Elsevier

Critical Care Clinics

Volume 15, Issue 4, 1 October 1999, Pages 719-742
Critical Care Clinics

INTRA-ARTERIAL THROMBOLYSIS FOR VERTEBROBASILAR CIRCULATION ISCHEMIA

https://doi.org/10.1016/S0749-0704(05)70084-1Get rights and content

The poor prognosis in acute basilar artery occlusion approaches 80% to 90%.2, 15, 18, 27 Logic dictates that early recanalization of the vessel before tissue death would lead to preservation of the brain stem and cerebellum. The success of thrombolysis in myocardial infarction has led to resurgence of interest in thrombolysis for cerebral ischemia. There have been promising results of thrombolytic therapy in anterior circulation stroke, but there is no placebo control equivalent in stroke of basilar artery occlusion.1 In the past, progress in this area has been hampered by the lack of good imaging and the availability of small mobile angiographic catheters to cannulate the basilar artery. In the past 10 years there have been several uncontrolled series of intra-arterial thrombolysis in basilar artery occlusion with promising results.4, 7, 13, 17, 18, 34, 49, 54 However, the appropriate patient for intra-arterial thrombolysis for basilar artery occlusion has not been well defined. Although patients who are in coma and tetraplegic have nothing to lose from such therapy, experience at the Mayo clinic and elsewhere has not supported this approach. The question arises as to whether thrombolytic therapy should be reserved for patients who have milder symptoms and signs. There are three small series of angiographically proven basilar artery occlusion in which patients have benign outcome. The patients in these series have less severe neurologic signs.6, 9, 16 This has raised doubts in the minds of many clinicians as to whether to subject patients to thrombolysis or standard care with intravenous heparin only. This article briefly reviews the anatomy and the anatomic basis for the clinical features of vertebrobasilar ischemia. This is followed by a discussion on the natural history and scientific basis for thrombolysis.

Section snippets

ANATOMY

The vertebral artery comes off the subclavian artery and ascends in the foramen of the sixth cervical vertebrae. The two vertebral arteries are often unequal in size. The left vertebral artery is larger in 45% of normal subjects; in 21%, the right vertebral artery is larger; and in 34%, both arteries are equal in size.32 Vertebral artery hypoplasia has been noted to be associated with vertebral artery occlusion on the other side. Severe atherosclerosis with narrowing of the lumen may also give

NATURAL HISTORY OF BASILAR ARTERY OCCLUSION

The high mortality associated with basilar artery occlusion stems from clinicopathologic research in the past and the lack of easily accessible neuroimaging facility. Thus, only patients presenting to teaching hospitals or those with severe diseases may have angiographic studies, and series may be biased toward patients who were diagnosed at autopsy.2, 15, 18, 27 Although basilar artery occlusion was first recognized by Hayem21 in 1868, it was not until 1960 that the first angiographic

Diagnosis

Ischemia in the territory of the basilar artery reflects involvement of the pons, midbrain, cerebellum, thalami, and occipital lobes. The onset may be abrupt or stuttering over several days. Spontaneous lysis of the clot can occur with improvement of neurologic deficit. Involvement of the reticular formation leads to alteration in the level of consciousness. Pyramidal tract involvement causes (alternating) hemiplegia or quadriplegia. Lesion of the ventral pons and sparing the reticular

Patient Selections

Selection of patients for intra-arterial thrombolysis in basilar artery occlusion is more difficult than listing the conditions in which thrombolysis is contraindicated or not required (Table 3). Patients who have had recent trauma, surgical procedure, and coagulopathy or who have evidence of hemorrhage or hemorrhagic infarct on neuroimaging are contraindicated for thrombolysis. It is general consensus that patients who are comatose for longer than 6 hours, who are ventilator dependent, and who

INTRAVENOUS THROMBOLYSIS

Successful systemic thrombolysis for basilar artery occlusion with t-PA was first described in a single case by Wildemann et al.51 A subsequent report by von Kummer et al47 has noted poor outcome in 4 of 5 patients. Hence systemic thrombolysis has not been embraced. Recently, Huemer et al25 treated 16 patients with 100 mg of t-PA with recanalization of the basilar artery in 10 patients, 5 of whom survived. The majority of the survivors were younger than 50. Although this study was scant in

ANGIOPLASTY

Angioplasty of the basilar artery either alone or after intra-arterial thrombolysis has been proposed as a means of maintaining vessel patency. Sundt et al42 first reported on the use of angioplasty in vertebrobasilar disease. A subsequent report by Sundt et al41 noted that four of the six patients had died either from distal embolization or from rupture of the basilar artery. Interest in angioplasty declined until the arrival of the low-profile, 2- to 3.5-mm, balloon catheter (Stealth

CONCLUSIONS

Unlike intravenous for myocardial infarction and anterior circulation stroke, trials involving intra-arterial thrombolysis can only be performed in a large teaching hospital with the necessary team of a neurologist, an interventional radiologist, and a neurosurgeon on standby. However, such trials will be biased to patients who have major neurologic deficit unless community hospitals are involved. Unless all patients who have brain-stem ischemia undergo cerebral angiography—an impractical

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    Address reprint requests to Eelco F. M. Wijdicks, MD, Department of Neurology, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905

    *

    Department of Neurology, Mayo Clinic, Rochester, Minnesota

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