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Background and Purpose: Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively)., Methods: We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC., Results: Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01)., Conclusions: In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Alemseged reported research grants from Medical Research Future Fund, Australian Heart Foundation, Sylvia & Charles Viertel Charitable Foundation. Dr Fischer reported research grants from Medtronic; consultant for Medtronic, Stryker, CSL Behring; advisory board for Alexion/Portola. Dr Kaesmacher reported grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, Clinical Trials Unit Bern, and the Swiss National Science Foundation. Dr Nagel reported consultancy for Brainomix, speaker bureaus with Boehringer Ingelheim and Pfizer. Dr Nguyen reported research support from Medtronic and SVIN. Dr Puetz reported fees as lecturer for Daiichi Sankyo. Dr Sacco reported research grants from Novartis and Uriach; fees for advisor or speaker from Abbott, Allergan-Abbvie, AstraZeneca, Lilly, Lundbeck, Novartis, Novo Nordisk, Pfizer, Teva. Dr Siegler reported consulting from Ceribell and speakers’ bureau with AstraZeneca. Dr Thomalla reported fees as a consultant from Acandis, Alexion, Amarin, Bayer, Bristol Myers Squibb/Pfizer, Boehringer Ingelheim, Portola, and Stryker. Dr Yamagami reported research grants from Bristol-Myers Squibb, lecturer’s fees from Bayer, Daiichi-Sankyo, Stryker, Bristol-Myers Squib; advisory boards for Daiichi-Sankyo. Dr Banerjee reported consultancy for RapidAI. Dr Marto reports consulting fees from Amicus Therapeutics and Boehringer Ingelheim; speaker fees from Boehringer Ingelheim. Dr Kaiser reported grants from the Joachim Herz Foundation and the Else Kröner Fresenius Center for Digital Health.

Background: Randomized controlled trials indicate functional and mortality benefits in endovascular therapy for basilar artery occlusion (BAO). However, these studies only include patients who meet specific prognostic scores. This study investigates radiographic predictors of posterior circulation territory infarcts that may predict neurologic outcome at 90-day post-intervention., Methods: This is a retrospective cohort study of a prospectively maintained thrombectomy database of all patients who underwent mechanical thrombectomy for BAO. Baseline demographics, comorbidities, baseline functional status (mRS), and severity of presenting neurologic deficits (NIHSS) were collected. Pc-ASPECTS, posterior circulation collateral score (PCCS), and basilar artery on computed tomography angiography (BATMAN) measured radiographic characteristics. Core infarct territory was identified. Primary outcomes were good neurologic outcome (mRS 0-3) and poor neurologic outcome (mRS 4-6) at 90-day post-thrombectomy. 90-day mortality was a secondary outcome., Results: About 21.5% of patients achieved a good neurologic outcome. About 32.3% of patients were deceased at 90 days. Receiver operating characteristic analysis shows PCCS collateral scores (AUC = 0.74, SE = 0.03, CI = 0.62-0.74) and BATMAN (AUC = 0.72, SE = 0.04, CI = 0.35-0.49) have potential to differentiate between those with good neurologic outcome from those with poor neurologic outcome. Although there was no statistically significant difference in AUC between the three curves, pc-ASPECTS score trended toward being weaker predictor of neurologic outcome (AUC = 0.49, SE = 0.04, CI = 0.35-0.49). There were significant associations between 90-day poor neurologic outcome and established infarcts within the pons ( p  = 0.01), left cerebellum ( p  = 0.01), and left occipital lobe ( p  = 0.03) on pre-thrombectomy CT., Conclusion: Low BATMAN and PCCS collateral scores can be predictors of poor neurologic outcomes at 90-day post-thrombectomy for BAO while pc-ASPECTS score may be a weaker predictor of outcome., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender., Methods: From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO., Results: Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p  < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p  < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p  = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p  < .01)., Conclusions: Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

Objectives: Few experiences on vertebrobasilar occlusion over underlying intracranial atherosclerotic disease have been reported in literature and the optimal strategy on how to perform a mechanical thrombectomy is unclear. The aim of this paper is to bring our experience based on patients admitted with acute vertebrobasilar occlusion with underlying atheromatous lesions., Materials and Methods: Several data were collected from August 2009 to October 2022 including clinical history, pre- and post-treatment neurological objectivity, diagnostic images and angiographic procedural images, and clinical outcome at 6 months. We selected 13 patients from August 2009 to October 2022, 12 men and 1 woman, aged 40 to 82 years (mean age, 62.6 years)., Results: Mechanical thrombectomy with a thromboaspiration was performed in all patients as beginning of the procedure. In three patients, the procedures resulted in excellent angiographic result and clinical outcome, while in three patients, we observed a failure of the procedural and clinical outcome. For residual intracranial stenosis in three patients, an angioplasty was performed obtaining an ischemic area related to the posterior circulation. In four patients, a stent was placed, in three patients, we obtained a good clinical outcome with a mRS between 0 and 2, while one treatment resulted in death, probably due to a late endovascular treatment., Conclusions: Endovascular treatment with stent deployment appears to result in an excellent outcome in patients with occlusion of the vertebrobasilar circulation in cases of occlusion on atheromatic plaque. The degree of residual stenosis after thrombospiration can significantly affect subsequent type of treatment., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A decade on from the first positive thrombectomy trials, hyperacute therapies for ischemic stroke continue to rapidly advance. Effective treatments remain limited to reperfusion, although several cytoprotective approaches continue to be investigated. Intravenous fibrinolytics are now demonstrated to be beneficial up to 24 h in patients selected using perfusion imaging, but their role in patients with non-disabling symptoms appears very limited. Tenecteplase is superior to alteplase in meta-analysis of the latest trials, and adjuvant thrombolytics are an area of active investigation. Endovascular thrombectomy is beneficial in a wide range of anterior and posterior circulation large vessel occlusions up to 24 h after onset with the more distal occlusions, mild presentations, and >24 h window being the main frontiers to be tested in ongoing trials. Imaging parameters are prognostic but appear not to modify the relative treatment benefit of thrombectomy versus standard medical care. Therefore, deciding who not to treat with thrombectomy is a key clinical challenge that requires careful but rapid integration of clinical, imaging, and patient preference considerations. Systems of care to accelerate delivery of these highly effective therapies will maximize benefits for the greatest number of patients with stroke., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Age is often used as a predictor in determining outcomes in large vessel occlusions treated with mechanical thrombectomy. However, limited data exist for octo/nonagenarian outcomes compared to younger individuals in acute basilar artery occlusions treated with thrombectomy., Methods: Patient data were obtained from the PC-SEARCH Thrombectomy Registry which consists of 444 acute basilar artery occlusions treated with mechanical thrombectomy. Individuals were dichotomized based on age (>80 and ≤80 years old). Primary outcome was defined as modified Rankin Scale of 0-3 at 90 days. Logistic and multivariate regression, as well as control-matched analysis, were performed., Results: There were 373 and 71 patients in the younger and older cohorts, respectively. Gender, ethnicity, smoking status, atrial fibrillation, and coronary artery disease were noted to be significantly different between cohorts. At 90 days, 178 (47.7%) and 23 (32.4%) patients achieved primary outcome at 90 days (p = 0.02), however, after controlling for potentially confounding factors this association lost significance (OR 0.50 95% CI 0.24-1.05; p = 0.07). There were 84 patients included in the control matched analysis and demonstrated no significant differences on multivariate analysis between cohorts (OR 0.68 95% CI 0.25-1.84; p = 0.45)., Interpretation: Octa/nonagenarians presenting with an acute basilar artery occlusion treated with mechanical thrombectomy can achieve acceptable rates of favorable functional outcomes compared to younger individuals with similar baseline demographic and stroke characteristics., Competing Interests: Authors’ contributionThe authors who have contributed to at least one of the key contributions that justify authorship, including (1) conception and design of the study (ATM, PPR, MJ), (2) acquisition and analysis of data (ATM, PPR, MJ) or (3) drafting a significant portion of the manuscript or figures (i.e., a substantial contribution beyond copy editing and approval of the final draft, which is expected of all authors) (ATM, PPR, MJ). Individuals who contributed data acquisition (including phenotyping and gathering information on patients) but not to the final analysis that is unique to this manuscript (e.g., site investigators in a large clinical trial or contributors to a large patient database) (PC-SEARCH Thrombectomy REGISTRY Group includes: NA, KG, EA, SZ, AN, SAK, SOG, JVS, MF, APJ, SD, GT, AA, TNN, PK, MA, ZW, SV, and NV). Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Mouhammad Jumaa has received general payments (<$1000) and academic funding from Chiesi USA, Genentech, Medtronic, and Stryker. Dr Sami Al Kasab has received general payments (<$1000) from AstraZeneca Pharmaceuticals, MicroVention, and Stryker. Dr Santiago Ortega Gutierrez has received general payments and academic funding from Medtronic, and Siemens Medical Solutions USA, Stryker. Dr Ashutosh P Jadhav has received general payments (<$1000) and academic funding from Medtronic, Viz AI, and Medical Device Business Services, Inc. Dr Toth Gabor has received general payments (<$1000) and academic funding from BioSense Webster, Medtronic, and Stryker. Dr Thanh Nguyen has received academic funding from AtriCure.

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique., Competing Interests: Declaration of conflicting interestsJAH is a consultant for Medtronic. ABP is a consultant for Medtronic, Microvention, and Penumbra.

Purpose: To investigate the performance of the Critical Area Perfusion Score (CAPS), based on computed tomography perfusion (CTP) time to maximum (Tmax) > 10s maps, to predict the outcome in acute basilar artery occlusion (BAO) in patients undergoing endovascular treatment (EVT)., Methods: We perform a retrospective analysis of a prospectively collected database of acute BAO treated with EVT in a comprehensive stroke center. The favorable outcome was defined as the 90-day modified Rankin Scale (mRS) ≤ 3. We performed the logistic regression analysis to find the independent predictors of the favorable outcome. Then, we used receiver operating characteristic analyses to assess the predictive value of the imaging parameters, including CAPS, Posterior Circulation Alberta Stroke Program Early CT Score (PC-ASPECTS), pons midbrain index (PMI), posterior circulation computed tomography angiography (PC-CTA) score, Basilar Artery on Computed Tomography Angiography (BATMAN) score, and CTP parameters. Finally, the Delong test was used to compare the area under the curve (AUC) of CAPS against the other imaging parameters., Results: Of the 65 enrolled patients, the incidence of the favorable outcome was 44.6% (29/65). Low CAPS (per 1- point increased odds ratio [OR], 0.43; 95% confidence interval [CI], 0.22-0.86; P = 0.017) and admission National Institutes of Health Stroke Scale (NIHSS) (per 1- point increased OR, 0.80; 95% CI, 0.70-0.91; P = 0.001) were independently associated with favorable outcome. The AUC of CAPS was 0.83 (95% CI, 0.74-0.93; P < 0.001) with ≤ 3 cut-off value, 89.66% sensitivity, 77.22% specificity, and 80.00% accuracy, which was greater than the other imaging parameters (All P for Delong test < 0.05)., Conclusions: CAPS was the most accurate imaging-based outcome predictor in acute BAO patients. Future large prospective multicenter studies are needed to verify these results.

Basilar artery occlusion (BAO) is an uncommon event, and leads to poor outcome in an estimated 60 to 80% of patients. Two early randomized trials, BASICS and BEST demonstrated equivocal benefit of endovascular therapy (EVT) compared to medical management. These trials helped in forming the design, sample size and eligibility criteria for the subsequent two trials, ATTENTION and BAOCHE which demonstrated superiority of EVT over medical management. In this commentary, we look at the evolution of how early BAO studies formed the building blocks for successive BAO trials, review lessons learned, and opportunities for future research., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T. Nguyen reports advisory board for Idorsia. W. Schonewille reports PI of BASICS trial.

Background: Stroke caused by acute basilar artery occlusion (BAO) is devastating with high dependency and mortality. Recent trials have demonstrated the efficacy of endovascular treatment (EVT) for acute BAO, while pretreatment collaterals may be a valuable prognostic indicator for post-EVT outcomes., Aims: To systematically review and synthesize evidence on the associations between pretreatment collateral status and outcomes after EVT in acute BAO., Methods: We retrieved relevant full-text articles published in English since 1 January 2010, reporting associations between pretreatment collateral status and outcomes after EVT for BAO, by searching MEDLINE and Embase. The primary outcome was favorable or good 90-day functional outcome (modified Rankin Scale [mRS] 0-2 or 0-3); secondary outcomes included successful recanalization, symptomatic intracranial hemorrhage, final infarct volume, and 90-day mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) for good versus poor collaterals on the outcomes were synthesized using random-effects models. Subgroup and sensitivity analyses were conducted for the primary outcome., Results: Overall, 29 primary studies (2995 participants) were included in qualitative review, among which 16 studies (1447 participants) were meta-analyzed. With different imaging modalities and methods to grade the collateral status, good collaterals were found in 33-85% of patients in the individual primary studies (I 2  = 95.2%, p < 0.001), with a pooled proportion of 51% (95% CI: 40-62%) across all studies. Good pretreatment collaterals were associated with a doubled rate of favorable/good 90-day functional outcome (RR = 2.03, 95% CI: 1.63-2.51, p < 0.001), a higher rate of successful recanalization (RR = 1.23, 95% CI: 1.04-1.45, p = 0.015), and reduced 90-day mortality (RR = 0.59, 95% CI: 0.43-0.81, p = 0.001) after EVT for BAO. None of the primary studies reported the associations of good collaterals with the other secondary outcomes. Subgroup analyses revealed possibly more prominent protective effect of good pretreatment collaterals over the primary outcome, in studies with longer time windows in patient eligibility criteria for EVT (p = 0.028 for between-subgroup heterogeneity)., Conclusions: In patients with BAO receiving EVT, good pretreatment collateral status was associated with a higher chance of favorable 90-day functional outcome, despite the various methods in grading the collateral circulation. Efforts are needed for more standardized collateral assessment in BAO, for more reliable and generalizable investigations of its clinical implications.

Background: To investigate the relationship between clinical routine inflammatory markers, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), white blood cell count (WBC), neutrophils, lymphocytes, and platelets with clinical outcomes in acute basilar artery occlusion (BAO) patients receiving endovascular treatment (EVT)., Methods: We recruited 2134 acute BAO patients from 48 stroke centers across 22 Chinese provinces in the ATTENTION registry from 2017 to 2021. Blood samples were drawn at admission. An unfavorable functional outcome was defined using a modified Rankin Scale (mRS) of 4-6 at 90 days. Safety outcomes included mortality within 90 days and symptomatic intracerebral hemorrhage within 3 days., Results: A total of 1044 patients were included in the final study. After adjusting for confounding factors, the upper quartiles of WBC and NLR were related to 90-day unfavorable functional outcome (mRS = 4-6) compared with those in the lowest quartile (WBC: quartile 4, odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.22-2.80; NLR: quartile 4, OR = 2.02, 95% CI = 1.34-3.06). The higher quartiles of WBC and NLR were also related to the increased risk of mortality at 90 days. Restricted cubic spline regression analysis showed an incremental trend between NLR and 90-day unfavorable functional outcome (P nonlinearity  = 0.055). In subgroup analysis, a significant interaction was found between NLR and bridging therapy for predicting unfavorable functional outcome (P = 0.006)., Conclusion: Higher WBC and NLR on admission are significantly related to unfavorable functional outcome and mortality at 90 days in acute BAO patients receiving EVT. Significant interaction was found between increased NLR and bridging therapy on these outcome measures.

Background: Basilar artery occlusion (BAO) stroke is a catastrophic clinical event that results in significant morbidity and mortality. Whether MT is superior in improving outcomes remains largely inconclusive. We performed a meta-analysis of randomized controlled trials (RCTs) to better understand the efficacy and safety of MT in treating BAO compared to medical management (MM)., Methods: PubMed and EMBASE were searched to identify RCTs that directly compared the safety and efficacy of MT versus MM for patients with BAO. The primary outcome was modified Rankin scale (mRS) 0-3 at 3 months, and secondary outcome variables included National Institutes of Health Stroke Scale (NIHSS) at 24 hours, mRS 0-2 at 3 months, symptomatic intracranial hemorrhage (sICH), and 90-day mortality., Results: Four RCTs with 988 patients (432 in the MM arm and 556 in the MT arm), were included. Patients receiving MT had significantly higher rate of mRS 0-2 (OR = 1.994, 95% CI: 1.319-3.012) and mRS 0-3 (OR = 2.259, 95% CI: 1.166-4.374) at 3 months in comparison to patients receiving MM. Mortality was also significantly reduced in the MT group (OR = 0.640, 95% CI: 0.493-0.831). However, increased odds of sICH were found in the MT group compared to the MM group (OR = 8.193, 95% CI: 2.451-27.389). No difference was observed in terms of NIHSS at 24 hours between the two arms., Conclusions: Despite the higher risk of sICH, MT was associated with superior functional outcomes and reduced mortality compared to MM in BAO patients. A revision of current guidelines for treatment of acute ischemic stroke from basilar artery occlusion should be considered.

Background and Purpose: The benefit of thrombectomy (TE) for acute ischemic stroke (AIS) in patients suffering basilar artery occlusion (BAO) is still unclear. Our aim was to analyze functional outcome after 3 months in BAO compared to anterior circulation large vessel occlusion (ACLVO) in a nationwide registry., Methods: Patients enrolled into the Austrian Endostroke Registry from 2013 to 2018 were analyzed. We used propensity score matching to control for imbalances and to compare patients with BAO and ACLVO. The primary outcome was favorable functional outcome after 3 months measured by the modified Rankin Scale (mRS) (0-2). Multivariate models were applied to estimate the effect of localization (BAO vs ACLVO)., Results: In total, 2288 patients underwent TE for AIS with proximal vessel occlusion, of these 267 with BAO. Two hundred and sixty-four patients with BAO were matched to 264 patients with ACLVO. Baseline characteristics were well-balanced. The 90-day mortality did not significantly differ between patients with BAO and ACLVO. In a multivariate logistic regression model, we did not detect a significant difference in functional outcome between BAO and ACLVO (odds ratio for favorable outcome defined as mRS = 0-2: 1.19; 95% confidence interval (CI) = 0.78-1.81; p  = 0.42). In patients with an onset-to-door-time ⩾270 min, TE of BAO was associated with poor functional outcome defined as mRS 3-6 (odds ratio (OR) = 3.97; 95% CI = 1.32-11.94; p  = 0.01) as compared to ACLVO., Conclusion: In this study, functional outcome did not differ after TE in patients with BAO and ACLVO overall; however, we detected an association of BAO with poor outcome in patients arriving late.

Background and Hypothesis: Recently, two multicenter randomized controlled trials (RCT) failed to show a significantly beneficial effect of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO). However, both trials suffered from equipoise issues which may have hindered the validity of the trial results. Therefore, additional RCT studies are needed to explore the potential benefit of EVT in patients presenting with BAO., Study Design: ATTENTION is an investigator-initiated, multicenter, prospective, randomized, controlled clinical trial with open-label treatment and blinded outcome assessment (PROBE) of EVT versus best medical management (BMM). The primary effect parameter is a modified Rankin Score of 0-3 at day 90., Discussion: ATTENTION will provide evidence for the efficacy and safety of EVT in stroke patients within 12 h after BAO., Trial Registration: ClinicalTrials.gov NCT04751708.

Purpose: Clinical outcomes vary considerably among individuals with vessel occlusion of the posterior circulation. In the present study we evaluated machine learning algorithms in their ability to discriminate between favourable and unfavourable outcomes in patients with endovascular treatment of acute ischaemic stroke of the posterior circulation., Methods: This retrospective study evaluated three algorithms (generalised linear model, K-nearest neighbour and random forest) to predict functional outcomes at dismissal of 30 patients with acute occlusion of the basilar artery who were treated with thrombectomy. Input variables encompassed baseline as well as peri and postprocedural data. Favourable outcome was defined as a modified Rankin scale score of 0-2 and unfavourable outcome was defined as a modified Rankin scale score of 3-6. The performance of the algorithms was assessed with the area under the receiver operating curve and with confusion matrixes., Results: Successful reperfusion was achieved in 83%, with 30% of the patients having a favourable outcome. The area under the curve was 0.93 for the random forest model, 0.86 for the K-nearest neighbour model and 0.78 for the generalised linear model. The accuracy was 0.69 for the generalised linear model and 0.84 for the random forest and the K nearest neighbour models., Conclusion: Favourable and unfavourable outcomes at dismissal of patients with acute ischaemic stroke of the posterior circulation can be predicted immediately after the follow-up non-enhanced computed tomography using machine learning.

Basilar artery occlusion (BAO) is one of the most devastating types of ischaemic stroke and is identified by using computed tomography (CT) angiography. Marfan syndrome is an autosomal dominant disorder involving multisystem connective tissue, and the neurological complications are relatively rare. In this article, we report a case of a young Marfan syndrome patient complicated with BAO ischaemic stroke. The patient was an 18-year-old man with right hemiparesis, aphasia and impaired consciousness. CT angiography of the brain showed an occlusion distal to the basilar artery. Endovascular therapy including intravenous thrombolysis and mechanical thrombectomy (MT) was administered to this patient inside the therapeutic window. The patient had a favourable clinical outcome after endovascular therapy. Marfan syndrome may be a rare cause of ischaemic stroke with BAO. In addition, our report provides some evidence that can be used as a reference when planning therapeutic strategies for BAO patients with Marfan syndrome.

The long-term functional outcome of acute basilar artery occlusion (BAO) patients who received modern endovascular therapy (EVT) is unclear. We sought to assess the long-term functional outcome of BAO patients treated with EVT and determine the prognostic factors associated with favorable outcome. We enrolled consecutive BAO patients who received EVT between December 2012 and December 2018 in this observational study. Baseline characteristics and outcomes were presented. Multivariable logistic regression analysis was performed to identify the prognostic factors associated with long-term outcome. Among the 177 BAO patients included in this study, 80 patients (45.2%) obtained favorable outcome and 97 patients (54.8%) had unfavorable outcome at long-term follow-up with a median observation time of 12 months (interquartile range, 3-19). A total of 67 patients (37.9%) died. National Institutes of Health Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS), time from stroke onset to recanalization, and recanalization condition were identified as independent predictors for long-term outcome. Over 40% of BAO patients who were treated with modern EVT achieved favorable outcome at long-term follow-up. NIHSS, pc-ASPECTS, time from stroke onset to recanalization, and recanalization condition were identified as independent prognostic factors of long-term outcome.

Purpose: To assess the predictive value of three scoring systems based on diffusion weighted imaging in basilar artery occlusion patients after endovascular treatment., Methods: We analyzed clinical and radiological data of patients with basilar artery occlusion from January 2010 to June 2019, with modified Rankin Scale of 0-2 and 3-6 defined as favorable outcome and unfavorable outcome at three months. Diffusion weighted imaging posterior circulation ASPECTS Score (DWI pc-ASPECT Score), Renard diffusion weighted imaging Score, and diffusion weighted imaging Brainstem Score were used to evaluate the early ischemic changes., Results: There were a total of 88 basilar artery occlusion patients enrolled in the study after endovascular treatment, with 33 of them getting a favorable outcome. According to the analysis, the time from onset to puncture within 12 h (odds ratio: 4.34; 95% confidence interval: 1.55-12.16; P  = 0.01), presence of collateral flow via PCoA (odds ratio: 0.31; 95%CI: 0.12-0.79; P  = 0.01) or between PICA and SCA (odds ratio: 0.18; 95%CI: 0.07-0.47; P  = 0.00), equal or less than 15 points on baseline NIHSS (area under the curve 0.79, 95% CI 0.69-0.89; sensitivity = 69.1%, specificity = 81.8%; P  = 0.00), and equal or less than 1.5 points on diffusion weighted imaging Renard score (area under the curve 0.63, 95% CI 0.51-0.75; sensitivity = 83.6%, specificity = 39.4%; P  = 0.046) were independently associated with favorable outcome., Conclusions: Renard diffusion weighted imaging score may be an independent predictor of functional outcome in basilar artery occlusion patients after endovascular treatment.

Background: CT perfusion may improve diagnostic accuracy in posterior circulation stroke. The posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS) on Computed Tomography Angiography source images (CTA-SI) predicts functional outcome in patients with basilar artery occlusion., Aims: We assessed the prognostic value of pc-ASPECTS on CT perfusion in patients with vertebral and basilar artery occlusion (VBAO) in comparison with CTA-SI., Methods: Whole-brain CT perfusion from consecutive stroke patients with VBAO at four stroke centers was retrospectively analyzed. pc-ASPECTS - a 10-point score assessing hypoattenuation on CTA-SI - was calculated from CT perfusion parameters as focally reduced cerebral blood flow or cerebral blood volume, focally increased time to peak of the deconvolved tissue residue function (Tmax) or mean transit time. Two investigators independently reviewed the images. Reliability was assessed with intraclass correlation coefficient. Good outcome was defined as modified Rankin scale ≤3 at three months., Results: We included 60 patients with VBAO. After assessment of four CT perfusion maps simultaneously, area-under-ROC curve (AROC) was 0.83 (95%CI 0.72-0.93) for cerebral blood volume, 0.76 (95%CI 0.64-0.89) for cerebral blood flow, 0.77 (95%CI 0.64-0.89) for Tmax, 0.70 (95%CI 0.56-0.84) for mean transit time versus area-under-ROC curve 0.64 (95%CI 0.50-0.79) for CTA-SI. Cerebral blood volume had greater accuracy compared with CTA-SI for poor outcome (p = 0.04). In logistic regression analysis, cerebral blood volume pc-ASPECTS≤8 was independently associated with poor outcome (OR 9.3 95%CI 2.2-41; p = 0.003, adjusted for age and clinical severity). Inter-rater agreement was substantial for cerebral blood volume pc-ASPECTS (intraclass correlation coefficient 0.82 95%CI 0.71-0.90 versus 0.67 for CTA-SI 95%CI 0.43-0.81)., Conclusions: Cerebral blood volume pc-ASPECTS may identify VBAO patients at higher risk of disability.

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Background Coma is associated with poor outcome in patients with basilar artery occlusion. Aims We sought to assess whether the posterior circulation Acute Stroke Prognosis Early CT Score and the Pons-Midbrain Index applied to CT angiography source images predict the outcome of comatose patients in the Basilar Artery International Cooperation Study. Methods Basilar Artery International Cooperation Study was a prospective, observational registry of patients with acute basilar artery occlusion with 48 recruiting centers worldwide. We applied posterior circulation Acute Stroke Prognosis Early CT Score and Pons-Midbrain Index to CT angiography source images of Basilar Artery International Cooperation Study patients who presented with coma. We calculated adjusted risk ratios to assess the association of dichotomized posterior circulation Acute Stroke Prognosis Early CT Score (≥8 vs. <8) and Pons-Midbrain Index (<3 vs. ≥3) with mortality and favourable outcome (modified Rankin Scale score 0-3) at one month. Results Of 619 patients in the Basilar Artery International Cooperation Study registry, CT angiography source images were available for review in 158 patients. Among these, 78 patients (49%) presented with coma. Compared to non-comatose patients, comatose patients were more likely to die (risk ratios 2.34; CI 95% 1.56-3.52) and less likely to have a favourable outcome (risk ratios 0.44; CI 95% 0.24-0.80). Among comatose patients, a Pons-Midbrain Index < 3 was related to reduced mortality (adjusted RR 0.66; 95% CI 0.46-0.96), but not to favourable outcome (adjusted RR 1.19; 95% CI 0.39-3.62). Posterior circulation Acute Stroke Prognosis Early CT Score dichotomized at ≥ 8 vs. <8 was not significantly associated with death (adjusted RR 0.70; 95% CI 0.46-1.05). Conclusion In comatose patients with basilar artery occlusion, the extent of brainstem ischemia appears to be related to mortality but not to favourable outcome.

Background and Aim: Our aim was to assess the prognostic value of a semiquantitative computed tomography angiography-based grading system, for the prediction of outcome in patients with acute basilar artery occlusion, based on the presence of potential collateral pathways on computed tomography angiography: the posterior circulation collateral score (PC-CS)., Methods: One hundred forty-nine patients with acute basilar artery occlusion from the Basilar Artery International Cooperation Study were included. We related poor outcome at one month, defined as a modified Rankin scale score of 4 or 5, or death to collateral flow with Poisson regression. We used a 10 points grading system to quantify the potential for collateral flow in the posterior communicating arteries and the cerebellar arteries. Additionally, the relation between the presence and size of posterior communicating arteries and outcome was analyzed., Results: Thirty-six patients had poor (PC-CS: 0-3), 59 patients intermediate (PC-CS: 4-5), and 54 patients good (PC-CS: 6-10) collaterals. Multivariable analyses showed a statistically significant lower risk of poor outcome in patients with a good PC-CS than in patients with a poor PC-CS (risk ratio (RR): 0.74, 95% confidence interval (CI): 0.58-0.96), but not for patients with an intermediate PC-CS compared with patients with a poor PC-CS (RR: 0.95, 95% CI: 0.78-1.15). Multivariable analyses showed a statistically significant lower risk of poor outcome for the presence of at least one posterior communicating artery and for larger caliber of posterior communicating arteries (RR: 0.79, 95% CI: 0.66-0.95 and 0.76, 95% CI: 0.61-0.96, respectively)., Conclusions: The PC-CS predicted poor outcome at one month. In a separate analysis, both the absence and smaller caliber of posterior communicating arteries predicted poor outcome., (© 2016 World Stroke Organization.)

An acute basilar artery occlusion is not an uncommon cause of stroke. It represents 6-10% of large vessel strokes and has been associated with poor clinical outcomes. Multimodal treatments have been introduced to recanalise a basilar artery occlusion successfully. However, all mechanical thrombectomy devices are not always usable in an emergent situation. We present a case of basilar artery occlusion treated with a stent retriever assisted by a vertebral artery vasospasm. We attempted thrombectomy with a stent retriever several times. However, the captured thrombus was not pulled out and migrated to the distal basilar artery and posterior cerebral artery due to anterograde flow of the vertebral artery. We carefully advanced the catheter into the distal vertebral artery and generated a vasospasm. The vertebral artery vasospasm reduced the forward flow significantly like a balloon-guided catheter. The thrombus was pulled out with the stent., (© The Author(s) 2015.)

Background: Early arterial recanalisation with stent retrievers (SR) has been recently demonstrated to improve clinical outcome of patients with large-vessel occlusion of the anterior circulation. However, the benefit of SR thrombectomy in the setting of acute basilar artery occlusion (BAO) has not been proven yet. This study evaluated a series of consecutive patients with BAO treated with SR, focusing on the efficacy, safety and clinical results., Methods: We analysed 24 consecutive patients with acute BAO who were treated with SR mechanical thrombectomy. Good clinical outcome at three months was defined as mRS ≤ 2. Data from patients with good outcome were compared to that from patients with poor outcome., Results: Sufficient recanalisation (TICI 2 b or 3) was achieved in 63% (15/24) of patients. At three months, 33% (8/24) of patients had died; good clinical outcome was obtained in 21% (5/24). Age (46 vs. 60 years old, p = 0.05) and time from symptoms onset to recanalisation (370 vs. 521 minutes, p = 0.048) was significantly lower in patients with good outcome as compared to patients with poor outcome. There were three cases (12.5%) of periprocedural complications, all of them related to arterial wall dissection/perforation., Conclusions: SR thrombectomy might be an efficient and safe treatment for patients with acute BAO occlusion and might help improve outcome., (© The Author(s) 2015.)

Basilar artery occlusions (BAOs) are a subset of posterior circulation strokes. Particular issues relevant to BAOs include variable and stuttering symptoms at onset resulting in delays in diagnosis, high morbidity and mortality, and uncertain best management. Despite better imaging techniques, diagnosis, and therefore treatment, is often delayed. We will present the most common signs and symptoms of posterior circulation strokes. Data on optimal treatment strategies are gathered from multiple case series, registries, and one randomized trial, which was stopped early. Possible etiologies of BAOs, acute, and subacute treatment strategies and special topics in neuroimaging of the posterior fossa are discussed. This review may be helpful to neurohospitalists who are managing patients with acute stroke as well as emergency room physicians and neurologists.

Introduction: Basilar artery occlusion (BAO) causes mortality up to 90%., Methods: A total of 99 patients with BAO received either endovascular (endovascular mechanical recanalization and/or intra-arterial with optional intravenous thrombolysis [IVT] as bridging concept) or conservative medical treatment (IVT and/or medical oral therapy). Outcome parameters were measured in accordance with the thrombolysis in cerebral infarction (TICI), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin Scale (mRS) scores., Results: In all, 78% underwent endovascular and 22% conservative medical treatment. The NIHSS at admission was 20 in both the groups. Postprocedurally, 36% (95% confidence interval: 26%-48%) of the endovascular group and 9% (21%-64%) of the conservative group reached TICI 3 (P = .017). In all, 30% of the endovascular group and 9% of the conservative group were documented with TICI 2b (P = .057). At 90 days follow-up, 45% (31%-60%) of the endovascular-treated patientsand no patient (0%-25%) of the conservative-treated group reached mRS ≤2 (P = .012)., Conclusion: Endovascular treatment of BAO provides a better chance to survive this severe condition with good clinical outcome.