Neurointervention.  2023 Jun;18(2):90-106. 10.5469/neuroint.2023.00213.

A Review of Endovascular Treatment for Posterior Circulation Strokes

• Baik SH
• Kim JY
• Jung C

• KMID: 2543364
• DOI: http://doi.org/10.5469/neuroint.2023.00213

Abstract

Mechanical thrombectomy for acute posterior circulation strokes (PCSs) is recommended based on evidence from anterior circulation strokes (ACSs). Two recent randomized controlled trials showed that endovascular treatment (EVT) leads to better functional outcomes than those of the best medical care. However, many studies have shown that patients undergoing PC-EVT have a higher rate of futile recanalization than those undergoing AC-EVT. The characteristics and outcomes of PC-EVT may differ according to the pathological mechanisms, including cardioembolism, intracranial atherosclerosis, and tandem vertebrobasilar occlusion. We reviewed PC-EVT outcomes reported in recent studies and discussed technical considerations for maximizing treatment efficacy according to the etiology of a PCS.

Keyword

Endovascular treatment; Posterior circulation strokes; Embolism; Intracranial atherosclerosis; Tandem occlusion

Figure

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  Fig. 1. Illustrations and cases of basilar artery occlusion (BAO) according to etiology. (A–C) Middle BAO due to an underlying atherosclerotic stenosis. Initial recanalization was achieved after 2 trials of stent retriever thrombectomy (SRT, not shown). Re-occlusion of the lesion with impaired distal flow was seen on delayed angiogram despite intra-arterial administration tirofiban. Rescue SRT and subsequent balloon angioplasty was performed (not shown). Final angiogram shows recanalization with underlying atherosclerotic stenosis. (D–F) Embolic occlusion of the distal BA. Left vertebral artery (VA) anteroposterior angiogram shows filling defect clot at the tip of the BA involving right posterior cerebral artery origin (arrow). After a single attempt of contact aspiration thrombectomy (not shown), complete recanalization of the BA without residual stenosis is seen. (G–I) Tandem occlusion with a distal occlusion of the BA and a proximal occlusion of the right VA. Right subclavian anteroposterior angiogram shows occlusion at orifice of VA as spike sign (arrow) and distal VA filling (arrowheads) from cervical collateral arteries with impaired antegrade flow. Intracranial anteroposterior image shows occlusion of distal BA.

Reference

1. Greving JP, Schonewille WJ, Wijman CA, Michel P, Kappelle LJ, Algra A; BASICS Study Group. Predicting outcome after acute basilar artery occlusion based on admission characteristics. Neurology. 2012; 78:1058–1063.

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

3. Smith WS, Lev MH, English JD, Camargo EC, Chou M, Johnston SC, et al. Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA. Stroke. 2009; 40:3834–3840.

4. Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry. 2005; 76:1238–1241.

5. Schonewille WJ, Wijman CA, Michel P, Rueckert CM, Weimar C, Mattle HP, BASICS Study Group, 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.

6. Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring HP, Trenkler J, ENDOSTROKE Study Group, et al. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol. 2015; 77:415–424.

7. Sarraj A, Medrek S, Albright K, Martin-Schild S, Bibars W, Vahidy F, et al. Posterior circulation stroke is associated with prolonged door-to-needle time. Int J Stroke. 2015; 10:672–678.

8. Voetsch B, DeWitt LD, Pessin MS, Caplan LR. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Arch Neurol. 2004; 61:496–504.

9. Zi W, Qiu Z, Wu D, Li F, Liu H, Liu W, et al. Assessment of endovascular treatment for acute basilar artery occlusion via a nationwide prospective registry. JAMA Neurol. 2020; 77:561–573.

10. Bouslama M, Haussen DC, Aghaebrahim A, Grossberg JA, Walker G, Rangaraju S, et al. Predictors of good outcome after endovascular therapy for vertebrobasilar occlusion stroke. Stroke. 2017; 48:3252–3257.

11. Gory B, Mazighi M, Labreuche J, Blanc R, Piotin M, Turjman F, ETIS (Endovascular Treatment in Ischemic Stroke) Investigators, et al. Predictors for mortality after mechanical thrombectomy of acute basilar artery occlusion. Cerebrovasc Dis. 2018; 45:61–67.

12. Mokin M, Sonig A, Sivakanthan S, Ren Z, Elijovich L, Arthur A, et al. Clinical and procedural predictors of outcomes from the endovascular treatment of posterior circulation strokes. Stroke. 2016; 47:782–788.

13. Novakovic-White R, Corona JM, White JA. Posterior circulation ischemia in the endovascular era. Neurology. 2021; 97(20 Suppl 2):S158–S169.

14. Liu X, Dai Q, Ye R, Zi W, Liu Y, Wang H, BEST Trial Investigators, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial. Lancet Neurol. 2020; 19:115–122.

15. Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, de Carvalho JJF, Lima FO, Dippel DWJ, BASICS Study Group, et al. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med. 2021; 384:1910–1920.

16. Jovin TG, Li C, Wu L, Wu C, Chen J, Jiang C, BAOCHE Investigators, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion. N Engl J Med. 2022; 387:1373–1384.

17. Tao C, Nogueira RG, Zhu Y, Sun J, Han H, Yuan G, ATTENTION Investigators, et al. Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med. 2022; 387:1361–1372.

18. Adusumilli G, Kobeissi H, Ghozy S, Hardy N, Kallmes KM, Hutchison K, et al. Endovascular thrombectomy after acute ischemic stroke of the basilar artery: a meta-analysis of four randomized controlled trials. [published online ahead of print Dec 8, 2022]. J Neurointerv Surg. 2022.

19. Wang F, Wang J, He Q, Wang L, Cao Y, Zhang H, et al. Mechanical thrombectomy for posterior circulation occlusion: a comparison of outcomes with the anterior circulation occlusion - a meta-analysis. J Atheroscler Thromb. 2020; 27:1325–1339.

20. Alonso de Leciñana M, Kawiorski MM, Ximénez-Carrillo Á, Cruz-Culebras A, García-Pastor A, Martínez-Sánchez P, Madrid Stroke Network, et al. Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions. J Neurointerv Surg. 2017; 9:1173–1178.

21. Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Mosimann PJ, et al. Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation. J Neurointerv Surg. 2019; 11:1174–1180.

22. Caplan L, Chung CS, Wityk R, Glass T, Tapia J, Pazdera L, et al. New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes. J Clin Neurol. 2005; 1:14–30.

23. Baik SH, Park HJ, Kim JH, Jang CK, Kim BM, Kim DJ. Mechanical thrombectomy in subtypes of basilar artery occlusion: relationship to recanalization rate and clinical outcome. Radiology. 2019; 291:730–737.

24. Pirson FAVA, Boodt N, Brouwer J, Bruggeman AAE, Hinsenveld WH, Staals J, MR CLEAN Registry Investigators, et al. Etiology of large vessel occlusion posterior circulation stroke: results of the MR CLEAN registry. Stroke. 2022; 53:2468–2477.

25. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50:e344–e418.

26. Kayan Y, Meyers PM, Prestigiacomo CJ, Kan P, Fraser JF; Society of NeuroInterventional Surgery. Current endovascular strategies for posterior circulation large vessel occlusion stroke: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg. 2019; 11:1055–1062.

27. Puetz V, Lutsep HL, Nguyen TN. Endovascular therapy for basilar artery occlusion: among the first to conceptualize, last to prove. Stroke. 2023; 54:905–908.

28. Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular treatment for posterior circulation stroke: ways to maximize therapeutic efficacy. J Stroke. 2022; 24:207–223.

29. Kidwell CS, Alger JR, Saver JL. Beyond mismatch: evolving paradigms in imaging the ischemic penumbra with multimodal magnetic resonance imaging. Stroke. 2003; 34:2729–2735.

30. Raymond S, Rost NS, Schaefer PW, Leslie-Mazwi T, Hirsch JA, Gonzalez RG, et al. Patient selection for mechanical thrombectomy in posterior circulation emergent large-vessel occlusion. Interv Neuroradiol. 2018; 24:309–316.

31. Yeo LLL, Holmberg A, Mpotsaris A, Söderman M, Holmin S, Kuntze Söderqvist A, et al. Posterior circulation occlusions may be associated with distal emboli during thrombectomy: factors for distal embolization and a review of the literature. Clin Neuroradiol. 2019; 29:425–433.

32. Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. 2014; 5:30.

33. Ahmed RA, Dmytriw AA, Patel AB, Stapleton CJ, Vranic JE, Rabinov JD, et al. Basilar artery occlusion: a review of clinicoradiologic features, treatment selection, and endovascular techniques. [published online ahead of print Jun 12, 2022]. Interv Neuroradiol. 2022.

34. Nguyen TN, Strbian D. Endovascular therapy for stroke due to basilar artery occlusion: a basic challenge at best. Stroke. 2021; 52:3410–3413.

35. Cloud GC, Markus HS. Diagnosis and management of vertebral artery stenosis. QJM. 2003; 96:27–54.

36. Krejza J, Arkuszewski M, Kasner SE, Weigele J, Ustymowicz A, Hurst RW, et al. Carotid artery diameter in men and women and the relation to body and neck size. Stroke. 2006; 37:1103–1105.

37. Kocak B, Korkmazer B, Islak C, Kocer N, Kizilkilic O. Endovascular treatment of extracranial vertebral artery stenosis. World J Radiol. 2012; 4:391–400.

38. Boeckh-Behrens T, Pree D, Lummel N, Friedrich B, Maegerlein C, Kreiser K, et al. Vertebral artery patency and thrombectomy in basilar artery occlusions. Stroke. 2019; 50:389–395.

39. Hong JM, Chung CS, Bang OY, Yong SW, Joo IS, Huh K. Vertebral artery dominance contributes to basilar artery curvature and peri-vertebrobasilar junctional infarcts. J Neurol Neurosurg Psychiatry. 2009; 80:1087–1092.

40. Kim YW, Hong JM, Park DG, Choi JW, Kang DH, Kim YS, et al. Effect of intracranial atherosclerotic disease on endovascular treatment for patients with acute vertebrobasilar occlusion. AJNR Am J Neuroradiol. 2016; 37:2072–2078.

41. Lee WJ, Jung KH, Ryu YJ, Kim JM, Lee ST, Chu K, et al. Impact of stroke mechanism in acute basilar occlusion with reperfusion therapy. Ann Clin Transl Neurol. 2018; 5:357–368.

42. Cross DT 3rd, Moran CJ, Akins PT, Angtuaco EE, Diringer MN. Relationship between clot location and outcome after basilar artery thrombolysis. AJNR Am J Neuroradiol. 1997; 18:1221–1228.

43. Kwon H, Lee D, Lee DH, Suh DC, Kwon SU, Kang DW, et al. Etiology-related outcome of endovascular therapy in posterior circulation stroke compared to anterior circulation stroke. J Stroke. 2022; 24:245–255.

44. Piechowiak EI, Kaesmacher J, Zibold F, Dobrocky T, Mosimann PJ, Jung S, et al. Endovascular treatment of tandem occlusions in vertebrobasilar stroke: technical aspects and outcome compared with isolated basilar artery occlusion. J Neurointerv Surg. 2020; 12:25–29.

45. Baek JH, Kim BM, Heo JH, Kim DJ, Nam HS, Kim YD. Endovascular and clinical outcomes of vertebrobasilar intracranial atherosclerosis-related large vessel occlusion. Front Neurol. 2019; 10:215.

46. Berndt MT, Pree D, Kaesmacher J, Maegerlein C, Friedrich B, Zimmer C, et al. From perviousness to plaque imaging in acute basilar occlusions: the impact of underlying stenosis and how to detect it. Stroke. 2020; 51:766–774.

47. Gao F, Lo WT, Sun X, Mo DP, Ma N, Miao ZR. Combined use of mechanical thrombectomy with angioplasty and stenting for acute basilar occlusions with underlying severe intracranial vertebrobasilar stenosis: preliminary experience from a single Chinese center. AJNR Am J Neuroradiol. 2015; 36:1947–1952.

48. Jiang L, Yang JH, Ruan J, Xia WQ, Huang H, Zhang H, et al. A single-center experience of endovascular treatment in subtypes of basilar artery occlusion: embolization caused by tandem vertebral artery stenosis may be associated with better outcomes. World Neurosurg. 2021; 151:e918. –e926.

49. Sun X, Tong X, Gao F, Deng Y, Ma G, et al. Analysis of treatment outcome after endovascular treatment in different pathological subtypes of basilar artery occlusion: a single center experience. Transl Stroke Res. 2021; 12:230–238.

50. Kang DH, Yoon W, Baek BH, Kim SK, Lee YY, Kim JT, et al. Frontline thrombectomy for acute large-vessel occlusion with underlying severe intracranial stenosis: stent retriever versus contact aspiration. J Neurosurg. 2019; 132:1202–1208.

51. Lee JS, Lee SJ, Hong JM, Alverne FJAM, Lima FO, Nogueira RG. Endovascular treatment of large vessel occlusion strokes due to intracranial atherosclerotic disease. J Stroke. 2022; 24:3–20.

52. Lee JS, Hong JM, Lee KS, Suh HI, Choi JW, Kim SY. Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease. J Stroke. 2016; 18:96–101.

53. Park H, Baek JH, Kim BM. Endovascular treatment of acute stroke due to intracranial atherosclerotic stenosis-related large vessel occlusion. Front Neurol. 2019; 10:308.

54. Kim BM. Causes and solutions of endovascular treatment failure. J Stroke. 2017; 19:131–142.

55. Baek JH, Kim BM, Kim DJ, Heo JH, Nam HS, Yoo J. Stenting as a rescue treatment after failure of mechanical thrombectomy for anterior circulation large artery occlusion. Stroke. 2016; 47:2360–2363.

56. Siebert E, Bohner G, Zweynert S, Maus V, Mpotsaris A, Liebig T, et al. Revascularization techniques for acute basilar artery occlusion: technical considerations and outcome in the setting of severe posterior circulation steno-occlusive disease. Clin Neuroradiol. 2019; 29:435–443.

57. Kaesmacher J, Dobrocky T, Heldner MR, Bellwald S, Mosimann PJ, Mordasini P, et al. Systematic review and meta-analysis on outcome differences among patients with TICI2b versus TICI3 reperfusions: success revisited. J Neurol Neurosurg Psychiatry. 2018; 89:910–917.

58. Rizvi A, Seyedsaadat SM, Murad MH, Brinjikji W, Fitzgerald ST, Kadirvel R, et al. Redefining ‘success’: a systematic review and meta-analysis comparing outcomes between incomplete and complete revascularization. J Neurointerv Surg. 2019; 11:9–13.

59. Dargazanli C, Fahed R, Blanc R, Gory B, Labreuche J, Duhamel A, ASTER Trial Investigators, et al. Modified thrombolysis in cerebral infarction 2C/thrombolysis in cerebral infarction 3 reperfusion should be the aim of mechanical thrombectomy: insights from the ASTER trial (contact aspiration versus stent retriever for successful revascularization). Stroke. 2018; 49:1189–1196.

60. Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke. 2018; 49:660–666.

61. Aubertin M, Weisenburger-Lile D, Gory B, Richard S, Blanc R, Ducroux C, ETIS Investigators, et al. First-pass effect in basilar artery occlusions: insights from the endovascular treatment of ischemic stroke registry. Stroke. 2021; 52:3777–3785.

62. den Hartog SJ, Roozenbeek B, Boodt N, Bruggeman AAE, van Es ACGM, Emmer BJ, MR CLEAN Registry investigators, et al. Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke. J Neurointerv Surg. 2022; 14:333–340.

63. Lapergue B, Blanc R, Gory B, Labreuche J, Duhamel A, Marnat G, ASTER Trial Investigators, et al. Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA. 2017; 318:443–452.

64. Turk AS 3rd, Siddiqui A, Fifi JT, De Leacy RA, Fiorella DJ, Gu E, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial. Lancet. 2019; 393:998–1008.

65. Bernsen MLE, Bruggeman AAE, Brouwer J, Emmer BJ, Majoie CBLM, Coutinho JM, MR CLEAN Registry Investigators, et al. Aspiration versus stent retriever thrombectomy for posterior circulation stroke. Stroke. 2022; 53:749–757.

66. Texakalidis P, Giannopoulos S, Karasavvidis T, Rangel-Castilla L, Rivet DJ, Reavey-Cantwell J. Mechanical thrombectomy in acute ischemic stroke: a meta-analysis of stent retrievers vs direct aspiration vs a combined approach. Neurosurgery. 2020; 86:464–477.

67. Xenos D, Texakalidis P, Karras CL, Murthy NK, Kontzialis M, Rivet DJ, et al. First-line stent retriever versus direct aspiration for acute basilar artery occlusions: a systematic review and meta-analysis. World Neurosurg. 2022; 158:258–267.e1.

68. Ye G, Lu J, Qi P, Yin X, Wang L, Wang D. Firstline a direct aspiration first pass technique versus firstline stent retriever for acute basilar artery occlusion: a systematic review and meta-analysis. J Neurointerv Surg. 2019; 11:740–746.

69. Ye G, Wen X, Wang H, Sun C, Pan Z, Chen M, et al. First-line contact aspiration versus first-line stent retriever for acute posterior circulation strokes: an updated meta-analysis. J Neurointerv Surg. 2022; 14:neurintsurg-2021-017497.

70. Baik SH, Jung C, Kim BM, Kim DJ. Basilar tip morphology: impact on mechanical thrombectomy for acute distal basilar artery occlusion. [published online ahead of print Feb 14, 2023]. J Neurointerv Surg. 2023.

71. Choi JW, Han M, Park JH, Jung WS. Effect of manual aspiration thrombectomy using large-bore aspiration catheter for acute basilar artery occlusion: comparison with a stent retriever system. BMC Neurol. 2020; 20:434.

72. Eom YI, Hwang YH, Hong JM, Choi JW, Lim YC, Kang DH, et al. Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals. AJNR Am J Neuroradiol. 2014; 35:2354–2359.

73. Carneiro AA, Rodrigues JT, Pereira JP, Alves JV, Xavier JA. Mechanical thrombectomy in patients with acute basilar occlusion using stent retrievers. Interv Neuroradiol. 2015; 21:710–714.

74. Boisseau W, Escalard S, Fahed R, Lapergue B, Smajda S, Maier B, et al. Direct aspiration stroke thrombectomy: a comprehensive review. J Neurointerventional Surg. 2020; 12:1099–1106.

75. Brehm A, Maus V, Tsogkas I, Colla R, Hesse AC, Gera RG, et al. Stent-retriever assisted vacuum-locked extraction (SAVE) versus a direct aspiration first pass technique (ADAPT) for acute stroke: data from the real-world. BMC Neurol. 2019; 19:65.

76. Abdelrady M, Ognard J, Cagnazzo F, Derraz I, Lefevre PH, Riquelme C, RAMBO (Revascularization via Aspiration or Mechanical thrombectomy in Basilar Occlusion), et al. Frontline thrombectomy strategy and outcome in acute basilar artery occlusion. J Neurointerv Surg. 2023; 15:27–33.

77. Maus V, Styczen H, Liman J, Maier I, Brehm A, Tsogkas I, et al. Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE. BMC Neurol. 2019; 19:197.

78. Patro SN, Iancu D. Dual-stent retrieval for mechanical thrombectomy of refractory clot in acute stroke as a rescue technique. CMAJ. 2017; 189:E634–E637.

79. Li Z, Liu P, Zhang L, Zhang Y, Fang Y, Xing P, et al. Y-stent rescue technique for failed thrombectomy in patients with large vessel occlusion: a case series and pooled analysis. Front Neurol. 2020; 11:924.

80. Cohen JE, Leker RR, Gomori JM, Eichel R, Rajz G, Moscovici S, et al. Emergent revascularization of acute tandem vertebrobasilar occlusions: endovascular approaches and technical considerations-confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke. J Clin Neurosci. 2016; 34:70–76.

81. Xing PF, Zhang YW, Li ZF, Zhang L, Shen HJ, Zhang YX, et al. The “distal-to-proximal” strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience. Neuroradiology. 2020; 62:867–876.

82. Elhorany M, Boulouis G, Hassen WB, Crozier S, Shotar E, Sourour NA, et al. Outcome and recanalization rate of tandem basilar artery occlusion treated by mechanical thrombectomy. J Neuroradiol. 2020; 47:404–409.

83. Baik SH, Jung C, Kim BM, Kim DJ. Mechanical thrombectomy for tandem vertebrobasilar stroke: characteristics and treatment outcome. Stroke. 2020; 51:1883–1885.

84. Ecker RD, Tsujiura CA, Baker CB, Cushing D. Endovascular reconstruction of vertebral artery occlusion prior to basilar thrombectomy in a series of six patients presenting with acute symptomatic basilar thrombosis. J Neurointerv Surg. 2014; 6:379–383.

85. Cohen JE, Gomori JM, Leker RR, Eichel R, Itshayek E. Emergency revascularization of acute internal carotid artery occlusion: follow the spike, it guides you. J Clin Neurosci. 2016; 29:95–99.

86. Gross BA, Jadhav AP, Jankowitz BT, Jovin TG. Recanalization of tandem vertebrobasilar occlusions with contralateral vertebral occlusion or hypoplasia via either direct passage or the SHERPA technique. Interv Neurol. 2020; 8:13–19.

87. Du B, Wong EH, Jiang WJ. Long-term outcome of tandem stenting for stenoses of the intracranial vertebrobasilar artery and vertebral ostium. AJNR Am J Neuroradiol. 2009; 30:840–844.