Staged escalation therapy in acute basilar artery occlusion: intravenous thrombolysis and on-demand consecutive endovascular mechanical thrombectomy: preliminary experience in 16 patients.
OBJECTIVE
The prognosis of acute basilar artery occlusion (BAO) is poor if early recanalization is not achieved. Recanalization strategies include intravenous thrombolysis (IVT) and intra-arterial thrombolysis, as well as endovascular mechanical thrombectomy (EMT). The combination of IVT with consecutive on-demand EMT may allow for early treatment initiation with high recanalization rates but has never been systematically tested in patients with BAO.


METHODS
Starting in January 2006, we treated all eligible patients with acute BAO admitted to our academic stroke center or one of our cooperating community hospitals after a standardized protocol combining IVT with consecutive on-demand EMT. Inclusion criteria were: (1) presence of predefined symptoms clearly suggestive of BAO; (2) exclusion of intracerebral hemorrhage on CT scan; (3) evidence of BAO on CT angiography; (4) start of therapy within 6 hours after symptom onset; and (5) no contraindications for IVT. If CT angiography showed persistent BAO after IVT, EMT was performed.


RESULTS
Since January 2006, 16 patients have been treated. All patients received IVT; in 7 of them, EMT became necessary because of persistent BAO. Final recanalization was achieved in 15 patients. Three months after therapy, 12 of 16 patients were still alive; 7 of them had a good outcome (modified Rankin score <or=2).


CONCLUSIONS
Our data suggest that the combination of IVT with on-demand consecutive EMT in BAO is feasible, allows for early treatment, and provides excellent recanalization rates.
Pfefferkorn
Thomas
T
Klinikum Grosshadern, Department of Neurology, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany. Thomas.Pfefferkorn@med.uni-muenchen.de
Mayer
Thomas E
TE
Opherk
Christian
C
Peters
Nils
N
Straube
Andreas
A
Pfister
Hans-Walter
HW
Holtmannspötter
Markus
M
Müller-Schunk
Stefanie
S
Wiesmann
Martin
M
Dichgans
Martin
M
D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001488:Basilar Artery / Q000000981:diagnostic imaging / Q000187:drug effects / Q000601:surgery; D020526:Brain Stem Infarctions / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D002533:Cerebral Angiography; D002985:Clinical Protocols; D004632:Emergency Medical Services / Q000379:methods* / Q000592:standards; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007275:Injections, Intravenous; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011300:Preoperative Care / Q000379:methods; D017131:Thrombectomy / Q000295:instrumentation / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery*
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D010959:Tissue Plasminogen Activator