Journal Mobile Options
Table of Contents
Vol. 14, No. 1, 2002
Issue release date: June 2002

Endovascular Therapy of Acute Vertebrobasilar Occlusion: Early Treatment Onset as the Most Important Factor

Eckert B. · Kucinski T. · Pfeiffer G. · Groden C. · Zeumer H.
To view the fulltext, log in and/or choose pay-per-view option

Individual Users: Register with Karger Login Information

Please create your User ID & Password





Contact Information











I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in

Abstract

In view of the poor prognosis for patients with acute intracranial vertebrobasilar occlusion (VBO), factors were sought that predict survival and good neurologic outcome after acute endovascular treatment by means of local intra-arterial fibrinolysis (LIF) and percutaneous transluminal angioplasty (PTA). LIF was performed in 83 patients with angiographically established acute VBO. A significant residual stenosis after LIF was treated by additional PTA in 8 patients. The types of occlusion were classified as either embolic occlusion (EO) or atherothrombotic occlusion (AO). Outcome was evaluated after 3 months by the Barthel Index (BI) as favorable (BI >90), unfavorable (BI <90) or death and compared for each of 3 diagnostic or treatment variables: recanalization success, occlusion type and time to treatment. Four fibrinolytic treatment modes [urokinase, low-dose and high-dose recombinant tissue-type plasminogen activator (rt-PA), rt-PA + Lys-plasminogen] were also analyzed. The outcome was favorable in 19 patients (23%), unfavorable in 14 (17%) and 50 died (60%). Recanalization was successful in 54 patients (66%). The neurologic outcome was better in recanalized than in nonrecanalized patients (favorable outcome: 30 vs. 10%, mortality: 54 vs. 72%; p = 0.118). The neurologic outcome was better in EO than in AO (favorable outcome: 31 vs. 17%, mortality: 47 vs. 70%, p = 0.112). Under combined treatment by LIF and PTA in 8 patients with AO, 4 survived, 3 with a favorable outcome (38%). Early treatment onset (≤6 h) led to a significantly better neurologic outcome than delayed treatment onset (>6 h; favorable outcome: 36 vs. 7%, mortality: 52 vs. 70%, p = 0.005). Although no statistically significant differences were found between the types of fibrinolytic agents, treatment with rt-PA and Lys-plasminogen tended toward better results. Early treatment onset proved to be the most important factor for successful endovascular therapy in acute VBO, whereas recanalization and presence of an embolic occlusion also tended toward better results. Additional PTA may be a promising therapy in cases of significant residual stenosis after LIF.



Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Kubik CS, Adams RD: Occlusion of the basilar artery – A clinical and pathological study. Brain 1946;69:73–121.
  2. Labauge R, Pages M, Marty-Double C, Blard J, Boukobza M, Salvaing P: Occlusion du tronc basilaire. Rev Neurol (Paris) 1981;137:545–571.

    External Resources

  3. Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ: Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 1988;19:1216–1222.
  4. Zeumer H, Hacke W, Kolmann HL, Poeck K: Lokale Fibrinolysetherapie bei Basilaristhrombose. Dtsch Med Wochenschr 1982;107:728–731.

    External Resources

  5. Zeumer H, Hacke W, Ringelstein EB: Local intraarterial thrombolysis in vertebrobasilar thromboembolic disease. AJNR Am J Neuroradiol 1983;4:401–404.

    External Resources

  6. Tsai FY, Berberian B, Matovich V, Lavin M, Alfieri K: Percutaneous transluminal angioplasty adjunct to thrombolysis for acute middle cerebral artery rethrombosis. AJNR Am J Neuroradiol 1994;15:1823–1829.

    External Resources

  7. Ueda T, Sakaki S, Nochide I, Kumon Y, Kohno K, Ohta S. Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries. Stroke 1998;29:2568–2574.
  8. Nakayama T, Tanaka K, Kaneko M, Yokoyama T, Uemura K: Thrombolysis and angioplasty for acute occlusion of intracranial vertebrobasilar arteries: Report of three cases. J Neurosurg 1998;88:919–922.
  9. Zeumer H, Freitag HJ, Zanella F, Thie A, Arning C: Local intra-arterial fibrinolytic therapy in patients with stroke: Urokinase versus recombinant tissue plasminogen activator (r-TPA). Neuroradiology 1993;35:159–162.
  10. Brandt T, von Kummer R, Muller Kuppers M, Hacke W: Thrombolytic therapy of acute basilar artery occlusion: Variables affecting recanalization and outcome. Stroke 1996;27:875–881.
  11. Cross D, Moran C, Akins P, Angtuaco EE, Diringer MN: Relationship between clot location and outcome after basilar artery thrombolysis. AJNR Am J Neuroradiol 1997;18:1221–1228.

    External Resources

  12. Archer CR, Horenstein S: Basilar artery occlusion: Clinical and radiological correlation. Stroke 1977;8:383–390.
  13. Castaigne P, Lhermitte F, Gautier JC: Arterial occlusions in the vertebrobasilar system: A study of 44 patients with postmortem data. Brain 1973;96:133–154.
  14. Fisher CM, Gore I, Okabe N, White PD: Atherosclerosis of the carotid and vertebral arteries, extracranial and intracranial. J Neuropathol Exp Neurol 1965;24:455–476.
  15. Caplan L, Baquis GD, Pessing MS, D’Alton J, Adelman LS, et al: Dissection of the intracranial vertebral artery. Neurology 1988;38:868–877.
  16. Masson C, Krespy Y, Masson M, Colombani JM: Magnetic resonance imaging in basilar artery dissection. Stroke 1993;24:1264–1266.
  17. Ross GJ, Ferraro F, DeRiggi L, Scotti LN: Spontaneous healing of basilar artery dissection: MR findings. J Comput Assist Tomogr 1994;18:292–294.
  18. Van den Kleft E, Kunnen J, Truyen L, Heytens L: Postpartum dissecting aneurysm of the basilar artery. Stroke 1992;23:114–116.
  19. Pessin MS, Del Zoppo GJ, Estol CJ: Thrombolytic agents in the treatment of stroke. Clin Neuropharmacol 1990;13:271–289.
  20. Freitag HJ, Becker VU, Thie A, Tilsner V, Philapitsch A, Schwarz HP, Webhof U, Muller A, Zeumer H: Lys-plasminogen as an adjunct to local intra-arterial fibrinolysis for carotid territory stroke: Laboratory and clinical findings. Neuroradiology 1996;38:181–185.
  21. Becker K, Monsein L, Ulatowski J, Mirski M, Williams M, Hanley D: Intraarterial thrombolysis in vertebrobasilar occlusion. AJNR Am J Neuroradiol 1996;17:255–262.
  22. Egan, R, Clark W, Lutsep H, Nespit G, Barnwell S, Kellogg J: Efficacy of intraarterial thrombolysis of basilar artery stroke. J Stroke Cerebrovasc Dis 1999;8:22–27.
  23. von Kummer R, Forsting M, Sartor K, Hacke W: Intravenous recombinant tissue plasminogen activator in acute ischemic stroke; in Hacke W, del Zoppe GJ, Hirschberg M (eds): Thrombolytic Therapy in Acute Ischemic Stroke. Berlin, Springer, 1991, pp 161–167.
  24. Hennerici M, Hacke W, von Kummer R, Hornig C, Zangemeister W: Intravenous tissue plasminogen activator for the treatment of acute thromboembolic ischemia. Cerebrovasc Dis 1991;1(suppl 1):124–128.
  25. Huemer M, Niederwieser V, Ladurner G: Thrombolytic treatment for acute occlusion of the basilar artery. J Neurol Neurosurg Psychiatry 1995;58:227–228.
  26. Tissue plasminogen activator for acute ischemic stroke: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333:1581–1587.
  27. Grond M, Rudolf J, Schmulling S, Stenzel C, Neveling M, Heiss WD: Early intravenous thrombolysis with recombinant tissue-type plasminogen activator in vertebrobasilar ischemic stroke. Arch Neurol 1998;55:466–469.
  28. Levy EI, Firlik AD, Wisniewski S, Rubin G, Jungreis CA, Wechsler LR, Yonas H: Factors affecting survival rates for acute vertebrobasilar artery occlusions treated with intra-arterial thrombolytic therapy: A meta-analytical approach. Neurosurgery 1999;45:539–545.
  29. Rasmussen PA, Perl J, Barr JD, Markarian GZ, Katzan I, Silva C, Krieger D, Furlan AJ, Masaryk TJ: Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: An initial experience. J Neurosurg 2000;92:771–778.
  30. Chopko BW, Kerber C, Wong W, Georgy B: Transcatheter snare removal of acute middle cerebral artery thromboembolism: Technical case report. Neurosurgery 2000;46:1529–1531.
  31. Caplan LR: Occlusion of the vertebral or basilar artery: Follow-up analysis of some patients with benign outcome. Stroke 1979;10:277–282.
  32. Brandt T, Pessin M, Kwan A, Caplan L: Survival with basilar occlusion. Cerebrovasc Dis 1995;5:182–187.
  33. Wu, JH, Diamond SL: Tissue plasminogen activator (tPA) inhibits plasmin degradation of fibrin: A mechanism that slows tPA-mediated fibrinolysis but does not require alpha-2-antiplasmin or leakage of intrinsic plasminogen. J Clin Invest 1995;95:2483–2490.
  34. Abciximab in acute ischemic stroke: A randomized, double-blind, placebo-controlled, dose-escalation study. The Abciximab in Ischemic Stroke Investigators. Stroke 2000;31:601–609.


Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50