J Clin Neurol.  2014 Jan;10(1):17-23.

Outcomes of Endovascular Mechanical Thrombectomy and Intravenous Tissue Plasminogen Activator for the Treatment of Vertebrobasilar Stroke

• Brinjikji
• Rabinstein AA
• Clofta HJ

Abstract

BACKGROUND AND PURPOSE
Aggressive treatment of posterior-circulation occlusions is important due to the high rates of morbidity and mortality associated with these infarctions. A large administrative database was evaluated to determine the outcomes of mechanical thrombectomy and intravenous tissue plasminogen activator (IV-tPA) for the treatment of posterior-circulation (vertebrobasilar) strokes. Outcomes were compared across age groups.
METHODS
The United States Nationwide Inpatient Sample was used to evaluate the outcomes of patients treated for posterior-circulation acute ischemic stroke between 2006 and 2010. Patients who underwent endovascular mechanical thrombectomy and IV-tPA were selected. Primary outcomes were discharge status and mortality; secondary outcomes were length of stay, rate of intracranial hemorrhage, tracheostomy, and percutaneous endoscopic gastrostomy/jejunostomy tube placement. Outcomes were grouped according to age (i.e., <50, 50-64, and > or =65 years). Chi-squared test and Student's t-test were used for comparisons of categorical and continuous variables, respectively.
RESULTS
During 2006-2010 there were 36,675 patients who had discharge International Classification of Diseases (9th edition) codes indicating posterior-circulation strokes. Of these, 631 (1.7%) underwent mechanical thrombectomy and 1554 (4.2%) underwent IV-tPA. The in-hospital mortality rate for mechanical thrombectomy patients was significantly lower for those aged <50 years than for those aged 50-64 years (30.4% versus 47.4%, p<0.01) and those aged > or =65 years (30.4% versus 43.0%, p< or =0.01). Age had no effect on the in-hospital mortality for IV-tPA patients, with an incidence of 22.7% for patients aged <50 years, compared to 25.4% for patients aged 50-64 years (p=0.46) and 23.0% for patients aged > or =65 years (p=0.92).
CONCLUSIONS
Patients requiring IV-tPA and/or mechanical thrombectomy for the treatment of posterior-circulation strokes suffer from high mortality rates. Increased age is associated with significantly higher mortality rates among posterior-circulation stroke patients who require mechanical thrombectomy.

Keyword

stroke; brain infarction; posterior circulation; endovascular techniques; tissue-type plasminogen activator

MeSH Terms

Brain Infarction
Endovascular Procedures
Hospital Mortality
Humans
Incidence
Infarction
Inpatients
International Classification of Diseases
Intracranial Hemorrhages
Length of Stay
Mortality
Stroke*
Thrombectomy*
Tissue Plasminogen Activator*
Tracheostomy
United States
Tissue Plasminogen Activator

Reference

1. Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. 2008; 29:1409–1413.

2. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004; 363:768–774.

3. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. The European Cooperative Acute Stroke Study (ECASS). Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. JAMA. 1995; 274:1017–1025.

4. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008; 39:1205–1212.

5. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005; 36:1432–1438.

6. Davis SM, Donnan GA. Basilar artery thrombosis: recanalization is the key. Stroke. 2006; 37:2440.

7. Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006; 37:922–928.

8. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol. 2011; 10:1002–1014.

9. Schonewille WJ, Wijman CA, Michel P, Rueckert CM, Weimar C, Mattle HP, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009; 8:724–730.

10. Schulte-Altedorneburg G, Hamann GF, Mull M, Kühne D, Liebetrau M, Weber W, et al. Outcome of acute vertebrobasilar occlusions treated with intra-arterial fibrinolysis in 180 patients. AJNR Am J Neuroradiol. 2006; 27:2042–2047.

11. Brinjikji W, Rabinstein AA, Kallmes DF, Cloft HJ. Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: 2006 to 2008. Stroke. 2011; 42:1648–1652.

12. Nasr DM, Brinjikji W, Cloft HJ, Rabinstein AA. Utilization of intravenous thrombolysis is increasing in the United States. Int J Stroke. 2013; 8:681–688.

13. Sairanen T, Strbian D, Soinne L, Silvennoinen H, Salonen O, Artto V, et al. Intravenous thrombolysis of basilar artery occlusion: predictors of recanalization and outcome. Stroke. 2011; 42:2175–2179.

14. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40:373–383.

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; 5:221–225.

16. Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke. 2011; 42:1929–1935.

17. 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; 34:1044–1048.

18. Lutsep HL, Rymer MM, Nesbit GM. Vertebrobasilar revascularization rates and outcomes in the MERCI and multi-MERCI trials. J Stroke Cerebrovasc Dis. 2008; 17:55–57.

19. Miteff F, Faulder KC, Goh AC, Steinfort BS, Sue C, Harrington TJ. Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. AJNR Am J Neuroradiol. 2011; 32:1078–1081.

20. Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Heldner MR, et al. Technical feasibility and application of mechanical thrombectomy with the Solitaire FR Revascularization Device in acute basilar artery occlusion. AJNR Am J Neuroradiol. 2013; 34:159–163.

21. Pfefferkorn T, Holtmannspötter M, Schmidt C, Bender A, Pfister HW, Straube A, et al. Drip, ship, and retrieve: cooperative recanalization therapy in acute basilar artery occlusion. Stroke. 2010; 41:722–726.

22. Arnold M, Fischer U, Compter A, Gralla J, Findling O, Mattle HP, et al. Acute basilar artery occlusion in the Basilar Artery International Cooperation Study: does gender matter? Stroke. 2010; 41:2693–2696.

23. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013; 368:904–913.

24. Hassan AE, Chaudhry SA, Grigoryan M, Tekle WG, Qureshi AI. National trends in utilization and outcomes of endovascular treatment of acute ischemic stroke patients in the mechanical thrombectomy era. Stroke. 2012; 43:3012–3017.

25. Vergouwen MD, Algra A, Pfefferkorn T, Weimar C, Rueckert CM, Thijs V, et al. Time is brain(stem) in basilar artery occlusion. Stroke. 2012; 43:3003–3006.