Abstract
Objective: Mechanical thrombectomy (MT) has been an effective first-line therapeutic strategy for ischemic stroke. With impairment characteristics separating it from anterior circulation stroke, we aimed to explore prognostic structural neural markers for basilar artery occlusion (BAO) after MT.Methods: Fifty-four BAO patients with multi-modal magnetic resonance imaging at admission from the multicenter real-world designed BASILAR research were enrolled in this study. Features including volumes for cortical structures and subcortical regions, locations and volumes of infarctions, and white matter hyperintensity (WMH) volumes were recorded from all individuals. The impact features were identified using ANCOVA and logistic analysis. Another cohort (n = 21) was further recruited to verify the prognostic roles of screened prognostic structures.Results: For the primary clinical outcome, decreased brainstem volume and total infarction volumes from mesencephalon and midbrain were significantly related to reduced 90-day modified Rankin score (mRS) after MT treatment. WMH volume, WMH grade, average cortex thickness, white matter volume, and gray matter volume did not exhibit a remarkable relationship with the prognosis of BAO. The increased left caudate volume was obviously associated with early symptomatic recovery after MT. The prognostic role of the ratio of pons and midbrain infarct volume in brainstem was further confirmed in another cohort with area under the curve (AUC) = 0.77.Conclusions: This study was the first to provide comprehensive structural markers for the prognostic evaluation of BAO. The fully automatic and semiautomatic segmentation approaches in our study supported that the proportion of mesencephalon and midbrain infarct volume in brainstem was a crucial prognostic structural neural marker for BAO.
Highlights
Accounting for only 1–4% of ischemic strokes, basilar artery occlusion (BAO) is a rare but devastating subtype of stroke, causing over 70% of deaths or a substantial part of severe disability in survivors [1], which has obtained abundant attention recently [2]
BASILAR research, 54 patients from different medical centers after mechanical thrombectomy (MT) with multi-modal magnetic resonance imaging (MRI) detection including fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and T1-weighted imaging at admission were enrolled in the training cohort, while another 21 patients with DWI at admission were recruited in the validation set
21 patients showed favorable clinical outcomes of 90-day modified Rankin score (mRS) after the intervention. Between these subjects with differential clinical outcomes, patients with poor clinical outcome exhibited a decline in the initial National Institutes of Health Stroke Scale (NIHSS) [29 (14.00–34.00) vs. 16 (8.00–22.50), p = 0.03] and NIHSS at 24 h [35.00 (30.00–35.50) vs. 10.00 (4.50–19.50), p < 0.01] after MT
Summary
Accounting for only 1–4% of ischemic strokes, basilar artery occlusion (BAO) is a rare but devastating subtype of stroke, causing over 70% of deaths or a substantial part of severe disability in survivors [1], which has obtained abundant attention recently [2]. In 2020, the results of the BEST randomized controlled trial and our real-world multicenter BASILAR research illustrated the improvement of mechanical thrombectomy (MT) for BAO [3, 4] Despite this progress, the current understanding of the prognostic imaging markers of BAO in response to MT was limited, due to the challenges faced in performing multi-modal magnetic resonance imaging (MRI), which were caused by the rare prevalence of BAO and the low usage rate of MRI in a preoperative examination [2]. As an extremely lethal disease, BAO was characterized by lesions located subcortically with clinical manifestations significantly different from those of anterior circulation stroke [1] These impaired subcortical areas contained the brainstem, thalamus, and cerebellum, which were the essential components of conduction bundles and neural circuits, helping in the maintenance of multiple brain functions including consciousness maintenance, motor activities, and verbal response [5, 6]. Neurological findings of WMH were linked to cerebral hypoperfusion and impaired white matter integrity, little attention has been paid to their characteristics in BAO [14]
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