Oral Presentation Asia Pacific Stroke Conference 2024

Intravenous thrombolysis before successful angiographic reperfusion in patients with basilar artery occlusion   (107468)

Fana Alemseged 1 2 , Felix C. Ng 1 3 , Cameron Williams 1 4 , Francesco Arba 5 , Volker Puetz 6 7 , Gregoire Boulouis 8 , Vignan Yogendrakumar 1 , Fabrizio Sallustio 9 , Andrea Morotti 10 , Andrea Zini 11 , Daniel P.O. Kaiser 7 12 , Thomas Oxley 13 14 , Teddy Y. Wu 15 , Darshan Shah 16 , Gagan Sharma 1 , Steven Bush 4 , Richard Dowling 4 , Bernard Yan 1 4 , Peter Mitchell 4 , Marina Diomedi 2 , Mark Parsons 17 , Timothy J. Kleinig 18 , Nawaf Yassi 1 19 , Stephen Davis 1 , Bruce Campbell 1
  1. Department of Medicine and Neurology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
  2. Stroke Unit, University Hospital of "Tor Vergata", Rome, Italy
  3. Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
  4. Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  5. Stroke Unit, Careggi University Hospital, Florence, Italy
  6. Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
  7. Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
  8. Diagnostic and Interventional Neuroradiology, University Hospital, Tours, France
  9. Stroke Unit, Castels Hospital, Ariccia, Rome, Italy
  10. Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
  11. IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
  12. Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
  13. Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  14. Department of Neurosurgery, Mount Sinai Health System, New York, USA
  15. Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
  16. Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
  17. Department of Neurology, Liverpool Hospital, UNSW South-West Sydney, Sydney, NSW, Australia
  18. Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
  19. Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia

Background/Aims: Ineffective tissue reperfusion despite successful angiographic reperfusion may contribute to unfavourable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolytic (IVT) before EVT. We compared functional outcomes in patients with basilar artery occlusion (BAO) and successful reperfusion with and without prior IVT.

Methods: Clinical and procedural data of prospectively collected consecutive patients from the multicenter Basilar Artery Treatment and Management (BATMAN) registry between 1/1/2015 and 31/12/2023 were analyzed. EVT patients with successful reperfusion (eTICI 2b-3) were analyzed according to prior IVT using propensity score matching (PSM). Independent ambulation was defined as modified Rankin Scale score (mRS) 0–3; functional independence as mRS 0-2 at 90 days.

Results: Among 361 BAO patients who achieved successful reperfusion after EVT [mean age 68±14; median NIHSS 14 (IQR 7-28)],143 patients were treated with IVT before EVT. In the PSM cohort analysis (139 IVT+EVT vs 138 EVT patients), after logistic regression analysis adjusted for age, NIHSS and time from onset-to-arterial puncture, IVT+EVT was associated with independent ambulation (61.2% vs 45.7%, aOR=1.86, 95%CI 1.07–3.26, p=0.028) and functional independence (52.5% vs 36.2%, aOR=2.01, 95%CI 1.15-3.51, p=0.014) at 90 days compared with EVT alone. Symptomatic intracranial haemorrhage rates were comparable (1.4% vs 0.7%, p=0.761).

Conclusions: In the setting of successful reperfusion by EVT, prior IVT was associated with improved outcomes in BAO patients, without increased bleeding. Randomized trials to assess the safety and efficacy of thrombolytic agents targeting downstream microvascular reperfusion in BAO are warranted.

  1. Ng FC, Churilov L, Yassi N, et al. Prevalence and significance of impaired microvascular tissue reperfusion despite macrovascular angiographic reperfusion (no-reflow). Neurology 2022;98:e790–e801.
  2. Renu A, Millan M, San Roman L, et al. Effect of intra-arterial alteplase vs placebo following successful thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: the choice randomized clinical trial. JAMA 2022;327:826–835.
  3. Alemseged F, Van der Hoeven E, Di Giuliano F, et al. Response to Late-Window Endovascular Revascularization Is Associated With Collateral Status in Basilar Artery Occlusion. Stroke. 2019 Jun;50(6):1415-1422.