Mechanical Thrombectomy in Basilar Artery Occlusion

Presence of Bilateral Posterior Communicating Arteries is a Predictor of Favorable Clinical Outcome
  • Volker Maus
  • Alev Kalkan
  • Christoph Kabbasch
  • Nuran Abdullayev
  • Henning Stetefeld
  • Utako Birgit Barnikol
  • Thomas Liebig
  • Christian Dohmen
  • Gereon Rudolf Fink
  • Jan Borggrefe
  • Anastasios Mpotsaris
Original Article



Mechanical thrombectomy (MT) of basilar artery occlusions (BAO) is a subject of debate. We investigated the clinical outcome of MT in BAO and predictors of a favorable outcome.

Material and Methods

A total of 104 MTs of BAO (carried out between 2010 and 2016) were analyzed. Favorable outcome as a modified Rankin scale (mRS) ≤ 2 at 90 days was the primary endpoint. The influence of the following variables on outcome was investigated: number of detectable posterior communicating arteries (PcoAs), patency of basilar tip, completeness of BAO and posterior circulation Alberta Stroke Program early computed tomography score (PC-ASPECTS). Secondary endpoints were technical periprocedural parameters including symptomatic intracranial hemorrhage (sICH).


The favorable clinical outcome at 90 days was 25% and mortality was 43%. The rate of successful reperfusion, i.e. modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was 82%. Presence of bilateral PcoAs (area under the curve, AUC: 0.81, odds ratio, OR: 4.2, 2.2–8.2; p < 0.0001), lower National Institute of Health Stroke Scale (NIHSS) on admission (AUC: 0.74, OR: 2.6, 1.3–5.2; p < 0.01), PC-ASPECTS ≥ 9 (AUC: 0.72, OR: 4.2, 1.5–11.9; p < 0.01), incomplete BAO (AUC: 0.66, OR: 2.6, 1.4–4.8; p < 0.001), and basilar tip patency (AUC: 0.66, OR: 2.5, 1.3–4.8; p < 0.01) were associated with a favorable outcome. Stepwise logistic regression analysis revealed that the strongest predictors of favorable outcome at 90 days were bilateral PcoAs, low NIHSS on admission, and incomplete BAO (AUC: 0.923, OR: 7.2, 3–17.3; p < 0.0001).


The use of MT for BAO is safe with high rates of successful reperfusion. Aside from baseline NIHSS and incomplete vessel occlusion, both known predictors of favorable outcome in anterior circulation events, we found that collateral flow based on the presence or absence of PcoAs had a decisive prognostic impact.


Embolectomy Collateral Circulation Cerebral Stroke Cerebrovascular Occlusion Intracranial Thrombosis 


Compliance with ethical guidelines

Conflict of interest

V. Maus, A. Kalkan, C. Kabbasch, N. Abdullayev, H. Stetefeld, U.B. Barnikol, T. Liebig, C. Dohmen, G.R. Fink, J. Borggrefe and A. Mpotsaris declare that they have no competing interests.

Ethical standards

The study was approved by the local ethics committee (Registration ID: 16-347) and was conducted in accordance with the Declaration of Helsinki.


  1. 1.
    Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011;10:1002–14.CrossRefPubMedGoogle Scholar
  2. 2.
    Ferbert A, Brückmann H, Drummen R. Clinical features of proven basilar artery occlusion. Stroke. 1990;21:1135–42.CrossRefPubMedGoogle Scholar
  3. 3.
    Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42:1775–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006;37:922–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Millán M, Davis SM, Roy D, Thornton J, Román LS, Ribó M, Beumer D, Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver JL, Hill MD, Jovin TG; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–31.CrossRefPubMedGoogle Scholar
  6. 6.
    Möhlenbruch M, Stampfl S, Behrens L, Herweh C, Rohde S, Bendszus M, Hametner C, Nagel S, Ringleb PA, Pham M. Mechanical thrombectomy with stent retrievers in acute basilar artery occlusion. AJNR Am J Neuroradiol. 2014;35:959–64.CrossRefPubMedGoogle Scholar
  7. 7.
    Espinosa de Rueda M, Parrilla G, Zamarro J, García-Villalba B, Hernández F, Moreno A. Treatment of acute vertebrobasilar occlusion using thrombectomy with stent retrievers: initial experience with 18 patients. AJNR Am J Neuroradiol. 2013;34:1044–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Heldner MR, Ludi R, Mattle HP, Schroth G, Gralla J. Technical feasibility and application of mechanical thrombectomy with the Solitaire FR Revascularization Device in acute basilar artery occlusion. AJNR Am J Neuroradiol. 2013;34:159–63.CrossRefPubMedGoogle Scholar
  9. 9.
    Du S, Mao G, Li D, Qiu M, Nie Q, Zhu H, Yang Y, Zhang Y, Li Y, Wu Z. Mechanical thrombectomy with the solitaire AB stent for treatment of acute basilar artery occlusion: a single-center experience. J Clin Neurosci. 2016;32:67–71.CrossRefPubMedGoogle Scholar
  10. 10.
    Mourand I, Machi P, Milhaud D, Picot MC, Lobotesis K, Arquizan C, Costalat V, Héroum C, Sablot D, Bouly S, Lalu T, Bonafé A. Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion. J Neurointerv Surg. 2014;6:200–4.CrossRefPubMedGoogle Scholar
  11. 11.
    Shu L, Riedel C, Meyne J, Jansen O, Jensen-Kondering U. Successful recanalization in acute basilar artery occlusion treated with endovascular therapy is independent of thrombus length. J Neurointerv Surg. 2017;9(11):1047-52.CrossRefPubMedGoogle Scholar
  12. 12.
    Gory B, Eldesouky I, Sivan-Hoffmann R, Rabilloud M, Ong E, Riva R, Gherasim DN, Turjman A, Nighoghossian N, Turjman F. Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review. J Neurol Neurosurg Psychiatr. 2016;87:520–5.CrossRefGoogle Scholar
  13. 13.
    Gilberti N, Gamba M, Premi E, Costa A, Vergani V, Delrio I, Spezi R, Mardighian D, Frigerio M, Gasparotti R, Padovani A, Magoni M. Endovascular mechanical thrombectomy in basilar artery occlusion: variables affecting recanalization and outcome. J Neurol. 2016;263:707–13.CrossRefPubMedGoogle Scholar
  14. 14.
    Nagel S, Kellert L, Möhlenbruch M, Bösel J, Rohde S, Ringleb P. Improved clinical outcome after acute basilar artery occlusion since the introduction of endovascular thrombectomy devices. Cerebrovasc Dis. 2013;36:394–400.CrossRefPubMedGoogle Scholar
  15. 15.
    Andersson T, Kuntze Söderqvist Å, Söderman M, Holmin S, Wahlgren N, Kaijser M. Mechanical thrombectomy as the primary treatment for acute basilar artery occlusion: experience from 5 years of practice. J Neurointerv Surg. 2013;5:221–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Baek JM, Yoon W, Kim SK, Jung MY, Park MS, Kim JT, Kang HK. Acute basilar artery occlusion: outcome of mechanical thrombectomy with Solitaire stent within 8 hours of stroke onset. AJNR Am J Neuroradiol. 2014;35:989–93.CrossRefPubMedGoogle Scholar
  17. 17.
    Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring HP, Trenkler J, Gröschel K, Müller-Forell W, Niederkorn K, Deutschmann H, Neumann-Haefelin T, Hohmann C, Bussmeyer M, Mpotsaris A, Stoll A, Bormann A, Brenck J, Schlamann MU, Jander S, Turowski B, Petzold GC, Urbach H, Liebeskind DS; ENDOSTROKE Study Group. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol. 2015;77:415–24.CrossRefPubMedGoogle Scholar
  18. 18.
    Yoon W, Kim SK, Heo TW, Baek BH, Lee YY, Kang HK. Predictors of good outcome after stent-retriever thrombectomy in acute basilar artery occlusion. Stroke. 2015;46:2972–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Souza LC, Yoo AJ, Chaudhry ZA, Payabvash S, Kemmling A, Schaefer PW, Hirsch JA, Furie KL, González RG, Nogueira RG, Lev MH. Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol. 2012;33:1331–6.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.CrossRefPubMedGoogle Scholar
  21. 21.
    Archer CR, Horenstein S. Basilar artery occlusion: clinical and radiological correlation. Stroke. 1977;8:383–90.CrossRefPubMedGoogle Scholar
  22. 22.
    Puetz V, Sylaja PN, Coutts SB, Hill MD, Dzialowski I, Mueller P, Becker U, Urban G, O’Reilly C, Barber PA, Sharma P, Goyal M, Gahn G, von Kummer R, Demchuk AM. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke. 2008;39:2485–90.CrossRefPubMedGoogle Scholar
  23. 23.
    Tei H, Uchiyama S, Usui T, Ohara K. Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome. J Neurol. 2010;257:767–73.CrossRefPubMedGoogle Scholar
  24. 24.
    Delgado Almandoz JE, Kayan Y, Young ML, Fease JL, Scholz JM, Milner AM, Hehr TH, Roohani P, Mulder M, Tarrel RM. Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg. 2016;8(11):1123–8. Scholar
  25. 25.
    Maus V, Behme D, Kabbasch C, Borggrefe J, Tsogkas I, Nikoubashman O, Wiesmann M, Knauth M, Mpotsaris A, Psychogios MN. Maximizing first-pass complete reperfusion with SAVE. Clin Neuroradiol. 2017 Scholar
  26. 26.
    Kabbasch C, Mpotsaris A, Liebig T, Söderman M, Holtmannspötter M, Cronqvist M, Thornton J, Mendes Pereira V, Andersson T. First-in-man procedural experience with the novel embotrap(R) revascularization device for the treatment of Ischemic stroke-A European Multicenter series. Clin Neuroradiol. 2016;26:221–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, Spiotta A, Mokin M, Dewan M, Quarfordt S, Battenhouse H, Turner R, Chaudry I. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014;6:260–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Kowoll A, Weber A, Mpotsaris A, Behme D, Weber W. Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center. J Neurointerv Surg. 2016;8:230–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Kabbasch C, Möhlenbruch M, Stampfl S, Mpotsaris A, Behme D, Liebig T. First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA. Interv Neuroradiol. 2016;22:333–9.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Vergouwen MD, Algra A, Pfefferkorn T, Weimar C, Rueckert CM, Thijs V, Kappelle LJ, Schonewille WJ; Basilar Artery International Cooperation Study (BASICS) Study Group. Time is brain(stem) in basilar artery occlusion. Stroke. 2012;43:3003–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Sairanen T, Strbian D, Soinne L, Silvennoinen H, Salonen O, Artto V, Koskela I, Häppölä O, Kaste M, Lindsberg PJ; Helsinki Stroke Thrombolysis Registry (HSTR) Group. Intravenous thrombolysis of basilar artery occlusion: predictors of recanalization and outcome. Stroke. 2011;42:2175–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Goyal N, Tsivgoulis G, Nickele C, Doss VT, Hoit D, Alexandrov AV, Arthur A, Elijovich L. Posterior circulation CT angiography collaterals predict outcome of endovascular acute ischemic stroke therapy for basilar artery occlusion. J Neurointerv Surg. 2016;8:783–6.CrossRefPubMedGoogle Scholar
  33. 33.
    van der Hoeven EJ, McVerry F, Vos JA, Algra A, Puetz V, Kappelle LJ, Schonewille WJ; BASICS registry investigators. Collateral flow predicts outcome after basilar artery occlusion: the posterior circulation collateral score. Int J Stroke. 2016;11:768–75.CrossRefPubMedGoogle Scholar
  34. 34.
    Alqadri S, Adil MM, Watanabe M, Qureshi AI. Patterns of collateral formation in basilar artery steno-occlusive diseases. J Vasc Interv Neurol. 2013;6:9–13.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Drabek P. The basilar artery terminal branch syndrome. Paramedian meso-thalamic infarct. Cesk Neurol Neurochir. 1990;53:352–7.PubMedGoogle Scholar
  36. 36.
    Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, Dillon W, Warach S, Broderick J, Tilley B, Sacks D; Technology Assessment Committee of the American Society of Interventional and Therapeutic Neuroradiology; Technology Assessment Committee of the Society of Interventional Radiology. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003;34:e109–e37.CrossRefPubMedGoogle Scholar
  37. 37.
    Schonewille WJ, Wijman CA, Michel P, Rueckert CM, Weimar C, Mattle HP, Engelter ST, Tanne D, Muir KW, Molina CA, Thijs V, Audebert H, Pfefferkorn T, Szabo K, Lindsberg PJ, de Freitas G, Kappelle LJ, Algra A; BASICS study group. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009;8:724–30.CrossRefPubMedGoogle Scholar
  38. 38.
    Nagel S, Schellinger PD, Hartmann M, Juettler E, Huttner HB, Ringleb P, Schwab S, Köhrmann M. Therapy of acute basilar artery occlusion: intraarterial thrombolysis alone vs bridging therapy. Stroke. 2009;40:140–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Maus V, You S, Kalkan A, Borggrefe J, Kabbasch C, Barnikol UB, Stetefeld H, Dohmen C, Liebig T, Fink GR, Mpotsaris A. Incomplete large vessel occlusions in mechanical thrombectomy: an independent predictor of favorable outcome in Ischemic stroke. Cerebrovasc Dis. 2017;44:113–21.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Volker Maus
    • 1
  • Alev Kalkan
    • 1
  • Christoph Kabbasch
    • 1
  • Nuran Abdullayev
    • 1
  • Henning Stetefeld
    • 2
  • Utako Birgit Barnikol
    • 3
  • Thomas Liebig
    • 4
  • Christian Dohmen
    • 2
  • Gereon Rudolf Fink
    • 2
    • 5
  • Jan Borggrefe
    • 1
  • Anastasios Mpotsaris
    • 6
  1. 1.Department of NeuroradiologyUniversity Hospital CologneCologneGermany
  2. 2.Department of NeurologyUniversity Hospital CologneCologneGermany
  3. 3.Clearing Unit Ethics, Medical Faculty of Cologne & Research Unit Ethics, Department of Child and Adolescence PsychiatryUniversity Hospital CologneCologneGermany
  4. 4.Department of NeuroradiologyCharitéBerlinGermany
  5. 5.Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3)Research Centre JülichJülichGermany
  6. 6.Department of NeuroradiologyUniversity Hospital AachenAachenGermany

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