Impact of ischemic stroke topography on early clinical outcome of basilar artery occlusion: a retrospective study

Moritz R Hernandez Petzsche; Christian Maegerlein; Silke Wunderlich; Benno Ikenberg; Claus Zimmer; Jan S Kirschke; Tobias Boeckh-Behrens; Maria Berndt

doi:10.1007/s00330-024-10755-y

Impact of ischemic stroke topography on early clinical outcome of basilar artery occlusion: a retrospective study

Eur Radiol. 2024 Apr 25. doi: 10.1007/s00330-024-10755-y. Online ahead of print.

Authors

Moritz R Hernandez Petzsche¹, Christian Maegerlein², Silke Wunderlich³, Benno Ikenberg³, Claus Zimmer², Jan S Kirschke², Tobias Boeckh-Behrens², Maria Berndt²

Affiliations

¹ Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany. moritz.hernandez@tum.de.
² Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
³ Department of Neurology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.

PMID: 38662099
DOI: 10.1007/s00330-024-10755-y

Abstract

Objectives: Basilar artery occlusion (BAO) may be etiologically attributed to embolism or in situ thrombosis due to basilar stenosis (BS). Patients with BAO due to BS (BAOS) are known to have worse outcomes than patients with embolic occlusions (BAOE). BAOS occurs more proximally in the basilar artery (BA) than BAOE. We hypothesize that differing brain stem infarct patterns contribute to outcome differences between these stroke etiologies.

Methods: This retrospective study includes 199 consecutive patients with BAO who received endovascular treatment at a single center. Final infarction in brain parenchyma dependent on the posterior circulation was graded semiquantitatively on magnetic resonance imaging (MRI). Associations to underlying stenosis and angiographic and clinical outcome variables were tested. The primary endpoint was early good clinical outcome (EGCO, mRS score ≤ 3 at discharge).

Results: Infarct extension of the medulla oblongata (OR = 0.25; 95% CI = 0.07-0.86; p = 0.03), the inferior pons (OR = 0.328; 95% CI = 0.17-0.63; p = 0.001), the superior pons (OR = 0.57; 95% CI = 0.33-0.99; p = 0.046), and the occipital lobes (OR = 0.46; 95% CI = 0.26-0.80; p = 0.006) negatively predicted EGCO. Infarct extension for other posterior-circulation-dependent brain regions was not independently associated with unfavorable early outcomes. Patients with BAOS had more proximal occlusions and greater infarct volumes in the inferior brain stem. Successful reperfusion (mTICI 2b-3) occurred more often in patients with BAOE than in BAOS (BAOE: 131 (96.3%); BAOS: 47 (83.9%), p = 0.005).

Conclusion: Unfavorable early outcomes in patients with BAOS may be explained by a higher likelihood of inferior brain stem infarcts and lower rates of reperfusion success.

Clinical relevance statement: Basilar artery occlusion due to underlying stenosis is associated with a poorer prognosis than that caused by embolism; these results suggest that aggressive endovascular therapy, usually involving the placement of a permanent stent, may be warranted in these patients.

Key points: Inferior brain stem and occipital infarcts are prognostically unfavorable in basilar artery occlusion. Basilar artery occlusion due to stenosis occurs more proximally and is associated with worse outcomes. Differentiating etiologies of basilar artery occlusion may influence how aggressively treated the occlusion is.

Keywords: Basilar Artery; Diffusion-weighted imaging; Stenosis; Stroke; Thrombectomy.