Vertebrobasilar Revascularization Rates and Outcomes in the MERCI and Multi-MERCI Trials

doi:10.1016/j.jstrokecerebrovasdis.2007.11.003

Journal of Stroke and Cerebrovascular Diseases

Volume 17, Issue 2, March–April 2008, Pages 55-57

https://doi.org/10.1016/j.jstrokecerebrovasdis.2007.11.003 Get rights and content

Objective

Mortality of 40% to 86% and good outcomes in only 13% to 21% of patients beg for treatment options for basilar occlusion. This study determined outcomes of patients with vertebrobasilar occlusion treated with mechanical embolus removal in cerebral ischemia (MERCI) retriever mechanical thrombectomy.

Methods

Patients with vertebrobasilar occlusion in the MERCI and Multi-MERCI trials received treatment up to 8 hours after symptom onset. Recanalization was determined after retriever use and adjunctive therapy. Mortality and good outcomes, modified Rankin scale score 0-3, were determined at 90 days in patients who were recanalized and not recanalized.

Results

Recanalization occurred in 21 of 27 (78%) patients. Mortality was 44% and good outcomes were seen in 41%. Patients with recanalization tended to have better outcomes than those without.

Conclusions

Outcomes in patients with vertebrobasilar occlusions treated with the MERCI retriever compared favorably with natural history reports and tended to be better in those patients with recanalization.

Section snippets

Methods

The methods of the MERCI and Multi-MERCI trials have been previously described.4, 5, 6 These were single-arm, multicenter trials that assessed the ability of the retriever devices to restore vascular patency, defined as thrombolysis in myocardial infarction II or more of the entire treatable vascular territory. The studies were approved by the institutional review board of each institution. The current study included only those patients who had vertebral or basilar occlusion.

Patients were

Results

A total of 27 patients were included. In all, 26 had basilar occlusions and one had vertebral plus bilateral posterior cerebral artery occlusions. In all, 30% were women. Their mean age was 58 years. Hypertension was seen in 13 of 27 (48%), a history of atrial fibrillation in 8 of 26 (30%), tobacco use in 7 of 24 (29%), coronary artery disease in 8 of 25 (32%), dyslipidemia in 8 of 23 (35%), and diabetes in 2 of 26 (8%). The median baseline NIHSS score was 22 (range 4-40). The mean time to

Discussion

Mortality in patients with vertebrobasilar thromboemboli treated with the MERCI retrievers and adjunctive therapies was 44%, at the low end of the range reported for the natural history of basilar thrombosis.1, 2 Good outcomes (mRS score 0-3) were seen in 41% and functional independence (mRS score 0-2) were seen in 33% of all patients and compared favorably with the 13% to 21% rate of good outcomes reported in the natural history studies.1, 2

The percentage of patients in whom revascularization

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Outcome in patients with basilar artery occlusion treated conventionally
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Safety and efficacy of mechanical embolectomy in acute ischemic stroke
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There are more references available in the full text version of this article.

Cited by (74)

Characteristics and prognosis of acute basilar artery occlusion in minor to moderate stroke and severe stroke after endovascular treatment: A multicenter retrospective study
2021, Clinical Neurology and Neurosurgery
Citation Excerpt :
However, there are conflicting data about outcomes after MT in acute BAO patients. Some studies suggested that MT may be safe and effective for acute BAO patients [6–14], but other studies displayed that either intra-arterial therapy (IAT) / MT or MT plus standard medical therapy did not show any superiority than IVT in posterior circulation stroke patients with BAO or vertebrobasilar artery occlusion [5,15]. Moreover, more than 35 % of BAO patients treated with MT died within 90 days despite high recanalization rates [32].
We aimed to investigate characteristics and outcomes of patients receiving mechanical thrombectomy (MT) between minor to moderate stroke and severe stroke caused by acute basilar artery occlusion (BAO).
We retrospectively reviewed the data of all patients with BAO who underwent MT from three stroke centers between January 2016 and January 2020. The patients were dichotomized as minor to moderate or severe stroke group according to their admission National Institutes of Health Stroke Scale (NIHSS) score <21and ≥21. Patient characteristics, imaging findings, and outcomes were compared between the two groups.
A total of 72 patients were included in this study. The posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) in the minor to moderate stroke patients were significantly higher than that of patients with severe stroke (P = 0.013). The good posterior circulation collateral scores (PC-CS) (6−10) were more commonly found in patients with minor to moderate stroke than in patients with severe stroke (58.14 % vs 10.34 %,P < 0.001). There were similar rates of successful recanalization between the two groups. Patients with minor to moderate stroke had a higher rate of favorable outcomes (mRS score 0−2, 60.47 % vs 20.69 %, P = 0.002) and a lower rate of periprocedural complications (4.65 % vs 31.03 %, P = 0.005) and mortality (4.65 % vs 24.14 %, P = 0.026) at 3 months after MT compared with the patients with severe stroke.
Acute BAO patients with minor to moderate stroke had better posterior circulation collateral and had better outcomes after MT than those patients with severe stroke.
Clinical outcomes of mechanical thrombectomy following intravenous administration of recombinant tissue-type plasminogen activator for basilar artery occlusion
2020, Clinical Neurology and Neurosurgery
Mechanical thrombectomy (MT) following intravenous administration of recombinant tissue-type plasminogen activator (IV-rt-PA) is considered an effective treatment for the occlusion of the internal carotid artery or the M1 segment of the middle cerebral artery. However, its efficacy in treating basilar artery (BA) occlusion is still unclear. In order to evaluate the efficacy of MT in treating BA occlusion, we aimed to analyzed the clinical outcomes of those patients who had undergone MT following IV-rt-PA administration.
We retrospectively analyzed the clinical outcomes of 11 patients with BA occlusion who had undergone MT following IV-rt-PA administration between January 1, 2015, and March 31, 2019.
The patients consisted of 8 men and 3 women. The mean (±standard deviation) age was 73 ± 9.4 years. Stroke subtypes were found to be atherothrombosis in 2 patients, cardiogenic embolism in 6, arterial dissection in 1, and an unknown cause in 2. The median pretreatment scores were 9 on the Glasgow Coma Scale (GCS) and 25 on the National Institutes of Health Stroke Scale. The time elapsed from onset of the stroke to reperfusion was 281 min. Successful reperfusion, characterized by a modified Thrombolysis in Cerebral Infarction grade ≥ 2b, was achieved in all patients. The 3-month outcomes were good [modified Rankin Scale (mRS) 0–2] in 5 patients and poor (mRS 3–6) in 6 patients. The pretreatment median GCS scores were significantly higher in patients with a good outcome compared to that in those with a poor outcome with scores of 11 and 7.5, respectively (P =  0.044). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off score on the GCS was 9.5 [area under the curve (AUC), 0.867; sensitivity, 0.8; specificity, 1.0]. Complications occurred in 1 patient with arterial dissection who had developed a subarachnoid hemorrhage and later died.
The results of the present study suggests that the pretreatment GCS score might affect the clinical outcomes in patients with BA occlusion who underwent MT following IV-rt-PA therapy.
Endovascular Treatment of Acute Basilar Artery Occlusion: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) Study Group Experience
2018, Journal of Stroke and Cerebrovascular Diseases
Acute basilar artery occlusion (BAO) is considered among the most severe medical emergencies, with very high morbidity and mortality. The aims of this study are to present 5 years experience of 12 centers in Lombardy region on BAO endovascular treatment and to evaluate prognostic factors that may improve clinical outcomes and recanalization rates.
Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) registry is a retrospective multicentric collection of patients with acute BAO who underwent endovascular treatment between 2010 and 2015. A total of 102 patients (mean age 65 years) were included. Clinical, procedural, and neuroradiological data were collected. Angiographic results (Treatment in Cerebral Ischemia scale [TICI] score 2b-3) were assessed by each center's interventional neuroradiologist. Good clinical outcome was considered as a modified Rankin Scale score ranging between 0 and 2 in a 3-month follow-up.
Thirty-nine percent of patients showed good clinical outcome at 3 months. Mortality rate was 30%. TICI 2b-3 was achieved in 62% of patients. Univariate analysis showed that age, National Institutes of Health Stroke Scale (NIHSS) at onset, time to recanalization, and TICI score were all statistically significant clinical outcome predictors (P < .05). Multivariate logistic regression showed that time to recanalization, age, and NIHSS at onset were significant independent predictors of good outcome.
BAO treatment needs more efforts to assure patients better clinical outcomes. Mechanical thrombectomy is feasible and effective in patients with acute BAO. These results must be confirmed by further prospective studies within randomized controlled settings.
Factors Associated with 90-Day Outcomes of Patients with Acute Posterior Circulation Stroke Treated By Mechanical Thrombectomy
2018, World Neurosurgery
Citation Excerpt :
Therapeutic strategies for this condition remain limited, whereas mechanical thrombectomy (MT) using stent retrievers has become a standard treatment for acute anterior circulation stroke caused by large-vessel occlusion.2-6 Several pilot studies have suggested that MT with stent retrievers may be safe and effective for acute posterior circulation stroke caused by basilar artery occlusion (BAO).7-20 The good clinical outcome at 90 days of patients undergoing MT may be around 30% despite successful recanalization.
Early recanalization of acute posterior circulation stroke caused by large intracranial vessel occlusion by mechanical thrombectomy with stent retrievers may improve the outcome of patients. However, evidence of patient selection is still lacking. This study investigated the prognostic factors of acute posterior circulation stroke caused by large intracranial arterial occlusion when treated with stent-retriever thrombectomy.
A total of 69 patients from March 2012 to November 2016 were included in the study. These patients presented with acute posterior circulation stroke caused by large intracranial vessel occlusion and underwent mechanical thrombectomy with Solitaire AB or combined with additional balloon and/or stenting angioplasty. Baseline characteristics, clinical course, and imaging data of the patients were analyzed. Good clinical outcome (defined as a modified Rankin Scale score of 0–2 at 90 days) and safety outcome (defined as death within 90 days after thrombectomy) were considered as end points. The association between factors with good clinical outcome and safety outcome was evaluated with both logistic regression and receiver operating characteristic curve analyses.
Of the 69 patients, mean age was 59 years (standard deviation, 8 years) and men comprised 82.6% (57/69). The median onset-to-treatment time was 360 minutes (interquartile range, 250–537 minutes). The median National Institutes of Health Stroke Scale (NIHSS) score was 25 (interquartile range, 17–30) on admission. Successful recanalization was achieved in 62 of the 69 cases (89.9%) and 36.2% (25/69) were independent at 90 days. Regression analysis showed that stroke subtype (intracranial atherosclerotic disease vs. embolism; odds ratio [OR], 0.101; 95% confidence interval [CI], 0.020–0.501; P = 0.005), baseline NIHSS score (≥22 vs. <22; OR, 0.157; 95% CI, 0.040–0.614; P = 0.008) and posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) on diffusion-weighted imaging [DWI] (weighted magnetic resonance imaging) before thrombectomy (≥6 vs. <6; OR, 7.335; 95% CI, 1.495–36.191; P = 0.014) were independent predictive factors of good clinical outcome, respectively at 90 days, whereas high NIHSS score (≥30 vs. <30; OR, 5.569; 95% CI, 1.573–19.716; P = 0.008) and collateral status (≥2 vs. <2; OR, 0.210; 95% CI, 0.059–0.752; P = 0.016) before treatment were associated with mortality at 90 days. Based on receiver operating characteristic curves, baseline NIHSS score (area under the curve [AUC] = 0.779; cutoff, ≥22; P < 0.001; sensitivity, 72%; specificity, 77.3%), pc-ASPECTS on DWI (AUC = 0.820; cutoff, ≥6; P < 0.001; sensitivity, 72%; specificity, 77.3%) before treatment were independent indicators predicting good clinical outcome at 90 days. Increased risk of death by 90 days was associated with baseline NIHSS score (AUC = 0.719; cutoff, ≥30; P = 0.007; sensitivity, 64.7%; specificity, 78.9%) and worse collateral status (AUC = 0.820; cutoff, ≥2; P < 0.001; sensitivity, 58.8%; specificity, 80.8%) before treatment.
Stroke subtype, initial stroke severity, and pc-ASPECTS on DWI as well as collateral status before thrombectomy are independent factors affecting the clinical outcome in patients treated with Solitaire AB thrombectomy for acute posterior circulation stroke caused by large intracranial vessel occlusion.
Endovascular Mechanical Thrombectomy with the Solitaire Device for the Treatment of Acute Basilar Artery Occlusion
2016, World Neurosurgery
To determine the safety and efficacy of endovascular treatment with the Solitaire device for acute basilar artery occlusion (ABAO) and identify factors affecting clinical outcomes.
We enrolled 36 consecutive ABAO patients (aged 58.6 ± 8.10 years) who underwent mechanical thrombectomy with the Solitaire device. We analyzed baseline characteristics, mechanical thrombectomy results, and factors predicting clinical outcomes, which were assessed at 90 days.
The median prethrombectomy National Institutes of Health Stroke Scale (NIHSS) score was 25.50 (interquartile range: 21.00–29.00); the median prethrombectomy Glasgow Coma Scale (GCS) score was 8.00 (5.00–9.75). Thirty patients (83.3%) had atherosclerotic stenosis of the occluded artery, and 25 underwent angioplasty (69.4%). Recanalization was successful (Thrombolysis in Cerebral Infarction grade: 2b–3) in 34 patients (94.4%). Six symptomatic intracranial hemorrhages (16.67%) occurred. Favorable outcomes (modified Rankin scale [mRS] score: 0–2) were achieved in 27.8% patients (10/36). The overall mortality rate was 30.6% (11/36) at 90 days. On univariate analysis, low prethrombectomy GCS and high post-thrombectomy NIHSS scores were associated with poor outcomes (mRS score >2) and mortality. Prethrombectomy unconsciousness, onset-to-recanalization time > 10.5 hours, and severe stenosis were associated with poor outcomes. Age ≥ 60 years was associated with mortality.
Endovascular treatment with the Solitaire device yielded high recanalization rates in ABAO patients and favorable clinical outcomes in approximately one third of patients. Intracranial stenosis was the main cause of occlusion. Angioplasty was commonly performed during mechanical thrombectomy to improve recanalization and prognosis. Early recanalization and better prethrombectomy status predicted better outcomes.
Direct Microsurgical Embolectomy for an Acute Distal Basilar Artery Occlusion
2016, World Neurosurgery
Citation Excerpt :
Intravenous thrombolysis with recombinant human tissue plasminogen activator (rtPA) has a limited effect on basilar artery revascularization within a 4.5-hour window.4,5 It is because of this limitation that intra-arterial thrombolysis and the endovascular mechanical thrombectomy are used increasingly to achieve basilar artery recanalization even after unsuccessful intravenous thrombolysis.6-10 However, the best treatment modality has yet to be studied effectively.
Acute basilar artery occlusion is associated with high mortality rates, up to 35%–40%. Early revascularization by intravenous thrombolysis, intra-arterial thrombolysis, and endovascular mechanical embolectomy is considered the best option to date. The objective of this technical report is to present the direct microsurgical embolectomy technique for an acute distal basilar artery occlusion as an urgent life-saving revascularization procedure.
A 71-year-old male patient suffered from an acute embolic basilar artery occlusion and became unconscious (Glasgow Coma Scale 4). Computed tomography angiography and MRA revealed the distal basilar artery occlusion along with an increased diffusion-weighted imaging signal in the corresponding territory. After an individual case discussion, the patient underwent a microsurgical embolectomy via a frontotemporal craniotomy and an anterior temporal approach.
Intraoperative indocyanine green and postoperative computed tomography angiography revealed complete revascularization of the previously occluded basilar quadfurcation. The patient steadily recovered and was able to walk with assistance after 4 weeks.
Microsurgical embolectomy can be an effective treatment option for acute distal basilar artery occlusion in selected cases with experienced surgeons, but a critical preoperative decision-making process is needed.

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: Concentric Medical funded the trials from which these data were derived.

: Disclosures: Dr Rymer is on the speakers bureau of Concentric Medical. Dr Nesbit has stock ownership in Concentric Medical. Dr Lutsep has no conflicts of interest to declare.

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Original ArticleVertebrobasilar Revascularization Rates and Outcomes in the MERCI and Multi-MERCI Trials

Objective

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease

Stroke

Outcome in patients with basilar artery occlusion treated conventionally

J Neurol Neurosurg Psychiatry

Intra-arterial thrombolytic therapy for acute basilar occlusion: Pro

Stroke

Safety and efficacy of mechanical embolectomy in acute ischemic stroke

Stroke

Original Article
Vertebrobasilar Revascularization Rates and Outcomes in the MERCI and Multi-MERCI Trials