Understanding the Complexities and Significance of Treating Basilar Artery Occlusions

Russell Cerejo, MD

Basilar artery occlusion (BAO) is a potentially fatal diagnosis, yet is one of the most challenging conditions for clinicians to diagnose and manage. Unlike hemispheric ischemic, where there is usually a sudden onset of focal symptoms, BAO syndromes may mimic other nonstroke conditions, resulting in a delay in neurological evaluation. Compared with anterior circulation stroke syndromes, posterior circulation ischemia may have a longer prodrome and an evaluation that is important to recognize.

Identifying the symptoms and signs of BAOs is critical to early intervention, considering the disabling effects, says Russell Cerejo, MD. Cerejo, a vascular neurologist at Allegheny Health Network, believes the clinical community has made some headway in the treatment of BAOs; however, there are still questions as to how effective certain approaches are like mechanical thrombectomy. Above all, recanalization is crucial to the long-term outcome of patients presenting with BAOs.

In an interview with NeurologyLive®, Cerejo provided perspective on the complexities with this condition, and some of the difficulties with finding consistent and effective treatment strategies. Additionally, he discussed how BAOs differ from other known strokes, the signs and symptoms neurologists and emergency room physicians should be aware of, and whether rehab changes for these patients.

NeurologyLive®: What are some of the differences between basilary artery occlusions and other strokes?

Russell Cerejo, MD: In the human body, we have what are called the anterior circulation and the posterior circulation. The basilar artery is part of the posterior circulation, and it is one of the most important arteries in the body. The reason for that is because it basically supplies the brainstem. Think of the brainstem like a funnel. It funnels all the information from the lobes of the brain, brings it down to the brainstem, and goes to the spinal cord. It's a huge area of prime real estate, so to speak.

This one artery is supplying the majority of the brain stem, and occlusion or a blockage in that area could be pretty devastating because even a small stroke in the brainstem can be very disabling. So far, most of the trials that have shown benefit for mechanical thrombectomy in large vessel occlusions have been in the anterior circulation, which is great, but there have not been many trials that have successfully shown that opening a basil artery has been significantly beneficial until now.

Why is this a difficult condition to diagnose?

Because the basilar artery supplies the brainstem—which can control a lot of functions—some of the symptoms that may be a sign of basil artery stroke, or a brainstem stroke, may not be very obvious to a lot of people. For example, issues with balance, having vertigo, sometimes double vision, those can be the initial signs and symptoms of the stroke. People may not be aware of that, and so they may not seek medical care. By the time they seek medical care, or we realize what's going on, it may be too late and we will not be able to help them.

What are some of the clinical features neurologists and those in the emergency department should be paying close attention to?

One of the things that the American Heart Association and American Stroke Association has kind of adapted is the acronym for stroke signs and symptoms. It used to be FAST, which was face, arm, speech, and time. And now, they've added BE-FAST, which the B stands for balance, and the E stands for eyes. Any kind of visual symptoms or balance issues should also kind of trigger a stroke or a stroke alert. In terms of other presentations, if people are completely unresponsive or comatose and there is no other obvious etiology identified, one should be cognizant that this could be a basilar artery occlusion as a cause of someone being completely obtunded or comatose.

What has been the typical treatment management for basilary occlusions?

There’s obviously a suspicion that the patient's having a stroke, so if you’re a candidate for IV thrombolysis, it’s still an important thing to be administered. However, if there is a large vessel occlusion, I think now considering mechanical thrombectomy is definitely beneficial for these patients.

Does the rehab process look different for these types of strokes?

These strokes can be very disabling, and the effects from untreated strokes, or even sometimes treated strokes can be pretty disabling. They can take a long time for patients to heal from them compared to anterior circulation strokes. Even if the size of the stroke is small, it can still affect quite a lot of similar systems. It can affect swallowing, people can have difficulty breathing, people can be paralyzed quite densely. And so, there are a few things that are a little bit unique to posterior circulation. They can have issues of balance, even after they improve. A lot of things that can be affected in a small area of space. There are many facets of rehab that come into play for that, like swallowing, speech therapy. Patients may need a feeding tube for long term before they can strengthen their muscles to swallow normally. All of those things take much longer time to recover from compared with the anterior circulation stokes.

How can we create consensus guidelines for basilar occlusions?

The stroke community does realize that basilar occlusions and basilar occlusion circulation strokes are, as I said, one of the most disabling and on the most serious kinds of stroke. The guidelines do state that, up till now, mechanical thrombectomy could be tried for these patients. However, the trials were not very robust, and the data was not very conclusive. I think now with the most recent trials that have came out of China and will publish in the NEJM, more and more patients should benefit with mechanical thrombectomy and acute stroke interventions. As a community, it's important to first recognize and then treat these patients in a timely manner. Obviously, even after acute stroke treatment, rehab is going to be a main part of the recovery.

Transcript edited for clarity.