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BACKGROUND: Randomized controlled trials indicate functional and mortality benefits in endovascular therapy for basilar artery occlusion (BAO). However, these studies only include patients who meet specific prognostic scores. This study investigates radiographic predictors of posterior circulation territory infarcts that may predict neurologic outcome at 90-day post-intervention. METHODS: This is a retrospective cohort study of a prospectively maintained thrombectomy database of all patients who underwent mechanical thrombectomy for BAO. Baseline demographics, comorbidities, baseline functional status (mRS), and severity of presenting neurologic deficits (NIHSS) were collected. Pc-ASPECTS, posterior circulation collateral score (PCCS), and basilar artery on computed tomography angiography (BATMAN) measured radiographic characteristics. Core infarct territory was identified. Primary outcomes were good neurologic outcome (mRS 0-3) and poor neurologic outcome (mRS 4-6) at 90-day post-thrombectomy. 90-day mortality was a secondary outcome. RESULTS: About 21.5% of patients achieved a good neurologic outcome. About 32.3% of patients were deceased at 90 days. Receiver operating characteristic analysis shows PCCS collateral scores (AUC = 0.74, SE = 0.03, CI = 0.62-0.74) and BATMAN (AUC = 0.72, SE = 0.04, CI = 0.35-0.49) have potential to differentiate between those with good neurologic outcome from those with poor neurologic outcome. Although there was no statistically significant difference in AUC between the three curves, pc-ASPECTS score trended toward being weaker predictor of neurologic outcome (AUC = 0.49, SE = 0.04, CI = 0.35-0.49). There were significant associations between 90-day poor neurologic outcome and established infarcts within the pons (p = 0.01), left cerebellum (p = 0.01), and left occipital lobe (p = 0.03) on pre-thrombectomy CT. CONCLUSION: Low BATMAN and PCCS collateral scores can be predictors of poor neurologic outcomes at 90-day post-thrombectomy for BAO while pc-ASPECTS score may be a weaker predictor of outcome.

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The presence of the hyperdense basilar artery (HDBA) sign, which indicates basilar artery occlusion (BAO), plays an important role in the early diagnosis and intervention in patients with acute ischemic stroke. However, qualitative and quantitative assessment of the HDBA sign is challenging. This case report describes a 60-year-old woman with a history of diabetes mellitus, hypertension, and cerebral infarction. She developed progressive loss of consciousness and ataxic respiration. A noncontrast-enhanced head computed tomography (CT) scan performed three hours after symptom onset revealed the HDBA sign compared with previously obtained CT images. Quantitative measurements revealed a significant increase in Hounsfield units (HUs) in the basilar artery. Subsequent three-dimensional CT angiography confirmed the occlusion of the vertebrobasilar artery. This case highlights the importance of comparing current and previous imaging findings in detecting the HDBA sign. Quantitative HU measurements may further aid diagnosis. Early detection of the HDBA sign on noncontrast-enhanced head CT is critical for expediting the diagnosis and treatment of BAO.

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An estimated 6.8 million people in the United States have an unruptured intracranial aneurysms, with approximately 30,000 people suffering from intracranial aneurysms rupture each year. Despite the development of population-based scores to evaluate the risk of rupture, retrospective analyses have suggested the limited usage of these scores in guiding clinical decision-making. With recent advancements in imaging technologies, artery wall motion has emerged as a promising biomarker for the general study of neurovascular mechanics and in assessing the risk of intracranial aneurysms. However, measuring arterial wall deformations in vivo itself poses several challenges, including how to image local wall motion and deriving the anisotropic wall strains over the cardiac cycle. To overcome these difficulties, we first developed a novel in vivo MRI-based imaging method to acquire cardiac gated images of the human basilar artery (BA) over the cardiac cycle. Next, complete BA endoluminal surfaces from each frame were segmented, producing high-resolution point clouds of the endoluminal surfaces. From these point clouds we developed a novel B-spline-based surface representation, then exploited the local support nature of B-splines to determine the local endoluminal surface strains. Results indicated distinct regional and temporal variations in BA wall deformation, highlighting the heterogeneous nature BA function. These included large circumferential strains (up to ∼ 20 % ), and small longitudinal strains, which were often contractile and out of phase with the circumferential strains patterns. Of particular interest was the temporal phase lag in the maximum circumferential perimeter length, which indicated that the BA deforms asynchronously over the cardiac cycle. In summary, the proposed method enabled local deformation analysis, allowing for the successful reproduction of local features of the BA, such as regional principal stretches, areal changes, and pulsatile motion. Integrating the proposed method into existing population-based scores has the potential to improve our understanding of mechanical properties of human BA and enhance clinical decision-making.

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OBJECTIVES: There are limited data available demonstrating the safety and efficacy of intravenous tenecteplase versus alteplase in patients with acute ischemic stroke in the posterior circulation. MATERIALS AND METHODS: This is a post-hoc analysis of the Alteplase compared to Tenecteplase (AcT) pragmatic, phase 3, registry-linked randomized controlled trial. Patients with any posterior circulation vessel occlusion on baseline imaging were included. Study outcomes included 90-day modified Rankin Scale (mRS) 0-1, mRS 0-2, ordinal mRS, death within 90 days, 24 h symptomatic intracerebral haemorrhage (sICH) and successful reperfusion/recanalization. Mixed effects regression adjusting for age, sex and stroke severity was used to analyze differences in outcomes between patients administered tenecteplase vs. alteplase. Further, sensitivity analysis was conducted for basilar artery occlusion (BAO) alone. RESULTS: Of 1577 patients, 136 (8.6 %, 77:alteplase, 59:tenecteplase) had posterior circulation stroke. Baseline characteristics were similar[median age 71 (IQR 60-81) vs. 72 (IQR 65-82) years, 57.1 % vs. 67.8 % males, median baseline NIHSS 7 (IQR 4-12) vs. 7 (IQR 4-16) in alteplase vs. tenecteplase arms, respectively]. 28 patients (20.6 %, 16:alteplase, 12:tenecteplase arm) underwent EVT. The median 90-120 days mRS was 2 (IQR 1-4). There were no differences between alteplase and tenecteplase for 90-d mRS 0-1 (adjRR 0.93;95 %CI 0.63-1.36), 90-day mRS 0-2 (adjRR 0.95; 95 %CI 0.72-1.26), sICH (RR 0.65; 95 %CI 0.06-7.02) and mortality (RR 1.21; 95 %CI 0.61-2.38). Successful reperfusion eTICI 2b-3 and successful recanalization rAOL 2b-3 was achieved in 23/28 (82 %, 12:alteplase, 11:tenecteplase) and in 16/28 (57 %, 14:alteplase, 12:tenecteplase), respectively. Similar results were seen in 31 patients (22.8 %) with BAO. CONCLUSION: Intravenous tenecteplase has a similar effect on outcome as alteplase, without increased safety concerns in patients with acute posterior circulation strokes.

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BACKGROUND: The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender. METHODS: From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO. RESULTS: Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p < .01). CONCLUSIONS: Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

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The article presents a case of a 54-year-old female patient who, over the course of 2 years, suffered 5 cerebrovascular accidents (CVA) due to infectious arteritis of both internal carotid arteries (ICA) and basilar artery as a complication of sphenoiditis and otitis. According to neuroimaging data, the steno-occlusive process in the ICA developed gradually, starting with the intracranial ICA narrowing with the contrast enhancement by vessel wall, the development of its occlusion six months later, and the detection of the extracranial ICA occlusion with the formation of «flame sign¼ at its mouth a year later. Repeated examination of the cerebrospinal liquid at an early stage of the disease revealed cytosis up to 367/3 and protein 0.66 g/l. The correct diagnosis was established only after 3 years with a retrospective analysis of clinical, neuroimaging, and laboratory data. Therefore, targeted antibiotic therapy was not carried out, which led to the progression of ICA occlusion and repeated strokes. Infectious arteritis should be taken into account in the differential diagnosis of the causes of the ICA occlusive process.

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OBJECT: Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms. METHODS: Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated. RESULTS: All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months. CONCLUSIONS: Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

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A decade on from the first positive thrombectomy trials, hyperacute therapies for ischemic stroke continue to rapidly advance. Effective treatments remain limited to reperfusion, although several cytoprotective approaches continue to be investigated. Intravenous fibrinolytics are now demonstrated to be beneficial up to 24 h in patients selected using perfusion imaging, but their role in patients with non-disabling symptoms appears very limited. Tenecteplase is superior to alteplase in meta-analysis of the latest trials, and adjuvant thrombolytics are an area of active investigation. Endovascular thrombectomy is beneficial in a wide range of anterior and posterior circulation large vessel occlusions up to 24 h after onset with the more distal occlusions, mild presentations, and >24 h window being the main frontiers to be tested in ongoing trials. Imaging parameters are prognostic but appear not to modify the relative treatment benefit of thrombectomy versus standard medical care. Therefore, deciding who not to treat with thrombectomy is a key clinical challenge that requires careful but rapid integration of clinical, imaging, and patient preference considerations. Systems of care to accelerate delivery of these highly effective therapies will maximize benefits for the greatest number of patients with stroke.

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Although the efficacy of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) has been established in two randomized controlled studies, many patients have miserable clinical outcomes after MT for ABAO. Predicting severe disability prior to the procedure might be useful in determining the appropriateness of treatment interventions. Among the ABAO cases treated at 10 hospitals between July 2014 and December 2021, 144 were included in the study, all of whom underwent MRI before treatment. A miserable outcome was defined as a modified Rankin Scale (mRS) of 5-6 at 3 months. The associations between clinical, imaging, and procedural factors and miserable outcomes were evaluated. A miserable outcome was observed in 54 cases (37.5%). Multivariate analysis identified the National Institutes of Health Stroke Scale (NIHSS), transverse diameter of brainstem infarction, and symptomatic intracerebral hemorrhage as independent factors associated with miserable outcomes, with cutoff values of NIHSS 22 and transverse diameter of brainstem infarction 15 mm. Cases with a higher preoperative severity may result in miserable postoperative outcomes. Particularly, the transverse diameter of a brainstem infarction can be easily measured and serves as a useful criterion for determining treatment indications.

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A 79-year-old woman presented at our hospital with sudden headache and vomiting. Computed tomography revealed diffuse subarachnoid hemorrhage. Although digital subtraction angiography (DSA) performed on admission and on the following day revealed no vascular abnormalities, DSA on Day 22 revealed microaneurysmal changes in the dorsal basilar artery. However, the aneurysmal changes gradually became smaller during follow-up, and DSA on Day 73 revealed complete disappearance. A 53-year-old man also presented to our hospital with sudden headache and vomiting. Computed tomography revealed perimesencephalic subarachnoid hemorrhage. DSA on Days 9 and 16 revealed microaneurysmal changes in the dorsal basilar artery. Conservative treatment was continued, and DSA on Day 42 revealed spontaneous disappearance of the lesion. It has been reported that basilar artery perforating aneurysms cause angiogram-negative subarachnoid hemorrhage, which disappears spontaneously. The fact that lesions previously reported as basilar artery perforating aneurysms may include cases of acute dissection of the main trunk or perforating branches of the basilar artery implies that surgical or endovascular treatment may worsen the condition. Therefore, conservative treatment may be an important option.

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BACKGROUND: There is currently no established criterion for determining when interventional treatment is necessary and what strategy is appropriate for basilar artery (BA) aneurysms. Through this study, we aimed to propose an algorithm that can effectively determine the optimal endovascular treatment (EVT) option for BA aneurysms. METHODS: We enrolled patients with BA aneurysms from June 2016 to December 2022 and performed procedures based on the algorithm. The analysis included demographic, clinical, and aneurysmal characteristics, procedural details, complications, angiographic outcomes, and clinical outcomes. RESULTS: This study included 124 patients (mean age 55.0 years) with a BA aneurysm who underwent EVT. Of these, 21 aneurysms were treated in the setting of subarachnoid hemorrhage (SAH). The majority of aneurysms were located at the basilar apex (74), followed by the basilar trunk (30) and vertebrobasilar junction (20). Coiling was used in 18.5% of cases, while stent-assisted coiling embolization was chosen for 58.9%. Overlapping stents were used in 12.9%, flow diverter (FD) implantation in 3.2%, Y/T stent techniques in 4.8%, and stent adjunctive coiling with unilateral vertebral artery (VA) occlusion in only 1.6%. Procedure-related complications occurred in 15 patients (12.1%). Patients had a modified Rankin Scale(mRS) score of 0.74±1.62; 98 (86.7%) had good prognosis with mRS scores ranging from 0 to 2 at the last follow-up. DSA was performed on 105 (84.7%) patients revealing that 101 (81.5%) achieved complete or near-complete occlusion. CONCLUSIONS: The endovascular treatment criteria for BA aneurysms depended on the multi-characteristics was safe and effective. However, further evidence is needed from large cohort studies.

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INTRODUCTION: Endovascular treatment (EVT) improves outcomes for basilar artery occlusion (BAO) with moderate-to-severe symptoms. However, the best treatment for mild symptoms (NIHSS score 0-10 and 0-5) remains unclear. This study compared EVT ± IVT to IVT alone in BAO patients with mild symptoms. PATIENTS AND METHODS: From the SITS-International Stroke Treatment Register, we included BAO patients with available baseline NIHSS score, treated by EVT, IVT, or both within 6 h of symptom onset from 2013 to 2021. Using the Doubly Robust approach (propensity score matching plus multivariable logistic regression), we analyzed efficacy (3-month mRS) and safety (SICH and 3-month death) outcomes for EVT ± IVT versus IVT alone in BAO patients with NIHSS scores 0-10 and 0-5. RESULTS: 1426 patients were included. For NIHSS scores 0-10 (180 matched, 1:1 ratio), outcomes were similar between EVT ± IVT and IVT alone groups. For NIHSS scores 0-5 (89 matched, 1:1 ratio), EVT ± IVT was associated with worse outcomes compared to IVT alone (mRS 0-2, aOR 0.20 [95% CI 0.06-0.61]; p = 0.005; mRS 0-3, aOR 0.27 [95% CI 0.08-0.89]; p = 0.031), but safety outcomes were similar. DISCUSSION: In early-treated BAO patients with mild symptoms, defined as NIHSS 0-10, there were no significant differences in outcomes between EVT ± IVT and IVT alone. However, for very mild symptoms, defined as NIHSS 0-5, IVT alone was associated with better outcomes compared to EVT ± IVT.Conclusion: Randomized trials are crucial to determine the optimal reperfusion therapy for BAO patients with mild symptoms.

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BACKGROUND: Limited data are available on the appropriate choice of blood pressure management strategy for patients with acute basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT). We evaluated the impact of blood pressure variability on clinical outcomes after MT in patients with acute BAO. METHODS: This multicenter cohort study included 108 patients with acute BAO who underwent successful emergency thrombectomy at two comprehensive stroke centers from 2016 to 2021. Blood pressure was measured hourly during the first 24 h after successful reperfusion. Blood pressure variability was calculated as mean arterial pressure (MAP) assessed by the standard deviation (SD). Multivariate logistic models were used to investigate the association between BPV, the primary outcome (futile recanalization, 90-day modified Rankin Scale score 3-6), and the secondary outcome (30-day mortality). Subgroup analysis was performed as a sensitivity test. RESULTS: Futile recanalization occurred in 60 (56 %) patients, while 26 (24 %) patients died within 30 days. In the fully adjusted model, MAP SD was associated with a higher risk of futile recanalization (OR adj=1.36, per 1 mmHg increase, 95 % CI: 1.09-1.69, P=0.006) and 30-day mortality (OR adj=1.56, per 1 mmHg increase, 95 % CI: 1.20-2.04, P=0.001). A significant interaction between MAP SD and the lack of hypertension history on futile recanalization (P<0.05) was observed. CONCLUSIONS: Among recanalized acute BAO ischemic patients, higher blood pressure variability during the first 24 h after MT was associated with worse outcomes. This association was stronger in patients without a history of hypertension.

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BACKGROUND: Subarachnoid hemorrhage is a severe neurological condition that requires prompt and appropriate treatment to prevent complications. Aneurysms are the most common cause of spontaneous subarachnoid hemorrhage. Conversely, basilar artery perforator aneurysms (BAPAs) are a rare etiology. There is no consensus on the optimal management of ruptured BAPAs in the acute setting. CASE SUMMARY: We present a case series of 3 patients with ruptured BAPAs who were treated at our institution. Two patients had a modified Fisher grade of I, and one had a grade of IV on initial presentation. The aneurysms were detected by computed tomography angiography in two cases and conventional angiography in one case. The 3 patients underwent endovascular treatment with Guglielmi detachable coils. Post-treatment, the patients had good clinical outcomes, and follow-up brain computed tomography scans showed reduced subarachnoid hemorrhage without any new hemorrhage. However, one patient experienced a cerebral infarction 2 months later and eventually succumbed to the condition. The other 2 patients showed progressive recovery, and no aneurysm recurrence was observed at the 2-year follow-up. CONCLUSION: Endovascular treatment may be a preferable approach for managing ruptured BAPAs compared with surgical intervention or conservative management. Early detection and prompt treatment is important to achieve favorable patient outcomes.

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Introduction: Neurogenic hypertension (HTN) is a type of HTN characterized by increased activity of the sympathetic nervous system. Vascular compression is one of the pathogenic mechanisms of neurogenic HTN. Despite Jannetta's solid anatomical and physiological arguments in favor of neurogenic HTN in the 1970's, the treatment for essential HTN by microvascular decompression (MVD) still lacks established selection criteria. Therefore, the subjects selected for our center were limited to patients with primary trigeminal neuralgia (TN) and primary hemifacial spasm (HFS) of the vertebral/basilar artery (VA/BA) responsible vessel type coexisting with neurogenic HTN who underwent MVD of the brainstem to further explore possible indications for MVD in the treatment of neurogenic HTN. Methods: A retrospective analysis of 63 patients who were diagnosed with neurogenic HTN had symptoms of HFS and TN cranial nerve disease. Patients were treated at our neurosurgery department from January 2018 to January 2023. A preoperative magnetic resonance examination of the patients revealed the presence of abnormally located vascular compression in the rostral ventrolateral medulla (RVLM) and the root entry zone (REZ) of the IX and X cranial nerves (CN IX- X). Results: There was no significant difference between the two groups in terms of gender, age, course of HFS, course of TN, course of HTN, degree of HTN, or preoperative blood pressure. Based on the postoperative blood pressure levels, nine out of 63 patients were cured (14.28%), eight cases (12.70%) showed a marked effect, 16 cases (25.40%) were effective, and 30 cases were invalid (47.62%). The overall efficacy was 52.38%. However, 39 cases of combined cranial nerve disease were on the left side of the efficacy rate (66.67%) and 24 cases of combined cranial nerve disease were on the right side of the efficacy rate (29.16%). Discussion: Over the last few decades, many scholars have made pioneering progress in the clinical retrospective study of MVD for neurogenic hypertension, and our study confirms the efficacy of MVD in treating vertebral/basilar artery-type neurogenic hypertension by relieving the vascular pressure of RVLM. In the future, with the development and deepening of pathological mechanisms and clinical observational studies, MVD may become an important treatment for neurogenic hypertension by strictly grasping the surgical indications. Conclusion: MVD is an effective treatment for neurogenic HTN. Indications may include the following: left-sided TN or HFS combined with neurogenic HTN; VA/BA compression in the left RVLM and REZ areas on MRI; and blood pressure in these patients cannot be effectively controlled by drugs.

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BACKGROUND: Stroke etiology could influence the outcomes in patients with basilar-artery occlusion (BAO). This study aimed to evaluate the differences in efficacy and safety of best medical treatment (BMT) plus endovascular treatment (EVT) versus BMT alone in acute BAO across different stroke etiologies. METHODS: The study was a post hoc analysis of the ATTENTION trial (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute BAO were classified into 3 groups according to stroke etiology (large-artery atherosclerosis [LAA], cardioembolism, and undetermined cause/other determined cause [UC/ODC]). The primary outcome was a favorable outcome (modified Rankin Scale score of 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 340 patients with BAO were included, 150 (44.1%) had LAA, 72 (21.2%) had cardioembolism, and 118 (34.7%) had UC/ODC. For patients treated with BMT plus EVT and BMT alone, respectively, the rate of favorable outcome at 90 days was 49.1% and 23.8% in the LAA group (odds ratio, 3.08 [95% CI, 1.38-6.89]); 52.2% and 30.8% in the cardioembolism group (odds ratio, 2.45 [95% CI, 0.89-6.77]); and 37.5% and 17.4% in the UC/ODC group (odds ratio, 2.85 [95% CI, 1.16-7.01]), with P=0.89 for the stroke etiology×treatment interaction. The rate of symptomatic intracranial hemorrhage in EVT-treated patients with LAA, cardioembolism, and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the BMT-treated patients. Lower 90-day mortality was observed in patients with EVT compared with BMT alone across 3 etiology groups. CONCLUSIONS: Among patients with acute BAO, EVT compared with BMT alone might be associated with favorable outcomes and lower 90-day mortality, regardless of cardioembolism, LAA, or UC/ODC etiologies. The influence of stroke etiology on the benefit of EVT should be explored by further trials. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04751708.

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Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.

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Objectives: This study aimed to evaluate whether the "weekend effect" would affect the time metrics and the prognosis of acute ischemic stroke (AIS) patients who underwent endovascular treatment (EVT) due to basilar artery occlusion (BAO). Methods: Clinical data of AIS patients who underwent EVT due to BAO between December 2019 and July 2023 were retrospectively analyzed. At the time when the patients were admitted, the study population was divided into the weekdays daytime group and weekends nighttime group. In the subgroup analysis, the study cohort was divided into four groups: the weekdays daytime group, weekdays nighttime group, weekend daytime group, and weekend nighttime group. A good outcome was defined as a modified Rankin Scale score of ≤3 at 90 days after EVT. Time metrics [e.g. onset-to-door time (ODT) and door-to-puncture time (DPT)] and clinical outcomes were compared using appropriate statistical methods. Results: A total of 111 patients (88 male patients, mean age, 67.7 ± 11.7 years) were included. Of these, 37 patients were treated during weekdays daytime, while 74 patients were treated during nights or weekends. There were no statistically significant differences in ODT (P = 0.136), DPT (P = 0.931), and also clinical outcomes (P = 0.826) between the two groups. Similarly, we found no significant differences in the time metrics and clinical outcomes among the four sub-groups (all P > 0.05). Conclusion: This study did not reveal any influence of the "weekend effect" on the time metrics and clinical outcomes in AIS patients who underwent EVT due to BAO at a comprehensive stroke center.

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Basilar apex aneurysms (BAAs) represent 5%-8% of cerebral aneurysms.1-3 Treating BAAs is long established in neurosurgery.4-6 The morbid and lethal characteristics of aneurysmal subarachnoid hemorrhage coupled with potential medical complications of neurointensive care contribute to poor prognosis of patients with ruptured BAAs.7,8 A 58-year-old woman presented to the emergency department with a 1-day course of intense headaches that progressed to loss of consciousness. Noncontrast computed tomography of the head revealed extensive intraventricular hemorrhage (Fisher grade 4). Computed tomography angiography revealed an 8.7 × 6.3 mm wide-neck BAA. Preoperatively, she developed rebleeding and cerebral vasospasm and was transferred to the neurointensive care unit. After initial management and consideration of her clinical course and complex aneurysm features, she underwent a right frontotemporal craniotomy and anterior extradural clinoidectomy to perform aneurysm neck clipping (Video 1). Endovascular treatment was not considered, given that our facility belongs to a low-income public health system with limited availability of endovascular devices. Postoperatively, the patient developed cerebral vasospasm and pneumonia, which led to respiratory failure and death. BAAs are vascular entities that require arduous microsurgical treatment. Despite the increasing trend in managing these patients with endovascular treatment, the role of microsurgery is predominant in clinical settings with limited availability of alternative therapies. This clinical scenario requires neurosurgery trainees to achieve a high-level microsurgical skill set to provide optimal treatment. Nonetheless, the course of BAAs can still be poor even after adequate surgical management. This case exemplifies the burdensome nature of BAAs and the difficult clinical course of patients despite meticulous microsurgical management. Fisher grade 4, which is associated with a 31% risk of vasospasm, was a notable factor contributing to this outcome.7 Further, the patient's recovery was complicated by hospital-acquired pneumonia, which has a mortality rate of 9.7%.8 Accordingly, amid the emergent discipline of enhanced recovery after surgery, optimized protocols for postoperative management could benefit these patients.9-11.

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INTRODUCTION: Age is often used as a predictor in determining outcomes in large vessel occlusions treated with mechanical thrombectomy. However, limited data exist for octo/nonagenarian outcomes compared to younger individuals in acute basilar artery occlusions treated with thrombectomy. METHODS: Patient data were obtained from the PC-SEARCH Thrombectomy Registry which consists of 444 acute basilar artery occlusions treated with mechanical thrombectomy. Individuals were dichotomized based on age (>80 and ≤80 years old). Primary outcome was defined as modified Rankin Scale of 0-3 at 90 days. Logistic and multivariate regression, as well as control-matched analysis, were performed. RESULTS: There were 373 and 71 patients in the younger and older cohorts, respectively. Gender, ethnicity, smoking status, atrial fibrillation, and coronary artery disease were noted to be significantly different between cohorts. At 90 days, 178 (47.7%) and 23 (32.4%) patients achieved primary outcome at 90 days (p = 0.02), however, after controlling for potentially confounding factors this association lost significance (OR 0.50 95% CI 0.24-1.05; p = 0.07). There were 84 patients included in the control matched analysis and demonstrated no significant differences on multivariate analysis between cohorts (OR 0.68 95% CI 0.25-1.84; p = 0.45). INTERPRETATION: Octa/nonagenarians presenting with an acute basilar artery occlusion treated with mechanical thrombectomy can achieve acceptable rates of favorable functional outcomes compared to younger individuals with similar baseline demographic and stroke characteristics.