS (AUC 0.49, 95% CI 0.34-0.64; p=0.051). Among 85.5% of patients with endovascular reperfusion, CLEOS had a statistically higher sensitivity than CAPS at identifying poor 90-day outcomes (71% versus 21%, p=0.003). CONCLUSIONS: CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and in patients achieving reperfusion after basilar thrombectomy.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy.

BACKGROUND AND PURPOSE: The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT. METHODS: We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS = (5 × age) + (10 × National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 × CTP cerebral blood volume index) and THRIVE (0-9 points) = age 60-79 years, 1 point; age ≥ 80 years, 2 points; NIHSS 11-20, 2 points; NIHSS ≥ 21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6. RESULTS: Fifty-seven patients had mean age 66.6 (± 14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR] = 1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p = .008), whereas THRIVE was not (OR = 1.0326, 95% CI: 0.9478-1.1250, p = .466). CLEOS > 503 best predicted poor outcomes. CONCLUSIONS: A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.

Cerebral blood volume index as a predictor of functional independence after basilar artery thrombectomy.

BACKGROUND AND PURPOSE: The role of CT perfusion (CTP)in the evaluation of acute basilar artery occlusion (aBAO) patients undergoing endovascular thrombectomy (EVT) is unclear. We investigated the association of individual CTP parameters with functional outcomes in aBAO patients undergoing EVT. METHODS: A health system's prospectively collected code stroke registry was used in this retrospective analysis of aBAO patients treated with EVT presenting between January 2017 and February 2021 with pre-EVT CTP. The primary outcome measure was modified Rankin Scale (mRS) score 0-2 at 90 days. Factors with a univariate association (p < .05) with mRS 0-2 were combined in a multivariable regression model to determine independent predictors of 90-day favorable functional outcome. RESULTS: Forty-six subjects, with median age 67 years and median National Institutes of Health Stroke Scale 16, were included, of whom 17 (37%) achieved mRS 0-2 at 90 days. In the multivariable logistic regression model, CTP cerebral blood volume (CBV) index (per 0.1-point increase, odds ratio = 1.843; 95% confidence interval: 1.039, 3.268; p-value .0365) was independently associated with a favorable 90-day outcome. CONCLUSIONS: CBV index was independently associated with a favorable 90-day outcome in aBAO patients treated with EVT, a novel finding in this patient population. CBV index may assist in treatment and prognosis discussions and inform future studies investigating the role of CTP in aBAO.

Age and discharge modified Rankin score are associated with 90-Day functional outcome after basilar artery occlusion treated with endovascular therapy.

INTRODUCTION: Prognostic factors for functional outcome after basilar artery occlusion (BAO) treated with modern endovascular therapy (EVT) are sparse. We investigated the association between clinical characteristics, readily available imaging variables, and outcome in BAO patients treated with EVT. METHODS: Retrospective analysis from a large healthcare system's prospectively collected code stroke registry of acute BAO patients treated with EVT between January 2017-January 2020. The primary outcome measure was a favorable 90-day modified Rankin score (mRS) of 0-2. RESULTS: 65 patients (median age 67 years, 57% male, median NIHSS 16) met the study inclusion criteria. Thrombolysis in Cerebral Infarction (TICI) 2 b-3 revascularization was achieved in 57/65 patients (88%) with a median time to revascularization of 445 minutes [IQR 302-840]. Ninety-day good outcome was seen in 35% (23/65) of patients. In a univariate analysis, age, history of ischemic stroke, baseline NIHSS, BAO site, and discharge mRS were associated with significant differences between the good and poor outcome groups. A multivariable logistic regression analysis demonstrated an independent association with 90-day good outcome and younger age (per 1-year, OR 0.79, 95% CI 0.64, 0.98) and good discharge mRS (0-2) (OR > 999.99, 95% CI 13.26, > 999.99). CONCLUSIONS: Patients presenting with an acute BAO treated with modern EVT have a good 90-day outcome in over one-third of cases. Age and discharge mRS are independently associated with good 90-day outcome. Additional studies may focus on factors that can enhance discharge function after BAO, a novel prognostic indicator for favorable 90-day outcome in our study.

A 52-Year-Old Man With Vertigo: A Common Symptom or an Urgent Syndrome?

Basilar occlusion syndrome is an uncommon cause of posterior circulation cerebrovascular syndromes. Approximately one-fifth of the ischemic strokes occur in the posterior cerebrovascular system and it is associated with an increased morbidity and mortality. The symptoms and signs are non-specific, resulting in delays in diagnosis, and a high index of suspicion is required that will lead to the correct diagnosis. Herein, we present a case of a 52-year-old patient who presented to the emergency department with acute onset of dizziness and vertigo due to partial thrombosis of the basilar artery.

Basilar Occlusion and Rupture Secondary to Rare Fungal Sinusitis.

BACKGROUND: Intracranial vascular infections of fungal etiology are extremely rare. Most cases occur in immunocompromised patients with invasive fungal disease, most commonly originating in the paranasal sinuses or the lungs. Granulomatous invasive rhinosinusitis, which is extremely rare in North America, has been reported to affect immunocompetent patients in most cases, and its causative strain has potential to invade the intracranial arteries. We present a rare case of basilar artery rupture and infarction secondary to granulomatous invasive rhinosinusitis. CASE DESCRIPTION: A 50-year-old man in Florida presented with ischemic symptoms and a 6-month history of headache, dizziness, and falls. After biopsy, the patient developed subarachnoid hemorrhage and thrombosis. Several thrombectomy attempts were performed, resulting in persistent occlusion of the basilar artery and subsequent comatous state. After discussion with the patient's family, compassionate weaning and autopsy were authorized. CONCLUSIONS: Invasive fungal rhinosinusitis is more frequent nowadays owing to increased use of immunosuppressive therapies. However, it is still a disease that mostly affects immunocompromised patients. The development of new microbiologic investigation techniques has enabled the discovery of fungal diseases that can also affect immunocompetent hosts, such as granulomatous invasive rhinosinusitis. This is an extremely rare condition in North America, with very few cases documented in the last few decades.

Patient selection for mechanical thrombectomy in posterior circulation emergent large-vessel occlusion.

Triage of posterior circulation stroke from emergent large-vessel occlusion (pc-ELVO) is challenging owing to the stuttering clinical course and potential for rapid decline. Growing clinical data support the use of mechanical thrombectomy in pc-ELVO, but there are limited data addressing the clinical and imaging criteria for patient selection. We present our triage algorithm used to select patients for endovascular therapy (EVT) in the setting of pc-ELVOS. We use a consecutive retrospective database from 2004 to 2016 to describe the practice patterns and prognostic factors for pc-ELVO patients treated using both medical and EVT. Patients with moderate to severe deficits (NIHSS > 10) did better when they received EVT ( p < 0.03), whereas patients with stable, mild deficits (NIHSS ≤ 10) did well (90% favorable outcome) regardless of treatment type. Roughly one-third of patients presenting with mild deficits deteriorated to moderate to severe deficits (NIHSS > 10), most of whom subsequently received EVT (9 of 12), with 56% favorable outcomes. Cerebellar and brainstem infarct volumes were independent imaging predictors of outcome. These results can be used to define triage criteria for use of EVT in pc-ELVO in future practice and clinical trials.

ADC quantification in basilar artery occlusion as an indicator of clinical outcome after endovascular treatment.

Background Acute ischemic stroke due to basilar artery occlusion (BAO) is associated with a dismal prognosis and, even though endovascular treatment (EVT) contributed to an improvement in clinical outcomes, patient selection is difficult and frequently results in futile recanalization. We investigated the prognostic value of baseline ADC quantification in patients with BAO undergoing EVT. Methods We retrospectively evaluated MRI at admission in 11 patients with BAO undergoing EVT. Ischemic lesions were defined on baseline DWI and minimum ADC (minADC), ADC ratio and total area were quantified. Final infarction area was determined on follow-up T2WI/CT. We assessed the correlation between imaging parameters, recanalization grade and clinical scores (NIHSS at admission, NIHSS and mRS at discharge and mRS at three months) using Spearman rank correlation coefficient and correcting for multiple comparisons with the false discovery rate (FDR). Results Lower values of minADC at admission MRI are strongly correlated with higher scores in NIHSS (rs = -0.845, p = 0.001) and mRS at discharge (rs = -0.743, p = 0.009). We also found a negative correlation between minADC and NIHSS at admission (rs = -0.67, p = 0.02), mRS at three months and difference between pre- and post-treatment ischemic area (rs = -0.664, p = 0.026) that lost significance with FDR correction. Ischemic area and TICI grade were not significantly associated with clinical results. Conclusions ADC quantification of ischemic lesions at baseline MRI seems to predict clinical outcome in patients with BAO undergoing EVT, more importantly than ischemic area or TICI grade.

Mechanical Thrombectomy Using Solitaire in a 6-Year-Old Child.

A six-year-old boy was diagnosed as recurrent posterior circulation stroke secondary to basilar artery occlusion with rapid progression of symptoms. Etiology of stroke was a dissection of V3 segment of left vertebral artery, which was treated using endovascular technique 26 hours after worsening of symptoms. Since the guidelines for acute revascularization in pediatric stroke are not well established, there is limited experience in the use of mechanical devices for acute ischemic stroke revascularization in children. To our knowledge, this is one of the youngest reported cases of acute ischemic stroke from Asia managed with newer mechanical clot removal devices.

Wake-up stroke in a young woman with rotational vertebral artery occlusion due to far-lateral cervical disc herniation.

Wake-up stroke is most likely to be caused by small-vessel disease, and is related to snoring. The authors present a rare case of far-lateral cervical disc herniation with neck rotation, resulting in wake-up stroke in a young woman. The patient, a 31-year-old woman, was admitted to the hospital because of dysarthria and confusion when she awoke in the morning. Brain MRI showed acute infarction in the posterior fossa. Cerebral angiography showed thrombus in the distal top of the basilar artery and the bilateral posterior cerebral arteries. During angiography, the thrombus size decreased with heparinization. There was severe stenosis of the right vertebral artery (VA) at C5-6, and head rotation to the right resulted in complete occlusion of the right VA. Neck MRI showed far-lateral intervertebral disc herniation. Surgical decompression of the VA was performed via the anterior cervical approach. Histological examination showed a degenerative intervertebral disc. Postoperative angiography confirmed successful decompression of the VA.