How is basilar artery thrombosis treated?

Updated: Jan 11, 2019
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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All patients should be admitted to a stroke unit. Patients with unstable or fluctuating neurologic symptoms, decreased level of consciousness, active cardiac or respiratory comorbid conditions, hemodynamic instability, or a need for interventional therapies (eg, thrombolysis) must be admitted to a neurologic intensive care unit (ICU).

Recanalization of the basilar artery is key to the successful treatment of basilar artery thrombosis and to improving its prognosis. Some unresolved issues need further clarification, such as the best method of recanalization (intra-arterial thrombolysis, mechanical thrombolysis, or a combination), the time window for the treatment, and patient selection.

In a study of103 patients with basilar artery occlusion recanalized after IV tissue-type plasminogen activator thrombolysis, thrombus length was independently associated with recanalization. Patients who underwent recanalization had shorter thrombi (median, 5.5 mm; mean, 9.7 mm) when compared with those not recanalized (median, 15.0 mm; mean, 16.6 mm; P< 0.001). Thrombi shorter than 10 mm had 70-80% probability of recanalization; 10-20 mm, 50-70% probability; 20-30 mm, 30-50% probability; and greater than 30 mm, 20-30% probability. [14]

In a meta-analysis, recanalization of acute basilar artery occlusion led to reduction in mortality by 2-fold and reduction in the risk of DoD by 1.5-fold. With recanalization, risk ratios (RR) for death or dependency (DoD) in those treated within 12 hours was 0.63; and for those treated after 12 hours, 0.67. RR for DoD in the intravenous thrombolysis subgroup was 0.68, and it was 0.67 in the intra-arterial/endovascular therapy subgroup. Recanalization resulted in mortality RR of 0.46 in those treated within 12 hours and 0.50 for those treated after 12 hours. [15]

While the largest randomized embolectomy trials to date did not include basilar occlusions and treating patients with basilar artery thrombosis in the context of a clinical trial may be reasonable, intra-arterial pharmacologic or mechanical thrombolysis should be considered given the poor prognosis of these patients when clinical trials aren't available.  Consideraton of IV thrombolysis with tPA is also reasonable.

General care

Care is required for all indwelling catheters, including monitoring for infection. Control body temperature because evidence suggests that fever worsens the outcome in patients with stroke. Glucose levels should be monitored to avoid hypoglycemia and hyperglycemia. Aggressive pulmonary toilet is instituted to avoid pneumonia.

Stroke-related therapy

Treatment of patients with basilar artery thrombosis includes the following:

  • Hemodynamic management

  • Respiratory management

  • Thrombolysis

  • Intra-arterial thrombolysis

  • Combination therapy - The combination of IV thrombolysis with consecutive, on-demand, mechanical endovascular thrombectomy may allow for early treatment initiation with high recanalization; in one small study, recanalization was achieved in 15 of 16 patients who received the combination therapy [16]

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