It is a true neurointerventional emergency and, if not treated early, brainstem infarction results in rapid deterioration in the level of consciousness and ultimately death. In addition to presenting our own case, we performed a pubmed search to comprehensively illustrate demographics, hemorrhage patterns, and treatment outcomes for these lesions. Basilar artery thrombosis statpearls ncbi bookshelf. Due to the severity of the stenosis, the rapid turbulent flow generates a flow void in the proximal portion of the basilar artery characteristic of severe stenosis. Clinical manifestations of isolated bad include ischemic stroke or transient ischemic attack, subarachnoid hemorrhage as a consequence of dissecting aneurysm rupture, and brainstem compression. How to reduce risk factors for basilar artery stroke. Further studies are required to evaluate new medical and endovascular treatment options for this group of patients to improve longterm strokefree survival. Cognitive and functional impairment in stroke survivors with. Basilar throm bosis has a poor prognosis because there is thrombus within the basilar artery that, with minimal extension. Contextbasilar artery occlusion bao is an infrequent disease with high morbidity and mortality. Diagnosis is often delayed, or even missed, as a result of the variety of clinical presentations seen with this condition. Vertebrobasilar stroke carries a mortality rate of more than 85%. The early use of intraarterial thrombolytic therapy has shown promise in improving the outcomes after acute ischemic stroke. Basilar artery occlusion is assumed to carry a grave prognosis, with mortality rates of up to 90%.
Acute ischemic stroke ais due to basilar artery occlusion. Isolated basilar artery dissection bad is a rare but important cause of ischemic stroke. Acute occlusion of the basilar artery may cause brainstem or thalamic ischemia or infarction. The bao syndrome presents as a subset of the larger category of posterior circulation strokes. Recanalization treatments in basilar artery occlusion. Acute basilar artery occlusion bao is associated with a very poor outcome and has the highest mortality rate among intracranial largevessel occlusions 1,2. Most strokes are ischemic usually due to blockage of an artery, but some are hemorrhagic due to rupture of an artery. The pathogenesis of occlusion can be secondary to both local atherothrombosis or cardioembolism. It is a true neurointerventional emergency and, if not treated early, brainstem infarction results in rapid deterioration in the level of consciousness. We present the case of a patient with acute brain stem ischemic. The frequency, incidence, and prevalence of basilar artery occlusion are not known. However, the advent of highquality, reliable, and noninvasive technology eg, magnetic resonance imaging mri has made its diagnosis possible even in subjects with mild symptoms see the image below. Jan 11, 2019 the frequency, incidence, and prevalence of basilar artery occlusion are not known. The vertebrobasilar flow evaluation and risk of transient.
Basilar artery ischemic syndromes a brief discussion of current concepts. Psap 2020 book 1 critical and urgent care 7 acute ischemic stroke acute ischemic stroke. Stroke from basilar artery disease is very variable and can range from a mild lacunar stroke, resulting from a small penetrator disease, to a large, devastating syndrome with extensive destruction of the brainstem from complete or almost complete basilar occlusion fig. Acute basilar artery occlusion radiology reference article. Factors affecting survival rates for acute vertebrobasilar. The vertebrobasilar arterial system perfuses the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Not wrong from a scientific point of view, but wrong from a human point of view. He is a man, a father, a son, a member of a community and he has experiences and a story worth telling.
The limited knowledge on the outcome after a conventional treatment approach comes from a few small case. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke, brain, volume 126, issue 9, september 2003, pages 19401954. The endovascular procedure was performed under general anesthesia, through a transfemoral arterial approach, using an 8f guide catheter neuron max 6f. This results in bilateral thalamic ischemia due to occlusion of perforator vessels. They can cause headtotoe paralysis called lockedin syndrome. The embryology of basilar artery formation has been described in the literature and results from the embryonic fusion of the longitudinal neural arteries to form the single basilar artery in the craniocaudal direction 5. Outcome in patients with basilar artery occlusion treated. The poor outcome in patients with basilar artery occlusion did not improve in more recent years 82% in 1997 to 2002 v 74% in 1991 to 1996, despite more patients being diagnosed with a minor stroke 47% v 35%. Thrombotic strokes are those in which the pathologic process giving rise to thrombus formation in an artery produces a stroke either.
Katherine metcalfe, department of stroke medicine, nottingham university hospitals nhs. Therapy of basilar artery occlusion stroke aha journals. The natural history of internal carotid and vertebral. There are some data to help guide clinicians as to which patients with bao. The symptoms of vertebral artery dissection include head and neck pain and intermittent or permanent stroke. Basilar artery occlusive disease in the new england.
E in a 73yearold man with proximal basilar artery occlusion, right carotid angiography shows filling of the posterior cerebral arteries, the distal basilar artery, and the superior cerebellar arteries from the anterior cerebral circulation via the posterior communicating artery. Basilar artery occlusion remains a significant treatment challenge, resulting in very high mortality and morbidity rates varying from 75 to 100% 1, 4, 6, 8, 10, 1214, 16, 17. Large basilar aneurysm with posterior inferior cerebellar. Brainstem compression syndrome caused by vertebrobasilar. Despite growing literature on posterior vascular disease, specific information about the cognitive and functional profiles of patients with basilar artery occlusion disease baod is scarce.
Surgery of posterior cerebral artery aneurysm springerlink. Basilar artery international cooperation study basics trial. The longterm prognosis of patients with vertebrobasilar dolichoectasia vbd is unknown. This study was designed to elucidate the outcome and prognosis of adults diagnosed with vbd by magnetic resonance angiography mra and to ascertain if these outcomes were independent of known vascular risk factors. It is not infrequent to have prodromal tia symptoms, as the mechanism of basilar artery stroke is frequently intrinsic atherosclerotic disease. The treatment of fusiform aneurysms of the basilar artery is challenging for several reasons, including the presence of perforating vessels, the proximity to the brain stem and the exiting cranial nerves, and the surgical approaches necessary to access the basilar artery 3,4,5.
Vertebral artery dissection vad is a flaplike tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. Acute basilar artery occlusion radiology reference. The difficulty lies within the acute management of ischemic events in patients with large basilar artery aneurysms due to the involvement of both bleeding and thrombosis. We conducted a prospective clinical and imaging followup study of 156 consecutive. The lockedin syndrome lis is a catastrophic condition caused most often by ischemic stroke or hemorrhage, affecting the corticospinal, corticopontine, and corticobulbar tracts in the brainstem. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow.
The most common stroke mechanism was arterytoartery thromboembolism. Publications from 1 january 1960 to 30 june 2011 in english, french, german, italian, and. Head ct showed no hemorrhage, no acute ischemic changes, and a hyperdense basilar artery. Acute ischemic stroke due to basilar artery occlusion bao is associated with the highest mortality and morbidity among strokes attributable. Thank you again for all your effort for the basics trial. Stroke in progress or in evolution increasing symptoms of stroke over time.
There are only limited epidemiological studies evaluating the association between vertebrobasilar dolichoectasia vbd and outcomes. Stroke or transient ischemic attacks with basilar artery. Overview of stroke brain, spinal cord, and nerve disorders. Acute basilar artery thrombosis is associated with a poor prognosis.
Backgroundbasilar artery occlusion bao is associated with a high. Because consciousness and higher cortical functions are spared, patients can sometimes communicate through eye movements. Clinical presentation as a guide to early prognosis in vertebrobasilar. Occlusion of the basilar artery is one of the most devastating forms of ischemic stroke. Abstractacute basilar artery occlusion has a mortality rate approaching 90%. Relationship between clot location and outcome after. Only stroke after carotid t occlusion in the anterior circulation tends to. The basilar artery is composed of two vertebral arteries that have joined together. Deliberate basilar or vertebral artery occlusion in the. Even with thrombolytic therapy, the survival rate in bao is only. The mean time to assessment was 28 days range 1 to 280 for all patients. Request pdf stroke attributable to acute basilar occlusion acute basilar artery occlusion carries a high risk of disabling stroke or death.
The aims of this study were 1 to compare the cognitive statuses of baod survivors versus healthy controls and 2 to correlate the functional capacity outcomes with the cognitive. Of 184 patients with basilar artery occlusion, 95% received intravenous tissue plasminogen activator tpa, and 97% of these also received fulldose intravenous heparin. A traditional recanalization approach based on historical controls and pathophysiological consideration is local intraarterial thrombolysis iat in eligible patients. Strokefree survival and its determinants in patients with. We report two patients with symptomatic highgrade stenosis of the basilar artery refractory to appropriate maximal medical therapy in whom endovascular stenting was performed successfully without preliminary balloon angioplasty. Endovascular embolectomy of acute basilar artery occlusion. Endovascular revascularization for basilar artery occlusion.
Excellent angiographic results were achieved and there were no procedural or periprocedural complications. Can a person survive with a 100% blocked basilar artery. Basilar artery stroke in childhood neuropaediatrie. Top of the basilar syndrome, also known as rostral brainstem infarction, occurs when there is thromboembolic occlusion of the top of the basilar artery. Timeofflight cerebral magnetic resonance angiography showing severe stenosis of the vertebrobasilar junction in a 65yearold man. It ascends superiorly in the basilar sulcus of the ventral pons and divides at the junction of the midbrain and pons into the posterior cerebral arteries. Relationship between clot location and outcome after basilar artery thrombolysis dewitte t.
Because of involvement of the brainstem and cerebellum, most survivors have. The circle of willis thereby serves a safety valve function for the brain, allowing collateral circulation or flow of blood through an alternate route to take place if the flow is reduced to one area. A 20 year old man with no past medical history presented to a primary stroke center with sudden left sided weakness and imbalance followed by decreased level of consciousness. Primary stenting for highgrade basilar artery stenosis. Background and purpose basilar artery occlusion bao is an infrequent form of acute stroke, which invariably leads to death or longterm disability if not recanalized. Mechanical thrombectomy of acute basilar artery occlusion. Basilar artery diameter and 5year mortality in patients with. The circle of willis also allows blood to flow across the midline of the brain if an artery on one side is occluded.
Stroke mechanisms and outcomes of isolated symptomatic basilar. The use of noninvasive imaging such as magnetic resonance imaging and. These are the vessels that are the main supply of blood to the back of the brain. Stroke within the posterior circulation posterior cerebral artery result from atheroma formation or emboli that lodge at the top of the basilar artery may also be caused by dissection of the vertebral artery or fibromuscular dysplasia 30.
Acute basilar artery occlusion carries an exceptionally high morbidity and mortality rate of 8090% without active intervention 5,6. Vanderbilt university medical center stroke symposium 20 41 basilar artery occlusion complete basilar syndrome impairment of consciousness bilateral sensory and motor dysfunction cerebellar signs cranial nerve signs indicative of site top of basilar occlusion lateral midbrain, thalamic, occipital and. Vertebrobasilar dolichoectasia diagnosed by magnetic. This finding suggests that symptomatic vertebrobasilar stenosis behaves similarly to symptomatic extracranial carotid artery stenosis, which is associated with a higher risk of ipsilateral stroke for each decile increase in percent stenosis above 70%.
Good outcomes are possible for basilar artery occlusion. Results stenoses of the intracranial vertebral artery 24 patients and basilar artery 6 patients were treated with stents 10 patients, angioplasty alone patients or both 5 patients. Exposure of the basilar artery within the opticocarotid window is well seen from this image. Clinical outcome varied according to aneurysm site. A low rate of strokefree survival is observed in patients with symptomatic vertebrobasilar stenosis. Jan 09, 20 among the most feared and devastating strokes are ones caused by blockages in the brains critical basilar artery system.
The vertebrobasilar flow evaluation and risk of transient ischemic attack and stroke. Compared to anterior circulation stroke syndromes, posterior circulation ischemia may have a longer prodrome and an evolution that is important to recognize. There is blood supply that can travel backwards down to supply the area bove a blocked basilar artery, so theoretically, there can still be blood supply to the area of the brain even after an entirely blocked basilar artery. We aimed to assess these variables in a comparatively large series of consecutive patients. The basilar artery arises from the union of the two vertebral arteries at the junction between the medulla oblongata and the pons between the abducens nerves cn vi. Natural history of vertebrobasilar dolichoectasia neurology. Prognosis of vertebrobasilar transient ischaemic attack. Kind regards, lucianne langezaal and wouter schonewille. These are believed to be distinct pathological processes. However, the advent of highquality, reliable, and noninvasive technology eg, magnetic resonance imaging mri has made its diagnosis possible even in subjects with mild symptoms see the. The basilar artery is a vital vessel contributing to the posterior cerebral circulation. Isolated basilar artery dissection with ischemic stroke. Post circ stroke case western reserve university school.
A rare case of basilar artery fenestration with anterior. Endovascular treatment of basilar artery occlusion by manual aspiration thrombectomy. The current study suggests that mechanical thrombectomy by use of a solitaire stent within 8 hours of stroke onset increases good outcomes and improves survival in patients with acute basilar artery occlusion. To identify factors that predict survival and good neurologic outcome in patients undergoing basilar artery thrombolysis. Basilar artery stroke symptoms answers on healthtap. Although basilar artery occlusion has been reported in 2 per autopsy cases, basilar artery thrombosis may, in stroke registries, explain as many as 27% of ischemic strokes occurring in the posterior circulation. Most data on the outcome of basilar artery occlusion are from recent case series of patients treated with intraarterial thrombolysis. Successful endovascular therapy for acute basilar thrombosis in. Basilar artery and single vertebral artery presentation, as demonstrated in the present case, account for only 4% of vbd location. Basilar artery aneurysms with subsequent thrombosis can be very difficult to manage in the critical care setting.
Basics basilar artery international cooperation study a. Among the 12 patients with embolism to the ba, 8 had a cardiac source. When basilar artery diameters were introduced into the cox proportionalhazards model as a continuous variable, the relation between basilar artery diameter and stroke death was significant, with a crude hazard ratio hr per 1mm increase in basilar artery diameter of 1. Basilar artery occlusions baos are a subset of posterior circulation strokes.
Acute stroke treatment in patients with basilar artery occlusion. Treating the most feared and devastating strokes sciencedaily. Basilar artery fenestration most frequently occurs in the proximal aspect with a typical extension of less than 5 mm 2,3,4. This study was designed to elucidate the outcome and prognosis of adults diagnosed with vbd by magnetic resonance angiography mra and to ascertain if these outcomes were independent of known vascular. We found 12 patients with basilar perforator artery aneurysms. This lockedin syndrome has a high mortality rate of approximately 75% in. It carries a high mortality of 8595% if recanalization does not occur, and a substantial part of survivors suffer severe disability, some being in locked in state. The remaining stroke mechanisms in groups a and b were artery to artery embolism secondary to ba dissection 3 patients, branch artery occlusive disease 3 patients, basilar migraine 2 patients, coagulopathy 1 patient, and unknown 1 patient. The purpose of this study was to explore the natural history of vbd, evaluate its progression, and examine factors that may influence the clinical course of this condition.
Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Among the most feared and devastating strokes are ones caused by blockages in the brains critical basilar artery system. Occlusion of large vessels in this system usually leads to major disability or death. Basilar artery occlusion bao, representing 20% of all ischemic strokes occurring in the posterior circulation, remains the stroke subtype with the highest mortality rate by far. Longterm outcome after intravenous thrombolysis of basilar artery. We are expecting to be able to present the basics trial results at the esoc in vienna. A low rate of stroke free survival is observed in patients with symptomatic vertebrobasilar stenosis. Perforator artery aneurysms of the basilar trunk are rarely described in the literature. Prognosis of patients with symptomatic vertebral or.
This book is distributed under the terms of the creative commons. Mechanical thrombectomy with stent retrievers in acute. Top of the basilar syndrome radiology reference article. A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply cerebral infarction and causing sudden symptoms. Stroke or transient ischemic attacks with basilar artery stenosis or. A cohort study define vbd as a basilar artery or vertebral artery diameter 4. Further studies are required to evaluate new medical and endovascular treatment options for this group of patients to improve longterm stroke free survival. Stroke attributable to acute basilar occlusion request pdf. Such a gloomy prognosis stands in contrast to the natural course of most other stroke types. Timeofflight cerebral magnetic resonance angiography centered on the posterior fossa showing moderate stenosis of the mid portion of the basilary artery in an 87yearold man with an acute paramedian bilateral pontine infarction manifested by left internuclear ophthalmoplegia, dysarthria, right hemiparesis, and cerebellar ataxia of the lower limbs outcome. Jan 11, 2019 acute basilar artery thrombosis is associated with a poor prognosis.
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