E-084 proximal versus distal occlusions in the posterior circulation: acute stroke etiology in endovascular therapy

Abstract

Background Acute posterior circulation stroke carries substantial morbidity and mortality. Development of second-generation clot retrieval devices has facilitated an improvement in recanalization rates, yet response to revascularization based on etiology has not been discerned. While overwhelmingly positive results have validated endovascular thrombectomy in multiple, randomized clinical trials (MR-CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME) as a therapy responsible for significant improvement in patient clinical outcomes, these trials have only evaluated anterior circulation occlusions. In this study, we focused on the role of stroke etiology in endovascular therapy of posterior circulation strokes in the stentriever era. Methods Retrospective review of consecutive cases treated between March 2011 to August 2014, from a total of 216 acute endovascular intervention cases. Cases were evaluated for clinical and radiographic presentation, vascular risk factors, angiographic diagnostic findings, treatment and outcomes. Results Amongst 216 consecutive acute stroke endovascular therapy cases, 20 patients (9.3%) presented with posterior circulation stroke, ages ranging from 39 to 93 years (mean of 66.5), 75% of whom were men. NIHSS ranged from 1, fluctuating to loss of consciousness, to an initial presenting NIHSS of 35. Seventeen cases were treated and analyzed based on clot location defining proximal occlusion as distal vertebral arteries, vertebrobasilar junction and proximal-to-mid basilar trunk while distal occlusion was defined as mid-basilar trunk to basilar tip as well as superior cerebellar and posterior cerebral arteries. Proximal occlusions were seen in 30% of patients and attributed in etiology to dissection or intracranial athersosclerosis necessitating angioplasty and stenting in 2 patients. Four out of 6 patients were treated with stentrievers and 2 with aspiration alone or aspiration in conjunction with stentriever device. Distal occlusions were seen in 70% of patients 11 of whom underwent endovascular treatment, of this subgroup the etiology for 72.7% was atrial fibrillation and 54.5% underwent aspiration alone or in combination with stentriever device. Overall, 29.4% of patients treated were discharged with minor symptoms or were clinically asymptomatic and death occurred in 23.5% of patients in spite of achieving AOL3 recanalization in 50% of patients. Conclusions While clinically devastating, posterior circulation stroke, may have favorable outcomes if endovascular strategies are targeted to arterial occlusion etiology. Disclosures M. Nour: None. S. Tateshima: 2; C; Reverse Medical, Stryker Neurovascular, Silkroad Medical, Blockade Medical. G. Duckwiler: 2; C; Sequent Medical, Asahi Medical. R. Jahan: 2; C; Covidien, Medina. N. Gonzalez: None. V. Szeder: None. L. Ai: None. J. Saver: 6; C; Dr. Saver is an employee of the University of California. The University of California, Regents receive funding for Dr. Saver’s services as a scientific consultant. D. Liebeskind: 2; C; Stryker Neurovascular, Covidien.