Response to Late-Window Endovascular Revascularization Is Associated With Collateral Status in Basilar Artery Occlusion
Authors: Alemseged Fana , Van der Hoeven Erik , Di Giuliano Francesca , Shah Darshan , Sallustio Fabrizio , Arba Francesco , Kleinig Timothy J. , Bush Steven , Dowling Richard J. , Yan Bernard , Sharma Gagan , Limbucci Nicola , Floris Roberto , Donnan Geoffrey A. , Puetz Volker , Diomedi Marina , Parsons Mark W. , Mitchell Peter J. , Davis Stephen M. , Yassi Nawaf , Schonewille Wouter J. , Campbell Bruce C.V. ,   on behalf of the Basilar Artery Treatment and Management (BATMAN) Collaboration*, Ng J.L. , Williams C. , Zhao H. , McDonald A. , Pesavento L. , Coote S. , Ng F.C. , Thijs V. , Drew R. , Garcia Esperon C. , Spratt N. , Wu T. , Fink J. , Rocco A. , Nappini S. , Morotti A. , Cavallini A. , Kaiser D. , Geber J. , Schwabova J.P. , Tomek A. , Boulouis G. , Benhassen W. , Oxley T.J. , Fifi J.T. 
Published: May 2019

Background and Purpose—
The benefit of endovascular therapy in extended time windows has been demonstrated in patients with anterior circulation large vessel occlusion ischemic stroke and favorable imaging profile. We evaluated whether collaterals and thrombus burden influence the associations between revascularization, time-to-treatment, and outcome in endovascular therapy-treated patients with basilar artery occlusion.

Methods—
We retrospectively analyzed clinical and imaging data of consecutive endovascular therapy-treated patients with basilar artery occlusion included in the multicenter Basilar Artery Treatment and Management Collaboration. The BATMAN (Basilar Artery on Computed Tomography Angiography score, which evaluates thrombus burden and collaterals) and the PC-CS (Posterior Circulation Collateral score, which evaluates collaterals) were assessed on computed tomography angiography, blinded to clinical outcome. Good outcome was defined as modified Rankin Scale score of ≤3 within 3 months; revascularization (successful reperfusion) as modified Thrombolysis in Cerebral Infarction 2b–3 (or TIMI [Thrombolysis in Myocardial Infarction] 2–3 in the BASICS [Basilar Artery International Cooperation Study] registry).

Results—

We included 172 patients with basilar artery occlusion treated with endovascular therapy (124 with mechanical thrombectomy): mean (SD) age 65 (13) years, median National Institutes of Health Stroke Scale 22 (interquartile range 12–30), 64 (37%) treated >6 hours. Revascularization (achieved in 79% of patients) was associated with good outcome (
P
=0.003). The use of new generation thrombectomy devices was associated with good outcome (
P
=0.03). In patients who achieved revascularization, 29/46 (63%) of patients with a favorable BATMAN score and 26/51 (51%) with favorable PC-CS had good outcomes. In logistic regression analysis (adjusted for age, National Institutes of Health Stroke Scale, and time-to-treatment ≤6/>6 hours), revascularization was associated with good outcome in patients with favorable BATMAN score (odds ratio, 15.8; 95% CI, 1.4–175;
P
=0.02) or PC-CS (odds ratio, 9.4; 95% CI, 1.4–64;
P
=0.02). In patients who achieved revascularization, early (time-to-treatment ≤6 hours) but not late treatment was associated with improved outcome in patients with unfavorable BATMAN score (18/52 [35%]; odds ratio, 15; 95% CI, 1.9–124;
P
=0.01) or PC-CS (16/44 [36%]; odds ratio, 5.5; 95% CI, 1.4–21;
P
=0.01).

Conclusions—
Revascularization is associated with good outcome in patients with basilar artery occlusion with good collaterals and less extensive occlusion, even >6 hours after onset.