Analysis Of Endovascular Treatment And Prognostic Factors For Acute Basilar Artery Occlusion

In recent years,endovascular therapy has played an important role in the clinical treatment of acute ischemic stroke by rapidly opening the blood vessels of patients with acute cerebral infarction,saving the ischemic penumbra of brain tissue and avoiding irreversible brain damage.Since the end of 2014,several multicenter randomized controlled trials,such as MR CLEAN,REVASCAT,ESCAPE and SWIFT PRIME,have demonstrated the safety and effectiveness of endovascular therapy in acute anterior circulation large vessel occlusive stroke.Therefore,the AHA/ASA guidelines for the early management of acute ischemic stroke and a number of domestic and foreign clinical guidelines or consensus regard endovascular therapy ASA grade Ia recommendation for the treatment of acute anterior circulation large vessel occlusion stroke.However,high-quality clinical studies on posterior circulation ischemic stroke with higher mortality and disability rate,such as ENDOSTROKE,BEST,BASICS and BASILAR,have gradually begun to emerge in recent years.Although these studies have suggested the efficacy of endovascular therapy for posterior circulatory ischemic stroke to varying degrees,some patients still do not have a good prognosis even after successful vascularization(the lowest proportion of postoperative functional independence is only 27.4%).So,what are the influencing factors of endovascular treatment and prognosis of acute basilar artery occlusion?In order to explore the optimal screening method and recommendation process of endovascular therapy for patients with posterior circulation,many clinical researchers are conducting a series of analytical studies based on high-quality clinical databases.Previously,the research team of our unit analyzed the time from onset to endovascular treatment and the impact of baseline PCaspects score on the efficacy of endovascular treatment based on BASILAR research database,but it has not been analyzed from the level of surgical operation.Previous studies on anterior circulation published by Kharoub et.and Huang et.showed that multiple thrombectomy or salvage treatment during the operation to achieve successful recanalization of occluded vessels may lead to a relatively poor postoperative prognosis of patients.The good prognosis of patients at 90 days after operation is significantly correlated with the number of surgical procedures.In addition,patients with the first recanalization effect during the surgical procedure have a relatively good prognosis.Therefore,successful thrombectomy during the first surgical procedure is an important factor affecting the efficacy of endovascular therapy in patients with posterior circulation ischemic stroke.In clinical practice,it is usually referred to as first pass effect(FPE)when the occluded vessel is successfully recanalized after the first stent thrombectomy.Therefore,in this study,we tested the effect of first recanalization in the posterior circulation system on the outcome of endovascular therapy in patients with ischemic stroke.Our results demonstrate that patients with a first pass effect during endovascular treatment for posterior circulation ischemic stroke have a higher percentage of favorable outcomes at 90 days after surgery.At the same time,we also analyzed the predictors of the first recanalization effect during surgery for posterior circulation ischemic stroke,and found that patients with the first recanalization effect had a higher proportion of atrial fibrillation,and cardiogenic stroke was a predictor of the first recanalization effect.Considering that atrial fibrillation is an important cause of cardiogenic stroke,the incidence of atrial fibrillation is high in China,and the treatment strategy for patients with posterior circulation ischemic stroke complicated with atrial fibrillation is unclear in clinical work.Although there have been a number of clinical studies on the anterior circulation system to analyze the effect of atrial fibrillation on the surgical complications and functional prognosis of ischemic stroke after endovascular treatment,there is still no unified conclusion,and the relevant research reports are even less seen in the posterior circulation.We further used BASILAR database to analyze the effect of atrial fibrillation on endovascular treatment in patients with posterior circulation ischemic stroke,in order to find evidence for endovascular treatment in patients with acute BASILAR artery occlusion complicated with atrial fibrillation.Part1: Analysis of Factors Related to the First Recanalization Effect of Acute Basilar Artery OcclusionBackground: The first recanalization effect mainly refers to the phenomenon that successful opening of occluded vessels and reperfusion of ischemic brain tissue(m TICI 2b-3)can be achieved in a single operation without remedial treatment in the endovascular treatment of patients with ischemic stroke.Previous studies have not clarified the impact of the first recanalization effect on the efficacy of endovascular therapy in patients with posterior circulatory ischemic stroke and the related factors of the first recanalization effect.The aim of this study was to analyze the factors related to the first recanalization effect of acute basilar artery occlusion,and to explore the impact of the first recanalization effect on the efficacy and safety of surgical and functional outcomes in patients with acute basilar artery occlusion.Methods: All data used in this study were obtained from the team’s previous study on Endovascular Treatment for Acute BASILAR Artery Occlusion(BASILAR).A nonrandomized,controlled,multicenter,observational,national registry study enrolled 829 patients with acute basilar artery occlusion within 24 hours of enrollment from January 2014 to May2019,including 647 surgical patients,482 patients with preferred stent thrombectomy.There were 83 cases of first recanalization,388 cases of non-first recanalization and 18 cases of final successful recanalization.We performed statistical analyses to compare the clinical outcomes of patients with first recanalization,non-first recanalization,and final successful recanalization,and to analyze the predictors of the effect of first recanalization.Results: On multivariate analysis,AF predicted a higher first-pass effect rate,and lower incidence of angioplasty and/or stenting(p<0.01).AF had no effect on intracranial hemorrhage incidence(adjusted odds ratio [a OR],1.093;95% confidence interval [CI] 0.451–2.652),90-day functional outcomes(adjusted OR 0.915;95% CI 0.588–1.424),or mortality(adjusted OR0.851;95% CI 0.491–1.475)after MT.The main findings were robust in the subgroup and 1-year follow-up analyses.Comorbid AF was the remaining predictor of ischemic recurrence(adjusted OR 4.076;95% CI 1.137–14.612).Conclusions: The first recanalization effect is associated with a good prognosis in patients with acute basilar artery occlusion.Patients with cardioembolism,distal basilar artery occlusion,and unexplained stroke are more likely to have the first recanalization effect,and higher baseline NIHSS score is less likely to have the first recanalization effect.Part2: Effect of Endovascular Therapy and Prognostic Factors in Patients with Acute Basilar Artery Occlusion Complicated with Atrial FibrillationBackground: We analyzed the factors related to the first recanalization effect during surgery for posterior circulation ischemic stroke,and found that patients with the first recanalization effect had a higher proportion of atrial fibrillation,and cardiac stroke was a predictor of the first recanalization effect.Considering that atrial fibrillation is an important cause of cardiogenic stroke,the incidence of atrial fibrillation is high in China,and the treatment strategy for patients with posterior circulation ischemic stroke complicated with atrial fibrillation is unclear in clinical work.In addition,a number of previous clinical studies on the anterior circulation system have shown that atrial fibrillation is associated with more surgical complications and poor functional prognosis in the endovascular treatment of ischemic stroke.There is no analysis study on the efficacy of atrial fibrillation in the endovascular treatment of ischemic occlusion of the posterior circulation system.We intend to analyze the effect of atrial fibrillation on endovascular treatment in patients with posterior circulation ischemic stroke based on BASILAR database,so as to seek evidence for endovascular treatment in patients with acute BASILAR artery occlusion complicated with atrial fibrillation.Methods: All data used in this study were obtained from the team’s previous study on Endovascular Treatment for Acute BASILAR Artery Occlusion(BASILAR).This is a nonrandomized,controlled,multicenter,observational,national registry study that enrolled 829 patients with acute basilar artery occlusion within 24 hours from January 2014 to May 2019.647 patients received endovascular therapy,136 of whom had atrial fibrillation.The baseline characteristics,surgical data and clinical outcomes of patients with and without atrial fibrillation were presented by baseline description and statistical analysis.Results: Statistically,atrial fibrillation was associated with fewer balloon angioplasty/stenting procedures(adjusted OR,0.192,95%CI 0.091-0.406),P <0.001),but with a firstrecanalization effect(adjusted OR 0.565,95%CI 0.249-1.284.P=0.173)was not related to the duration of operation(adjusted OR-2.257,95%CI-19.442-14.929,P=0.796).Incidence of atrial fibrillation not intracranial hemorrhage(adjusted OR 1.093,95% CI 0.451-2.652,P=0.844),functional outcome at 90 days and 1 year(adjusted OR 0.915,95% CI 0.588-1.424,P=0.694),OR death(adjusted OR 0.851,95% CI 0.588-1.424,P=0.694).Acute basilar artery occlusion combined with atrial fibrillation was a predictor of long-term recurrence of ischemic stroke(adjusted OR 4.076,95%CI 1.137-14.612,P=0.031).Conclusions: Atrial fibrillation in patients with acute basilar artery occlusion does not affect the safety and efficacy of endovascular therapy,but the risk of recurrent ischemic stroke within 1 year of endovascular therapy is higher.