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ECR 2013 / C-2384
Imaging diagnostic, treatment and outcomes of acute intracranial vertebrobasilar artery occlusion: Our experience.
Congress: ECR 2013
Poster No.: C-2384
Type: Scientific Exhibit
Keywords: Neuroradiology brain, Vascular, CT, CT-Angiography, Catheter arteriography, Recanalisation, Catheters, Embolism / Thrombosis
Authors: L. Aja Rodriguez1, G. C. Rivera Sierra2, J. Quispe Bravo3, M. Á. De Miquel Miquel3, H. Quesada García2, P. Cardona Portela2; 1Barcelona/ES, 2L´Hospitalet de Llobregat (Barcelona) /ES, 3L´ Hospitalet, Es/ES
DOI:10.1594/ecr2013/C-2384

Results

Five patients (33.3 %) had normal unenhanced-CT basal and all had partial or complete occlusion of the basilar artery demonstrated by CTA. Four (26.7%) with wake up stroke received CTP.

The mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 14.5.  Six patients received thrombolytic therapy and endovascular treatment using mechanical thrombectomy. Average time from presentation to initiation of the endovascular procedure was 6.1 hours.

The mean time for recanalization from the start of angiography was 2.99 hours; it was higher than S.Webb et al2 reported (1.63h). In 8 patients (53%), revascularization was successful (Thrombolysis in Cerebral Infarction [TICI] score of 2 or 3); it was lower than S.Webb et al2 reported (73%).  The overall survival rate was 60%, similar to S. Webb et al2 experience (64%), but lower than J. Kashiwagi et at1 reported (94.4%) at discharge using local fibrinolysis and additional balloon angioplasty. The average NIHSS score for the 9 surviving patients at discharge was 9.9. Better results have been reported (3.9)2. At the follow-up (average 3 months), 5 patients (33.3%) had achieved good outcomes ([mRS]score ≤ 2), 4(26.7%) had poor outcomes ([mRS] score 3-5) and 6(40%) had died ([mRS]score 6).

 

 

IMAGE GALLERY

  • FIG 2-10. A 49-year-old man with symptoms of vertebrobasilar artery occlusion. Initial non-contrast CT showed high density of the basilar top. Basilar artery occlusion was found in CT-Angiography. MR images showed acute infarction in the brain stem (limited to pons). Patient underwent interventional therapy using balloon angioplasty (MUSO) through right vertebral artery. Recanalization of the basilar, superior cerebellar and left posterior cerebral arteries was achieved. The right posterior cerebral artery was most likely supplied via anterior circulation and posteroinferior cerebellar artery was permeable. 20 days after, MR shows the same lesion and MR-Angiography shows permeability of basilar artery.  Patient had good clinical outcome.
Fig. 2: Unenhanced CT shows an hyperdense top of basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 3: CT-angiography. Basilar Artery Occlusion.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 4: T1/T2-weighted and FLAIR images before procedure show small but already established brain stem infarction.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 5: ADC/Diffusion-weighted images before procedure show small but already established brain stem infarction.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 6: Right and Left Vertebral Arteries, anteroposterior view reveals complete basilar artery occlusion.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 7: Balloon angioplasty of basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 8: Final angiography, right vertebral artery (anteroposterior and lateral views), shows recanalization of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 9: T1/T2-weighted and FLAIR images after procedure show brain stem infarction. No new ischemic lesions appeared
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 10: MR Angiography postreatment.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
  • FIG. 11-18. A 64-year-old woman with “locked in” syndrome, basilar artery occlusion was found in the CT-Angiography. Patient underwent to mechanical thrombectomy using SOLITAIRE device, two attempts were performed. Recanalization of the basilar and left posterior cerebral artery was achieved. Right posterior cerebral and superior cerebellar arteries had stenosis, which is severe in the right side, with slow flow. Intraarterial thrombolysis with rt-PA was administrated, at the top of the basilar artery. 5 days MR images show multiple temporal/occipital, right frontal, brain stem and both thalamus acute infarction; minimal bleeding in the left pons.  Patient had bad clinical outcome and died 6 months later.

 

Fig. 11: Non-contrast CT shows the high density of the basilar top.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 12: Left vertebral artery anteroposterior view. Basilar artery occlusion.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 13: Mechanical thrombectomy with Ev3 SOLITAIRE.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 14: Final angiography, left vertebral artery (AP view), shows complete recanalization of the basilar artery and left posterior cerebral artery. It was not possible to recanalize right posterior cerebral artery. The superior cerebellar arteries had stenosis. Intra-arterial endovascular therapy, with 4 ml of rt-PA, was administrated.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 16: FLAIR and ADC/Diffusion-weighted images 5 days after procedure show right posterior frontal, right temporo-occipital, brain stem and both thalamus acute infarction.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 17: Fast Field Echo(FFE)MR images showed small brain stem bleeding, limited to left pons.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 18: Angio-MRI postreatment.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

  • FIG. 19-22. A 48-year-old man, with acute onset of slurred speech and instability. Basilar artery occlusion was found in the CT-Angiography. Patient underwent to interventional therapy, mechanical thrombectomy with TREVO and SOLITAIRE devices was performed. Recanalization of the basilar artery was achieved; however, at the proximal portion of the right superior cerebellar artery a small thrombus remained.  While procedure was performing patient presented loss of consciousness. General anaesthesia was necessary.  48 hours later a non-contrast CT shows brain stem (midbrain and left pons), both cerebellar lobes and both thalamus infarction. The patient had intermediate clinical outcome;  mRS score 3.
Fig. 19: Cerebral angiography, left Vertebral Artery, AP and lateral view. Basilar Artery Occlusion.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 20: Mechanical thrombectomy with Concentric medical TREVO.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 21: Final angiography, left vertebral artery (AP and lateral view), shows complete recanalization of the basilar artery. However, there is a residual thrombus in the right superior cerebellar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 22: Noncontrast CT 48 hours after procedure shows brain stem (midbrain and pons), both cerebellar lobes and both thalamus acute infarction.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
  • FIG. 23-26. A 64-year-old man with history of right middle cerebral and right posterior cerebral arteries infarcts.  The patient presented with transient ischemic attacks. MR images show minimal acute infarcts in the hind brain. CT-Angiography showed several stenosis of the basilar artery.  Interventional therapy with angioplasty (Enterprise stent) was performed. Patient presented good clinical outcome at discharge, mRS score 0. However, 3 months later, patient presented “locked in” syndrome, with stent thrombosis; unsuccessful angioplasty was performed. The patient did not comply with the antiplatelet therapy.

 

Fig. 23: FLAIR and ADC/Diffusion-weighted images show acute infarction in the hind brain.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 24: CT-angiography demonstrates several stenosis of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 25: Angiography, right vertebral artery (AP and lateral view), shows stenosis of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 26: Cerebral angiography and CT-Angiography postreatment with stent Enterprise de 4’5 x 28 mm.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

  • FIG. 27-34. A 78-year-old man with loss of consciousness and mild left-side weakness.  Initial non-contrast CT shows the high density of the basilar top. Multiplanar reconstructions of CTA images demonstrated occlusive thrombus at the distal portion of the basilar artery and stenosis of right vertebral artery. Interventional therapy, mechanical thrombectomy with SOLITAIRE was performed. Post-interventional non-contrast CT showed anterior and left vermis infarct, with similar findings in MR images. Discharge mRS score 1.
Fig. 27: Noncontrast CT shows the high density of the basilar top.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 28: Multiplanar reconstructions of CTA (MIP and VR projections) images demonstrated occlusive thrombus at the distal portion of the basilar artery and stenosis of right vertebral artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 29: Micro catheter could be located distally to the thrombus, right posterior cerebral artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 30: Angiography. Occlusive thrombus at the distal portion of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 31: Mechanical thrombectomy with Ev3 SOLITAIRE was performed.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 32: Post-interventional therapy angiography.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 33: Post-interventional non-contrast CT showed anterior and left cerebellar vermis infarct.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 34: T2/FLAIR-weighted images demonstrated anterior and left cerebellar vermis infarct.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
  • FIG. 35-46. A 61-year-old woman with symptoms of vertebrobasilar artery occlusion. The basilar artery appears hyperdense on unenhanced CT. Presentation NIHSS score 10. Multiplanar reconstructions of CTA images demonstrated occlusive thrombus at the distal portion of the basilar artery and occlusion of left vertebral artery. Patient underwent to interventional therapy, mechanical thrombectomy with SOLITAIRE device was performed. Control CT scan shows acute infarction in the midbrain and small infarction in the medial bilateral thalamus. The patient presented severe stenosis of the left vertebral artery origin demonstrated by CTA and angiography; balloon angioplasty and stenting were successfully performed.
Fig. 35: The basilar artery appears hyperdense on unenhanced CT.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 36: Multiplanar reconstructions of CTA images demonstrated occlusive thrombus at the distal portion of the basilar artery and occlusion of left vertebral artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 37: CTA axial showed severe stenosis of the left vertebral artery origin.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 38: CTA coronal showed severe stenosis of the left vertebral artery origin.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

Fig. 39: Angiography (PA and lateral view). Mechanical thrombectomy for occlusion of the basilar artery with SOLITAIRE device was performed.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 40: Angiography (PA and lateral view). Mechanical thrombectomy for occlusion of the basilar artery with SOLITAIRE device was performed.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 41: Final angiography, left vertebral artery (AP and lateral view), shows complete recanalization of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES

 

 

Fig. 42: Left subclavia angiography. Severe stenosis of the left vertebral artery origin.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 43: Balloon angioplasty and stenting of the left vertebral artery origin were successfully performed.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 44: Balloon angioplasty and stenting of the left vertebral artery origin were successfully performed.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 45: CT-Angiography (axial and coronal) shows stent location of the left vertebral artery origin.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 46: CT-Angiography (coronal) shows stent location of the left vertebral artery origin.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
  • FIG. 47-52. A 78-year-old man with symptoms of vertebrobasilar artery occlusion. Presentation NIHSS Score was 14. Non-contrast CT did not show infarction. CT angiography demonstrated V4 portion occlusion of the right vertebral artery and short severe stenosis of the basilar artery. Patient underwent angioplasty of the basilar.
Fig. 47: Non-contrast CT did not show infarction.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 48: CT angiography demonstrated V4 portion occlusion of the right vertebral artery and short severe stenosis of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 49: Angiography. V4 portion occlusion of the right vertebral artery and short severe stenosis of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 50: Balloon angioplasty of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 51: Balloon angioplasty of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
Fig. 52: Final angiography, left vertebral artery (AP and lateral view), showed improved flow of the basilar artery.
References: Radiology Department, Institut catalá de la Salut, Universitari de Bellvitge - L´Hospitalet de Llobregat (Barcelona) /ES
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