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Ischemic stroke
Original research
Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level
  1. Louis Tournier1,
  2. Jonathan Cortese1,2,
  3. Arturo Consoli3,
  4. Laurent Spelle1,2,
  5. Gaultier Marnat4,
  6. Mariana Sarov5,
  7. Francois Zhu6,
  8. Sebastien Soize7,
  9. Julien Burel8,
  10. Géraud Forestier9,
  11. Simon Escalard10,
  12. Raoul Pop11,
  13. Baptiste Bonnet12,
  14. Quentin Alias13,
  15. Julien Ognard14,
  16. Olivier Naggara15,
  17. Maeva Kyheng16,
  18. Bertrand Lapergue17,
  19. Jildaz Caroff1,2,18
  20. on behalf of the ETIS Registry Investigators
    1. 1Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, Le Kremlin-Bicêtre, France
    2. 2Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicêtre, France
    3. 3Department of Therapeutic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
    4. 4Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
    5. 5Neurology, Hopital Bicêtre, Le Kremlin-Bicêtre, France
    6. 6Service de Neuroradiologie Diagnostique et Thérapeutique, CHRU Nancy, Nancy, France
    7. 7Neuroradiology, University Hospital Centre Reims Medical Imaging, Reims, France
    8. 8Department of Radiology, CHU de Rouen, Rouen, France
    9. 9Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
    10. 10Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
    11. 11Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
    12. 12Neuroradiology, Hôpital Pitié-Salpétrière, Paris, France
    13. 13Neuroradiology, University Hospital of Rennes, Rennes, France
    14. 14Department of Neuroradiology, University and Regional Hospital Centre Brest, Brest, France
    15. 15Department of Neuroradiology, Center Hospitalier Sainte-Anne, Université Paris Descartes Faculté de Médecine, Paris, France
    16. 16Santé publique: épidémiologie et qualité des soins, University of Lille, Lille, France
    17. 17Department of Neurology and Stroke Center, Hospital Foch, Suresnes, France
    18. 18UMR-S INSERM U1176, Paris-Saclay University, Le Kremlin-Bicetre, France
    1. Correspondence to Dr Jildaz Caroff, Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, 94270, France; jildaz.caroff{at}aphp.fr

    Abstract

    Background Retrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per the occlusion level, considering differences in stroke etiology prevalence between proximal and distal BAO.

    Methods A retrospective, multicentric analysis of the Endovascular Treatment in Ischemic Stroke Registry (ETIS) included consecutive BAO patients treated from January 2016 to May 2022. Patients were categorized into SR (±aspiration) and CA alone groups. Occlusion levels were determined through digital subtraction angiography. Favorable clinical outcome was defined as 90-day modified Rankin Scale (mRS) 0–3.

    Results A total of 380 patients were analyzed (251 CA alone, 129 SR±aspiration). Globally, first-line SR showed lower recanalization rates (89.1% vs 94.8%, OR=0.29, 95% CI 0.16 to 0.53; p<0.001) and worse clinical outcomes (mRS 0–3: 46.0% vs 52.2%, OR=0.62, 95% CI 0.44 to 0.87; p=0.006) compared with CA. In proximal occlusions, SR was significantly associated with poorer clinical outcomes (mRS 0–3: 20.9% vs 37.1%; OR=0.40, 95% CI 0.19 to 0.83; p=0.014) despite similar recanalization rates. Conversely, in distal occlusions there was no difference in clinical outcomes although recanalization rates were higher with CA (modified Thrombolysis in Cerebral Infarction score (mTICI 2b/3): 97.7% vs 91.7%; OR=0.17, 95% CI 0.05 to 0.66; p=0.01).

    Conclusions In our BAO population, CA demonstrated better angiographic outcomes in middle and distal occlusions and better clinical outcomes in proximal occlusions. This translated into better angiographic and clinical results in the global study population. Clinical results were particularly influenced by the negative impact of SR on 90-day mRS, independently of recanalization rates in proximal BAO.

    • Stroke
    • Thrombectomy
    • Technique

    Data availability statement

    Data are available upon reasonable request.

    https://doi.org/10.1136/jnis-2024-021491

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      Data availability statement

      Data are available upon reasonable request.

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      Footnotes

      • Twitter @sarov, @RaoulPop25, @jildazz

      • Collaborators ETIS Investigators: Foch: Bertrand Lapergue, Adrien Wang, Arturo Consoli, Oguzhan Coskun, Federico Di Maria, Silvia Pizzuto, Alessandro Sgreccia, Charline Benoit, Lucas Gorza, David Weisenburger-Lile, Waliyde Jabeur, Maia Tchikviladze, Serge Evrard, Georges Rodesch. FOR: Raphaël Blanc, Michel Obadia, Jean-Philippe Desilles, Michel Piotin, Pierre Seners, Stanislas Smajda, Simon Escalard, Benjamin Maier, Candice Sabben, Hocine Redjem, Mikael Mazhigi, Grace Adwane, François Delvoye, Amira Al Raaisi, William Boisseau, Adnan Altayeb, Erwan Robichon. Lyon: Omer Eker, Tae-Hee Cho, Laurent Derex, Julia Fontaine, Laura Mechtouff, Norbert Nighoghossian, Elodie Ong, Lucie Rascle, Roberto Riva, Françis Turjman, Morgane Laubacher, Mehdi Beyragued, Yves Berthezene, Marc Hermier,Roxana Ameli, Alexandre Bani-Sadr, Andrea Filip, Matteo Cappucci, Laurent Derex, PIerre Pernot, Paul Clottes. Nantes: Romain Bourcier, Benjamin Daumas Duport, Pierre Louis Alexandre, Hubert Desal, Solene De Gaalon, Benoit Guillon, Cecile Preterre, Guillaume Tessier, Arthur Lionnet. Nancy: Benjamin Gory, Lisa Humbertjean-Selton, Rene Anxionnat, Anne-Laure Derelle, Liang Liao, Emmanuelle Schmitt, Sophie Planel, Sebastien Richard, Gioia Mione, Jean-Christophe Lacour, Marian Douarinou, Emilien Micard, Bailiang Chen, Gerard Audibert, Agnes Masson, Lionel Alb, Marine Beaumont, Adriana Tabarna, Marcela Voicu, Gregoire Barthel, Iona Podar, Madalina Brezeanu, Marie Reitter, François Zhu, Anxionnat Rene. Bordeaux: Gaultier Marnat, Jean-Sebastien Liegey, Pierre Briau, Victoire Lyon, Igor Sibon, Xavier Barreau, Jean Papaxanthos, Jerome Berge, Sabrina Debruxelles, Stephane Olindo, Mathilde Poli, Pauline Renou, Sharmila Sagnier, Thomas Tourdias, Thomas Courret, Malgorzata Milnerowicz, François Rouanet, Benoit Legghe, Aurelie Boyer, Tristan Kerdraon, Lisa Saleille, Laurine Bastardo. 007-Montpellier: Cyril Dargazanli, Vincent Costalat, Cagnazzo Federico, Pierre-Henri Lefevre, Gregory Gascou, Quentin Varnier, François Louis Collemiche, Isabelle Mourand, Caroline Arquizan, Lucas Corti, Adrien Ter Schiphorst, Imad Derraz. Kremlin Bicêtre: Laurent Spelle, Jildaz Caroff, Christian Denier, Vanessa Chalumeau, Cristian Mihalea, Nicolas Legris, Augustin Ozanne, Leon Ikka, Olivier Chassin, Sophie Gallas, Laura Venditti, Mariana Sarov, Jonathan Cortese. Rennes: Jean-Christophe Ferre, Stephane Vannier, Maria Veronica Lassalle, Jean-Yves Gauvrit, Clément Tracol, Cécile Malrain, Edouard Beaufreton, Quentin Alias, Julien Hissier, Maud Guillen, François Eugene, Julien Boucherit. Amiens: Cyril Chivot, Audrey Courselle, Sandrine Canaple, Chantal Lamy, Kevin Delaforge, Manuel Fernandez, Jérémie Vial, Quentin Laferte, Xavier Desdoit. Brest: Serge Timsit, Aurore Jourdain, Jean-Christophe Gentric, Julien Ognard, Mourad Cheddad El Aouni, Irina Viakhireva, Jordan Coris, François-Mathias Merrien, Denis Marechal, Marie Bruguet, Philippe Goas. Caen : Marion Boulanger, Emmanuel Touze, Charlotte Barbier, Romain Schneckenburger, Julien Cogez, Sophie Guettier, Estelle La Porte, Jean Bouchart, Mohammad Ismail. Limoges: Charbel Mounayer, Aymeric Rouchaud, Suzana Saleme, Géraud Forestier. Pitié-Salpêtrière: Sonia Alamowitch, Charlotte Rosso, Sara Leder, Flore Baronnet, Sophie Crozier, Anne Leger, Laure Bottin, Sam Ghazanfari, Marion Yger, Stephen Delorme, Aymeric Wittwer, Christine Vassilev, Gaparad Gerschenfeld, Clémence Blanc, Antonio Rainone, Frédéric Clarençon, Kevin Premat,Eimad Shotar, Stéphanie lenck, Nader Sourour, Julien Allard, Pierre Marie Chiaroni. Ste Anne: Olivier Naggara, Guillaume Turc, Wagih Ben Hassen, Denis Trystram, Christine Rodriguez-Regent, Finoana Laza-Nomenjanahary, Hugo Gortais. Rouen: Ozlem Ozkul-Wermester, Chrysanthi Papagiannaki, Evelyne Massardier, Aude Triquenot, Margaux Lefebvre, Julien Burel, Basille Florian, Adelya Curado. Toulouse: Alain Viguier, Christophe Cognard, Anne Christine Januel, Jean-François Albucher, Lionel Calviere, Jean-Marc Olivot, Nicolas Raposo, Fabrice Bonneville, Guillaume Bellanger, Louis Fontaine, Philippe Tall, Federico Sacchetti. Bayonne: Frédéric Bourdain, Patricia Bernady, Guillaume Ballan, Stephanie Bannier, Emmanuel Ellie, Olivier Flabeau, Julia Potenza, Antoine Soulages, Laurent Lagoarde-Segot, Hélène Cailliez, Louis Veunac, David Higue, Quentin Bourgeois-Beauvais. Vannes: Anthony Lebras, Sarah Adam, Benoit Pegat, Arnaud Le Guen, François Chedeville, Jérémy Jouan, Rémi Allibert, Alexandre Courtois, Lucile Lescot, Dorothée Videt, Thibaut Lapotre. Pau: Johann Sebastian Richter, Bruno Thierry Barroso, Camille Dahan, Alexis Gonnet, Régis Hubrecht, Zoé Lepine, Hélène Castagnet, Raluca Marasescu. Grenoble: Olivier Heck, Pauline Cuisenier, Olivier Detante, Isabelle Favre Wiki, Clémentine Bonaz, Garambois Katia, Loic Legris, Adrian Kastler, Kamel Boubagra, Corentin Berthet, Stéphane Charara, Florent Lepilliet. Poitiers: Victor Dumas, Jean Philippe Neau, Stéphane Velasco, Nathalie Nasr. Strasbourg: Valérie Wolff, Raoul Pop, Véronique Quenardelle, Valérie Lauer, Irène Pierre-Paul, Roxana Gheoca, Leonard Lorant. Reims: Solène Moulin, Hua Vi Tuan, Paolo Pagano, Alexandre Doucet, Christophe Gelmini, Pierre-François Manceau, Laurenti Paiusan, Isabelle Serre, Sébastien Soize, Thi Ngoc Phuong Nguyen, Maher Sahnoun, Nathalie Caucheteux. Colmar: Pablo Lebedinsky, Federico Bolognini, Francis Vuillemet. Clermont-Ferrand: Anna Ferrier, Abderrahim Zerroug, Ricardo Moreno, Emmanuel Chabert, Elie Lteif, Pauline Paris, Nathalie Bourgois, Marie Raquin. Angers: Anne Pasco-Papon, Jean Baptiste Girot, Alderic Lecluse, Sophie Godard, Vincent L'Allinec, Alice Corfu. Tours: Kevin Janot, Richard Bibi, Marie Gaudron, Arnaud Bretonniere, Mariam Annan, Héloïse Ifergan, Grégoire Boulouis, Marco Pasi, Séverine Debiais, Elisabeth Molinier, Denis Herbreteau, Fouzi Bala, Clémence Hoche. Bar le Duc: Anthony Wietrich, Valérie Ruche, Karine Lavandier, Hakim Amara. Dijon: Yannick Bejot, Brivael Lemogne, Frédéric Ricolfi, Laura Baptiste, Pierre Thouant, Gaulthier Duloquin, Pierre Olivier Comby, Christelle Blanc-Labarre, Simon Amaral, Bernard Angélique, Adrien Chavent, Alan Rhamani, Corinne Chevalier. Besançon: Guillaume Charbonnier, Louise Bonnet, Nicolas Raybaud, Benjamin Bouamra, Thierry Moulin, Alessandra Biondi. Versailles: Fernando Pico, Benjamin Dano, Carmen Patcas, Fernando Chaari, Daniela Stanciu, Duong Duc Long, Hmida Intissar, Marie-Laure Chadenat. Marseille: Laurent Suissa, Emilie Doche, Jean-François Hak, Anthony Reyre, Xavier Carle, Nadia Laksiri, Phelie Osmano, Roxane Peres, Emmanuelle Robinet-Borgmano, Cecile Dulau, Basile Kerleroux, Caroline Rey, Herve Brunel, Philippe Dory-Lautrec, Jean-François Hak, Pierre Lehmann, Vingadalassalom Sivadji. Bastia: Basile Kerleroux, Jérôme Berge, Federico Sacchetti. Annecy: Fabrice Bing, Mathieu Bonnerot, Isabelle Berger, Nathalie Morel, Gilles Rodier, Wilfried Vadot.

      • Contributors LT, JCo, AC, MK, BL, and JCa contributed to the conception and design of the study as well as the drafting of the manuscript. JCa, as the guarantor of this study, certifies the accuracy and integrity of all phases of the research, from data collection to analysis and writing of the article. All authors participated in data collection, analysis, and revising the manuscript for important intellectual content. Furthermore, all authors have given their approval for the final version to be published.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.