What is the management of basilar artery occlusion?

Management of Basilar Artery Occlusion

Endovascular thrombectomy is the preferred treatment for basilar artery occlusion, especially in patients with severe neurological deficits presenting within 24 hours of symptom onset. 1

Initial Management Algorithm

1. Confirm basilar occlusion with CT/MR angiography
2. Administer IV thrombolysis (alteplase 0.9 mg/kg) to eligible patients within 4.5 hours of symptom onset
3. Prepare for endovascular thrombectomy regardless of IV thrombolysis eligibility
4. Perform endovascular thrombectomy using retrievable stents as first-choice devices
5. Consider intra-arterial thrombolysis only when patients are ineligible for both IV thrombolysis and thrombectomy

Endovascular Thrombectomy

Endovascular thrombectomy has emerged as the superior treatment approach for basilar artery occlusion based on recent evidence. The International Journal of Stroke and American Heart Association strongly recommend this approach 1, which is supported by recent clinical trials.

Key points:

• Time window extends up to 24 hours from symptom onset
• Retrievable stents are the first-choice devices
• Should not be delayed due to coma or severe deficits
• Can be considered despite anticoagulation if patients are otherwise eligible

Recent trials (ATTENTION and BAOCHE) have demonstrated that EVT is beneficial for basilar artery occlusion within 24 hours of onset, with treatment effects similar to those shown in anterior circulation large vessel occlusion strokes 2.

Intravenous Thrombolysis

Intravenous thrombolysis should be administered to eligible patients even if thrombectomy is planned:

• Standard time window: within 4.5 hours of symptom onset
• Recanalization rate with IV tPA alone: approximately 30% 1
• Delay ASA (aspirin) until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage

Studies have shown that intravenous administration of alteplase for patients with BAO can achieve rates of survival, recanalization, and independent functional outcomes comparable to those reported with some endovascular approaches 3. However, more recent evidence and guidelines favor endovascular thrombectomy as the primary treatment when available.

Intra-Arterial Thrombolysis

Intra-arterial thrombolysis may be considered as an alternative in specific situations:

• When patients present within 6 hours of symptom onset
• When patients are not eligible for IV thrombolysis
• When endovascular thrombectomy is not available

The symptomatic intracranial hemorrhage rate with intra-arterial thrombolysis is approximately 10% 1.

Important Considerations

• Do not exclude patients in coma from treatment. Even patients presenting with coma can achieve moderate outcomes 1
• Factors associated with favorable outcomes include younger age, lower baseline NIHSS score, less baseline ischemic changes, and successful recanalization 1
• Without recanalization, the likelihood of good outcome is close to nil (approximately 2%) 4

Common Pitfalls to Avoid

• Delaying treatment due to coma or severe deficits
• Waiting for clinical improvement before initiating therapy
• Limiting treatment options based solely on time from symptom onset
• Failing to prepare for endovascular therapy while administering IV thrombolysis
• Not confirming basilar occlusion with appropriate imaging

Treatment Efficacy

Meta-analysis data suggests that mechanical thrombectomy offers superior outcomes compared to thrombolysis alone:

• Favorable outcome (mRS 0-2) rates: 37% with mechanical thrombectomy versus 22.6% with intra-arterial thrombolysis and 32.6% with intravenous thrombolysis 5
• Statistical superiority of mechanical thrombectomy over intra-arterial thrombolysis and over any rt-PA administration 5