title: Time window for recanalization in basilar artery occlusion: Speculative synthesis.
abstract: Basilar artery occlusion (BAO) is one of the most devastating forms of stroke and few patients have good outcomes without recanalization. Most centers apply recanalization therapies for BAO up to 12-24 hours after symptom onset, which is a substantially longer time window than the 4.5 hours used in anterior circulation stroke. In this speculative synthesis, we discuss recent advances in BAO treatment in order to understand why and under which circumstances longer symptom duration might not necrotize the brainstem and turn therapeutic attempts futile. We raise the possibility that distinct features of the posterior circulation, e.g., highly developed, persistent collateral arterial network, reverse filling of the distal basilar artery, and delicate plasma flow siding the clot, might sustain brittle patency of brainstem perforators in the face of stepwise growth of the thrombus. Meanwhile, the tissue clock characterizing the rapid necrosis of a typical anterior circulation penumbra will not start. During this perilous time period, recanalization at any point would salvage the brainstem from eventual necrosis caused by imminent reinforcement and further building up of the clot.
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland. perttu.lindsberg@hus.fi.
authors.forename: Perttu J
authors.initials: PJ
authors.lastname: Lindsberg
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
authors.forename: Johanna
authors.initials: J
authors.lastname: Pekkola
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Strbian
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
authors.forename: Tiina
authors.initials: T
authors.lastname: Sairanen
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
authors.forename: Heinrich P
authors.initials: HP
authors.lastname: Mattle
authors.affiliation: From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schroth
mesh_terms: D000818:Animals; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D001488:Basilar Artery / Q000000981:diagnostic imaging* / Q000601:surgery; D002406:Catheterization, Peripheral / Q000379:methods / Q000639:trends*; D006801:Humans; D011859:Radiography; D013997:Time Factors; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery