Predictors of devastating functional outcome despite successful basilar thrombectomy.

BACKGROUND: Basilar thrombosis frequently leads to poor functional outcomes, even with good endovascular reperfusion. We studied factors associated with severe disability or death in basilar thrombectomy patients achieving revascularization. METHODS: We retrospectively analyzed records from a health system's code stroke registry, including successful basilar thrombectomy patients from January 2017 to May 2023 who were evaluated with pretreatment computed tomography perfusion. The primary outcome was devastating functional outcome (90-day modified Rankin Scale [mRS] score 5-6). A multivariable logistic regression model was constructed to determine independent predictors of the primary outcome. The area under the receiver operator characteristics curve (AUC) was calculated for the model distinguishing good from devastating outcome. RESULTS: Among 64 included subjects, with mean (standard deviation) age 65.6 (14.1) years and median (interquartile range) National Institutes of Health Stroke Scale (NIHSS) 18 (5.75-24.5), the primary outcome occurred in 28 of 64 (43.8%) subjects. Presenting NIHSS (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.14, p = 0.02), initial glucose (OR 0.99, 95% CI 0.97-1.00, p < 0.05), and proximal occlusion site (OR 7.38, 95% CI 1.84-29.60, p < 0.01) were independently associated with 90-day mRS 5-6. The AUC for the multivariable model distinguishing outcomes was 0.81 (95% CI 0.70-0.92). CONCLUSION: We have identified presenting stroke severity, lower glucose, and proximal basilar occlusion as predictors of devastating neurological outcome in successful basilar thrombectomy patients. These factors may be used in medical decision making or for patient selection in future clinical trials.

Critical care in acute ischemic stroke.

Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.

An Unusually Benign Course of Extensive Posterior Circulation Occlusion.

BACKGROUND: Acute basilar artery occlusion is associated with poor outcome. In a few cases, occlusion occurs over a period allowing adequate collateral circulation to the posterior fossa. We describe a rare presentation with transient loss of consciousness (LOC) in a patient with extensive occlusion of the posterior circulation. METHODS: Case report. RESULTS: We describe a 70-year-old right-handed man with a history significant for atrial fibrillation and dolichoectasia of the basilar artery. Fourteen years ago, he had a small infarction in the pons resulting in right hemiparesis. Magnetic resonance angiogram at that time showed mild intracranial atherosclerosis. He was treated with warfarin for secondary stroke prevention. He presented to our emergency department after a witnessed spell of LOC after a large meal. On regaining consciousness, he had 2 episodes of emesis. Examination revealed only a spastic right hemiparesis from the old stroke in the pons. Cerebral angiogram showed absent flow in the mid and distal basilar arteries, both posterior cerebral arteries, and both posterior communicating arteries with bilateral stenoses of internal carotid arteries. His international normalized ratio in the emergency department was 1.1. He was treated with intravenous heparin and did well. Three months later, he underwent stent treatment of the worsening stenosis (90%) of the right internal carotid artery. CONCLUSIONS: Occasionally, collateral circulation has the potential to maintain adequate perfusion to the posterior fossa in severe cases of posterior circulation occlusion and diffuse intracranial atherosclerotic disease. Careful patient selection is essential before planning any endovascular intervention.

A simple collapse, agitation and pathological crying in a young woman? - Atypical onset of a basilar thrombosis.

BACKGROUND: A collapse and agitation in a young person comprises many differential diagnoses, but usually does not include a life-threatening basilar thrombosis. METHODS AND RESULTS: We report the case of a 19-year old woman who presented mainly with a collapse and agitation. CT and CT-angiography yielded distal basilar thrombosis which was successfully treated by intraarterial thrombolysis. MRI confirmed multiple small ischemic lesions in the vertebrobasilar territory. The patient improved quickly and returned to her normal daily activities of life after a few months. CONCLUSIONS: Posterior circulation ischemia should be included among the possible differential diagnoses of any acute onset of an agitated or confusional state. CONFLICTS OF INTEREST/DISCLOSURES: None to declare. ETHICS: Written informed consent of the patient has been obtained.