What is the treatment for basilar artery dissection?

Treatment of Basilar Artery Dissection

For basilar artery dissection presenting with acute ischemic stroke (NIHSS ≥10), endovascular therapy with mechanical thrombectomy plus best medical treatment should be performed within 12 hours, and is reasonable up to 24 hours from last known well. 1

Acute Management Based on Presentation

Ruptured Basilar Artery Dissection (Subarachnoid Hemorrhage)

Endovascular stent placement with or without coiling is the preferred treatment to prevent catastrophic rebleeding, which occurs in the majority of conservatively managed cases. 2

• Stent-assisted coiling or stent-only treatment should be performed urgently, as ruptured dissections carry a 30% mortality rate and high rebleeding risk 2
• Conservative management of ruptured dissections results in rebleeding in 100% of cases in observational series, with 67% mortality 2
• Endovascular treatment achieves favorable outcomes (mRS 0-2) in 90.9% versus 50% with conservative management 2
• Stent-only treatment appears safer during the peri-operative period compared to stent-assisted coiling, with fewer ischemic or hemorrhagic complications 3

Unruptured Basilar Artery Dissection with Ischemic Symptoms

For patients presenting with brain stem ischemia and NIHSS ≥10, mechanical thrombectomy is indicated within 12 hours and reasonable within 12-24 hours. 1

• Intravenous thrombolysis should be administered up to 24 hours unless contraindicated, followed by endovascular therapy 1
• Combined IVT plus EVT is preferred over direct EVT alone 1
• Posterior circulation ASPECTS (pc-ASPECTS) ≥6 supports intervention 1

For patients with NIHSS <10, best medical treatment alone is preferred over EVT, as BMT was safer and non-significantly better than EVT in this population 1

Endovascular Technique Specifics

Mechanical thrombectomy using direct aspiration is suggested as the first-line strategy over stent retrievers for basilar artery occlusion 1

• If dissection with residual stenosis is identified during thrombectomy, angioplasty and/or stenting may be considered, particularly with poor reperfusion or high re-occlusion risk 1
• For complicated EVT procedures (failed recanalization, imminent re-occlusion, or need for stenting), add-on antithrombotic treatment during or within 24 hours after EVT is suggested in patients without concomitant IVT 1

Time Windows for Intervention

• 0-12 hours from last known well: Thrombectomy is indicated (Class I, Level B-R) 1
• 12-24 hours from last known well: Thrombectomy is reasonable (Class IIa, Level B-R) 1
• Beyond 24 hours: Thrombectomy may be considered case-by-case (Class IIb, Level C-EO) 1
• IVT can be considered up to 24 hours in appropriate candidates 1

Conservative Management Considerations

Conservative management with antiplatelet or anticoagulation therapy may be considered for:

• Unruptured dissections with mild symptoms (NIHSS <10) where BMT is safer than EVT 1
• Patients with extensive bilateral brainstem ischemic lesions (pc-ASPECTS 0-6), where 7/10 expert panel members suggest no reperfusion therapy 1

However, conservative management of unruptured dissections with progressive brain stem ischemia carries 18% poor outcome rate versus 9% with endovascular treatment 2

Surgical Options (Historical)

Surgical approaches including proximal basilar artery clipping with flow reversal via posterior communicating arteries have been reported for ruptured dissections, but endovascular approaches are now preferred 4, 5

Critical Pitfalls to Avoid

• Never manage ruptured basilar dissections conservatively - rebleeding is nearly universal and often fatal 2
• Do not delay intervention in ruptured cases - immediate endovascular treatment is necessary 2
• Avoid assuming all dissections require aggressive intervention - mild ischemic presentations (NIHSS <10) may fare better with medical management alone 1
• Do not use stent retrievers as first-line for basilar occlusion - direct aspiration is preferred 1
• Recognize that stenting of ruptured aneurysms increases morbidity - use judiciously and consider stent-assisted coiling when feasible 6

Imaging Considerations

• CT angiography is recommended for initial evaluation 1
• Optical coherence tomography can confirm dissection features (intimal flap, double lumen, mural hematoma) when diagnosis is ambiguous, though it adds procedural risk 7
• pc-ASPECTS ≥6 on baseline imaging supports intervention 1