Abstract
Background
Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO).
Methods
We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups.
Results
A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0–2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35–2.05; aOR 0.93, 95% CI 0.35–2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496).
Conclusion
Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO.
Keywords: Tandem occlusions, stroke, vertebrobasilar, mechanical thrombectomy
Introduction
Acute basilar artery occlusion (BAO) is a severe disease that accounts for about 1% of acute ischemic strokes 1 and is associated with an 85% mortality rate if untreated. 2 About a quarter of patients with BAO also present with uni- or bilateral vertebral artery (VA) stenosis greater than 70% in the V1 or V2 segments, 3 also called tandem lesion, and about one-third of patients with BAO have an underlying basilar artery (BA) stenosis. 1
Although several studies have analyzed the use of mechanical thrombectomy (MT) in patients with acute vertebrobasilar tandem occlusion (VBTO) stroke,4–9 the results remain conflicting, the role of MT as standard of care for VBTO has not been confirmed10–12 and the selection of appropriate treatment is left to each individual interventionalist.
Considering that MT is establishing itself as standard treatment not only in tandem anterior circulation stroke but also in isolated BAOs (IBAO),13–15 our goal was to compare technical feasibility, safety, and functional outcome of endovascular treatment of VBTO with that for IBAO (with or without underlying intracranial stenosis) in an international multi-center study in order to optimize the treatment strategy.
Methods
Patient selection
All patients with BAO identified from prospectively collected databases from September 2016 to November 2021 at six tertiary academic centers were retrospectively reviewed: Bern University Hospital, Klinikum rechts der Isar (Technical University Munich), Knappschaftskrankenhaus Bochum, Helios General Hospital Erfurt, University Hospital Essen, University Hospital Magdeburg. Inclusion criteria were: (1) acute ischemic stroke in the vertebrobasilar territory, (2) MT as treatment choice, (3) acute neurologic symptoms due to IBAO or VBTO confirmed by vascular imaging, (4) onset to groin puncture time of less than 24 h. Exclusion criteria included: (1) the presence of intracranial hemorrhage on admission, (2) BAO resulting from other causes (e.g., dissection). Vertebrobasilar tandem occlusion was defined as simultaneous stenosis of the BA and of the V1-/V2-segment of the VA greater than 70%.
The acquired data included: patients’ baseline characteristics, risk factors, procedural timeframes, baseline National Institutes of Health Stroke Scale (NIHSS), angiographic data (BAO location, presence of simultaneous VA stenosis higher than 70%, VA-dominance (defined as a side-to-side diameter difference greater than the standard error of measurement), recanalization rates, arterial access, material used), procedural complications, modified Rankin Scale (mRS) at three months, NIHSS at discharge, and the occurence of new stroke at three months. Patients were divided into two groups: (1) patients with BAO and a simultaneous extracranial VA stenosis (Figure 1) and (2) patients with an IBAO (Figure 2). Subsequently, the IBAO group was subdivided into patients with and without underlying intracranial BA stenosis.
Figure 1.
Patient with hemiplegia on the left side and speech impairment due to vertebrobasilar tandem occlusion. (A) Diagnostic angiogram showing an occlusion in the distal segment of the basilar artery (BA). (B) Complete reperfusion of the BA after endovascular therapy seen on control angiogram. (C) Concomitant extracranial stenosis in the V1 segment of the left vertebral artery (VA). (D) Control angiogram after stent placement shows complete reperfusion of the VA stenosis.
Figure 2.
Patient with acute BA occlusion and an underlying stenosis. (A) Control angiogram after mechanical thrombectomy of the occlusion in the BA showing a high-grade underlying stenosis. (B) Complete reperfusion of the BA after balloon dilation and stent placement.
The stroke registries were approved by the local ethics committees. The stroke databases in each center were approved by the local ethics committees for quality control and research. The requirement for an informed consent form was waived by the ethics committees, and patients were informed about the registry and the potential use of their data for research. After receiving the information, patients could object to the use of their data for research (but not for quality control). In accordance with Swiss and German law, patients who refused the use of their data for research were excluded from this analysis.
Endovascular procedure
First, selective digital subtraction angiography was performed through a femoral approach. Then, a guiding catheter was advanced into the subclavian artery or VA. Access to the BA was achieved through either the occluded or non-occluded side (dirty- or clean-road pathway), depending on the vessel anatomy, dominance, and the interventionalist's preference.
A microcatheter was navigated through the stenosis over a microwire. If intracranial access could not be gained due to difficult vessel anatomy or high-grade stenosis, balloon angioplasty of the VA stenosis was performed. The intracranial thrombus was passed with the microcatheter over the microwire and MT with or without distal aspiration and proximal flow arrest was performed.
In some patients with simultaneous extracranial stenosis, balloon angioplasty or stenting of the proximal occlusion was performed. If stenting was necessary, antiplatelet therapy was initiated during the intervention. Digital subtraction angiography was newly performed after the end of the stent implantation to check for acute in-stent thrombosis, distal emboli, or other complications. If no intracranial hemorrhage was detected, dual antiplatelet therapy (DAPT) was initiated the day after the intervention and continued for 3–6 months in patients with stent placement.
In each center, intra- or extracranial stenting was accompanied by appropriate peri- and postprocedural pharmacological therapy. Periprocedural administration of anticoagulants (and, if indicated, antiplatelets) was followed by control imaging within 24 h. If no hemorrhage was detected, DAPT was initiated.
As the general approach to endovascular procedures and the antiplatelet treatment strategies differed among centers, a general description of the endovascular approach is given, without details of the specific materials used. A summary of basic interventional parameters for each center is provided in Supplementary Table 1, and the antiplatelet protocols for each center are shown in Supplementary Table 2.
Outcome evaluation
Procedure time was defined as time from the first intracranial angiography until the final angiographic control run. Successful recanalization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3. Procedural complications were defined as any technical or medical problem during the intervention.
The 90-day functional outcome was assessed by an experienced stroke neurologist at each center. Favorable outcome was defined as mRS 0–2 after 3 months. Symptomatic intracranial hemorrhage (sICH) was defined as any parenchymal, subarachnoid, or intraventricular hemorrhage that resulted in a NIHSS decline of ≥4 within 24 h. 16
Statistical analysis
To analyze the statistical difference between all groups, Fisher's exact test was used. Categorical variables (sex, arterial hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, VA dominance, VA stenosis, underlying BA stenosis, distal access catheter used, modality for intracranial occlusion, number of maneuvers, mTICI, intracranial stenting, dirty-road, treatment order, VA stenosis treatment, procedural complications, sICH, and new posterior circulation stroke at three months) are expressed as absolute numbers and percentages or as median with interquartile range (IQR). The Mann–Whitney U test was used for continuous variables (age, NIHSS at admission, time from onset to groin puncture, procedure duration, NIHSS at discharge, and mRS at three months), and results are presented as median ± IQR. Significant prognostic factors for three-month outcome and mortality rate were analyzed with binary logistic regression. Statistical significance was defined as p < 0.05. All calculations were performed using R (Version 4.0.0). 17
Results
Baseline characteristics
All 190 patients enrolled in this study underwent endovascular treatment for BA occlusion stroke. Mean age was 73 years (range, 63–83 years) and 45.3% were female. In the VBTO group, only 29.1% of patients were female (p = 0.007). Fifty-five (28.9%) patients had a tandem occlusion and 135 (71.1%) had an IBAO. In the IBAO group, 24 (17.8%) patients had an underlying stenosis at the level of the BAO compared to 7 (12.7%) patients in the VBTO group. The median NIHSS on admission was similar in both groups (VBTO = 13 [range, 7–21] and IBAO = 15 [7–31], p = 0.26). The onset-to-groin puncture time was significantly longer in patients with IBAO: 3.93 h (2.88–7.00 h) than in those with VBTO: 3.58 h (range, 2.56–4.71 h), p = 0.05. Among patients with VBTO, the left VA was more often occluded (left: 51% vs. right: 29% vs. both: 20%). The other baseline characteristics were similar in all groups and are summarized in Table 1.
Table 1.
Baseline characteristics.
| Overall (N = 190) | VBTO (N = 55) | IBAO (N = 135) | p | |
|---|---|---|---|---|
| Age [IQR] | 73 [63–83] | 72 [59–80] | 74 [64–83] | 0.125 |
| Women | 45.3% (86/190) | 29.1% (16/55) | 51.9% (70/135) | 0.007 |
| Admission NIHSS [IQR] | 15 [7–25] | 13.00 [7–21] | 15 [7–31] | 0.256 |
| Arterial hypertension | 74.2% (141/188) | 70.9% (39/55) | 75.6% (102/133) | 0.467 |
| Dyslipidemia | 42.1% (80/187) | 41.8% (23/55) | 42.2 (57/132) | 0.530 |
| Diabetes mellitus | 20.5% (39/188) | 21.8% (12/55) | 20.0% (27/133) | 0.645 |
| Atrial fibrillation | 28.9% (55/188) | 18.2% (10/55) | 33.3 (45/133) | 0.065 |
| Dominance of VA | 0.009 | |||
| Codominant | 36.8 (70) | 21.8 (12) | 43.0 (58) | |
| Left dominance | 37.4 (71) | 40.0 (22) | 36.3 (49) | |
| Right dominance | 25.8 (49) | 38.2 (21) | 20.7 (28) | |
| Underlying basilar artery stenosis | 16.3% (31/189) | 12.7% (7/54) | 17.8% (24/135) | 0.211 |
| Onset to groin puncture, hours [IQR] | 3.80 [2.75–6.14] | 3.58 [2.56–4.71] | 3.93 [2.88–7.00] | 0.050 |
VBTO: vertebrobasilar tandem occlusion; IBAO: isolated basilar artery occlusion; N: total number of patients in the specific group; IQR: interquartile range; NIHSS: National Institutes of Health Stroke Scale.
Procedural details
Procedure time was significantly longer in patients with VBTO: 57 min (36–99 min) than in those with IBAO: 42 min (26–67 min), p = 0.013. Forty-nine patients (89.1%) from the VBTO group were successfully recanalized (mTICI ≥ 2b). This percentage is similar to the 116 recanalized patients (86.0%) in the IBAO group. No significant difference in rates of successful recanalization (mTICI 2b vs. mTICI 3) was observed relating to the use of dirty-road or the different treatment orders (retrograde vs. antegrade approach).
A retrograde approach was chosen in 21.8% of patients (treatment of proximal VA stenosis or occlusion after intracranial recanalization). 18 In 32 patients (58%), the VA stenosis was left untreated. There was no difference in the number of thrombectomy attempts, modality for intracranial occlusion extraction (stent-retriever, aspiration, none) or frequency of intracranial stenting. The “clean-road” pathway through the unaffected VA was achieved in 27% of all patients with VBTO. In the others, either the dirty-road pathway was chosen due to tortuous, non-existent, or non-dominant vessel anatomy of the unaffected VA or because the patient had significant bilateral significant VA stenosis. No statistically significant effect of different treatment approaches for VBTO on the rates of successful recanalization was observed (Supplementary Table 3). In 38%, a stent was implanted to treat the extracranial VA stenosis. Antiplatelet and heparin treatment after intra- or extracranial stenting lightly differed among the involved centers (Supplementary Table 2). Four centers did not use the glycoprotein IIb/IIIa inhibitors in the periprocedural period for the extracranial stenting. Heparin was used in one center for the intracranial stenting, and in one center for the extracranial stenting. Heparization during the MT might be associated with the risk of sICH and distal embolization 19 ; however, physicians in these centers did not find this in this evidence in daily routine. For intracranial stenting, heparin, aspirin, or glycoprotein IIb/IIIa inhibitors were used periinterventionally. If no intracranial hemorrhage was detected on control imaging, DAPT with 100 mg aspirin and 75 mg clopidogrel was initiated and continued for 3–12 months; aspirin was continued lifelong. For extracranial stenting, mainly aspirin was administered during the intervention and DAPT was continued for 6–24 weeks, starting 24 h after treatment.
Both groups had a similar rate of procedural complications, most commonly: dissection, new distal emboli, or no access to the BA due to vessel hypoplasia or tortuous vessel anatomy. All procedural characteristics are presented in Table 2. Details on treatment strategy for VBTO are presented in Table 3.
Table 2.
Procedural characteristics.
| Overall (N = 190) | VBTO (N = 55) | IBAO (N = 135) | p | |
|---|---|---|---|---|
| Procedure time, min [IQR] | 45 [27–76] | 57 [36–99] | 42 [26–67] | 0.013 |
| Thrombectomy maneuvers, n [IQR] | 1 [1–2] | 1 [1–2] | 1 [1–2] | 0.513 |
| Distal access catheter used | 57.9% (110/189) | 63.6% (35/54) | 55.6% (75/135) | 0.148 |
| mTICI | 0.109 | |||
| ≤2a | 7.9% (15/180) | 5.5% (3/52) | 8.9% (12/128) | |
| 2b | 20.0% (38/180) | 30.9% (17/52) | 15.6% (21/128) | |
| 3 | 66.8% (127/180) | 58.2% (32/52) | 70.4% (95/128) | |
| Intracranial stenting | 11.1% (21/190) | 7.3% (4/55) | 12.6 (17/135) | 0.420 |
VBTO: vertebrobasilar tandem occlusion; IBAO: isolated basilar artery occlusion; N: total number of patients in the group; IQR: interquartile range; mTICI: modified treatment in cerebral infarction.
Table 3.
Treatment approach for vertebrobasilar tandem occlusion (VBTO) stroke.
| VBTO (N = 55) | |
|---|---|
| VA stenosis | |
| Both | 20.0% (11/55) |
| Left | 50.9% (28/55) |
| Right | 29.1% (16/55) |
| Dirty road | 61.8% (34/49) |
| Treatment order | |
| Retrograde | 21.8% (12/55) |
| Antegrade | 21.8% (12/55) |
| Only intracranial | 56.4% (31/55) |
| VA stenosis treatment | |
| None | 56.4% (31/55) |
| PTA | 5.5% (3/55) |
| Stenting | 38.1% (21/55) |
VA: vertebral artery; PTA: percutaneous transluminal angioplasty.
Outcomes and complications
No tendency toward higher NIHSS at 24 h after intervention was found in either group. There was no significant difference in the occurrence of sICH at the three-month follow-up between the groups (VBTO: 7.3% vs. IBAO: 4.2%, p = 0.496). Patients in the VBTO group more often presented with a new stroke in the posterior circulation within a three-month period (VBTO: 12.7% vs. IBAO: 3.7%, p = 0.068). The most common complication during the intervention was VA dissection occurring in eleven patients (5.8%) due to forced advancement of the guiding catheter into the VA. Other complications included: new distal emboli (4%) and inaccessible VA (3%). No difference was observed in peri- or postinterventional complications among patients undergoing the different treatment strategies for VA occlusion (Supplementary Table 4). Patients with IBAO had a significantly higher mortality rate (VBTO: 29.1% vs. IBAO: 33.3%, p = 0.025). Outcomes and complications are summarized in Table 4.
Table 4.
Outcomes and postprocedural complications.
| Overall (N = 190) | VBTO (N = 55) | IBAO (N = 135) | p | |
|---|---|---|---|---|
| NIHSS at 24 h [IQR] | 7 [2–18] | 7 [2–15] | 6 [1–18] | 0.607 |
| sICH | 4.2% (8/183) | 7.3% (4/52) | 4.2% (1/131) | 0.496 |
| mRS at 3 months [IQR] | 4 [1–6] | 3 [1–6] | 4 [2–6] | 0.280 |
| Favorable functional outcome | 28.4% (54/153) | 36.4% (20/50) | 25.2% (34/103) | 0.048 |
| New PC stroke at 3 months | 6.3% (12/124) | 12.7% (7/37) | 3.7% (5/87) | 0.068 |
| Mortality | 32.1% (61/153) | 29.1% (16/50) | 33.3% (45/103) | 0.025 |
VBTO: vertebrobasilar tandem occlusion; IBAO: isolated basilar artery occlusion; N: total number of patients in the group; IQR: interquartile range; NIHSS: National Institutes of Health Stroke Scale; sICH: symptomatic intracranial hemorrhage; mRS: modified Rankin Scale; PC: posterior circulation.
Favorable outcome at 3 months (mRS ≤ 2) was observed more often in patients with VBTO (VBTO: 36.4% vs. IBAO: 25.2%, p = 0.048). However, the results of multiple linear regression analysis showed that higher NIHSS on admission was the only independent predictor of favorable functional outcome and higher mortality rate (odds ratio [OR] = 0.90, 95% CI = 0.85–0.95, p < 0.001; OR = 1.11, 95% CI = 1.07–1.15, p < 0.001, respectively). No statistically significant association was found between the presence of VBTO or IBAO and favorable outcome. Results from the analysis are presented in Supplemental Table 5.
Discussion
Since our study from 2020, 20 more data have been published on MT in patients with VBTO. However, the best treatment approach in this patient subgroup is not yet clear. We therefore decided to perform an analysis of a larger number of patients from six tertiary centers in Switzerland and Germany.
Tandem occlusions in the anterior circulation are generally associated with higher mortality compared to isolated intracranial occlusions. 21 Although IBAO has shown similar rates of mortality and clinical outcome to anterior circulation tandem occlusions,22,23 published data on tandem occlusions in the vertebrobasilar territory have been inconclusive, overall pointing toward a higher mortality rate at 3 months (46.7%). 11 Even though this number represents a significant improvement over the former 85% in untreated patients, 24 the choice of the optimal endovascular treatment approach in order to further reduce mortality is of great importance, given the fact that VBTO still represents around 25% of acute BAO.20,25,26
Outcomes
Our results on the rate of mortality of the VBTO group (29.1%) are consistent with previous studies,11,25 yet contradict the results from a smaller study by Elhorany et al., who found VBTO to be associated with lower rates of successful recanalization and good clinical outcome. 11 No statistically significanthigher mortality was found in any group. In our cohort, greater tendency toward favorable clinical outcome was observed in the VBTO group (36.4% compared to 25.2% in the IBAO group), again which confirms our previous results, 20 but contradicts the results of Elhorany et al., 11 and Baik et al., 25 who reported a 53% favorable outcome rate in patients with embolism without VA steno-occlusion; and Yang et al. 12 who found the highest rates in the embolic IBAO group. One study from China, 10 which found that patients with tandem occlusions in the vertebrobasilar territory had the best outcome, reported a favorable outcome rate of 88% in the VBTO group. We believe this number was influenced by the exclusion of patients with fatal outcome from the analysis and the small number of patients involved in the study. A recent meta-analysis of the available studies reported high heterogeneity in rates of functional independence with an average rate of favorable clinical outcome of 32% in the VBTO group compared to 20% in the IBAO group. 3 However, after adjusting for confounding variables, our study found that the presence of VBTO or IBAO did not prove to an independent outcome for functional independence or mortality rare. Only lower NIHSS on admission was an independent predictor of favorable functional outcome and higher NIHSS an independent predictor for higher mortality rate. The fact that there were statistically less women represented in the VBTO group did not show significant in the multiple logistic regression analysis, therefore should not influence the results. The patient age also did not prove significantly different among the groups.
The overall rate of sICH (4.2%) was the lowest to date when compared to recently published studies on anterior as well as posterior circulation tandem occlusion.11,21,25,27 There was no statistical significance between any of the groups. However, the VBTO group showed a higher sICH rate (7.3%), which is in line with the results reported by Elhorany et al. 11 and Yang et al. 12 The higher number of new strokes in posterior circulation, although not significant, was not associated with any strategy of treatment of VA stenosis. The percentage of new strokes in group treated with PTA (33%) might have been influenced by the small group size (N = 3).
The largest study to date involving VBTO patients was published by Baik et al., 28 who included 55 VBTO patients. As in our study, the authors found that NIHSS on admission is an independent predictor of favorable functional outcome and mortality rate. Nevertheless, their study only included patients of Asian origin, who have a higher incidence of intracranial arterial stenosis, 29 and therefore, these results are not entirely generalizable.
Intervention
We achieved successful recanalization of 86.8% of the overall cohort, which is in line with previously published studies.10,11,28 In the VBTO group, the rate was slightly higher (89.1%) than in the IBAO group (86.0%). This is contrary to the findings of a recent meta-analysis, where the tandem occlusion group tended to have worse recanalization rates. 3 Similarly to our previous study, we found that the procedure time was significantly longer in patients with VBTO (57 min). This might because: (1) many VBTO patients required additional extracranial treatment, which prolonged the procedure or (2) the VA stenosis made the intracranial access more challenging. We report a lower rate of underlying BA stenosis of 16.3% (31 patients) compared to previous studies (ranging from 24.4% to 31.0%).11,12,25 Twenty-one of these patients were treated with intracranial stenting. Stenting of the extracranial VA stenosis was not associated with higher rate of complications, which agrees with the finding by Yahia et al. 30 in in anterior tandem stroke setting.
Vertebrobasilar tandem occlusions are comlex conditions, where procedural approach and patient outcome are influenced by many factors. We believe that our findings contribute to the establishment of MT as a safe and feasible therapeutic option for patients with VBTO, lower rates of mortality and higher rates of good functional outcome than patients with IBAO, where MT is already more established as standard treatment. Further prospective studies are needed to evaluate optimal treatment strategies for VBTO patients in different scenarios.
Limitations
Our study has some limitations: (1) its retrospective design, (2) selection bias, (3) treatment strategy was left to the discretion of the interventionalist, (4) self-assessed angiographic evaluation by the interventionalist, (5) a larger number of missing outcome values, especially for the IBAO group, and (6) heterogeneity of the protocols of antiplatelet/anticoagulant medication in each period of intracranial or extracranial stenting procedures among centers.
Conclusion
Overall, endovascular treatment of VBTO is technically feasible and the outcomes are similar to those of IBAO. None of the recanalization strategies proved to be superior to any other. Further prospective studies are warranted to evaluate optimal treatment strategies for VBTO patients.
Supplemental Material
Supplemental material, sj-docx-1-ine-10.1177_15910199241240045 for Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience by Tomas Klail, Eike I. Piechowiak, Nadja Krug, Christian Maegerlein, Volker Maus, Sebastian Fischer, Donald Lobsien, Daniel Pielenz, Hanna Styczen, Cornelius Deuschl, Maximilian Thormann, Elie Diamandis, Mirjam R. Heldner, Johannes Kaesmacher and Pasquale Mordasini in Interventional Neuroradiology
Supplemental material, sj-docx-2-ine-10.1177_15910199241240045 for Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience by Tomas Klail, Eike I. Piechowiak, Nadja Krug, Christian Maegerlein, Volker Maus, Sebastian Fischer, Donald Lobsien, Daniel Pielenz, Hanna Styczen, Cornelius Deuschl, Maximilian Thormann, Elie Diamandis, Mirjam R. Heldner, Johannes Kaesmacher and Pasquale Mordasini in Interventional Neuroradiology
Acknowledgements
The authors thank Susan Kaplan for editorial assistance.
Footnotes
Authors’ contribution: TK: Author of the manuscript, data collection, statistical evaluation, image editing. EIP: Author of the manuscript, correction of the manuscript, involved in the treatment. NK: Data collection, clinical evaluation. CM: Data collection, clinical evaluation. VM: Data collection, clinical evaluation. SF: Data collection, clinical evaluation. DL: Data collection, clinical evaluation. DP: Data collection, clinical evaluation. HS: Data collection, clinical evaluation. CD: Data collection, clinical evaluation. MT: Data collection, clinical evaluation. MRH: Data collection, clinical evaluation. JK: Senior author, study concept, correction of the manuscript, statistical analysis. PM: Study concept, involved in the treatment, correction of the manuscript.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Heldner reports grants from the Bangerter Foundation and Amgen Advisory board participation, not related to the present study. Dr Kaesmacher reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern during the conduct of the study. Dr Mordasini reports research support from Siemens, Cerenovus, iSchemaview, Medtronic and Stryker, and receipt of honoraria and consultation fees from Medtronic, Cerenovus, Phenox, and Microvention paid to the institution, not related to the present study.
Ethics: The stroke registries were approved by the local ethics committees. The stroke databases in each center were approved by the local ethics committees for quality control and research. The requirement for an informed consent form was waived by the ethics committees, and patients were informed about the registry and the potential use of their data for research.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Tomas Klail https://orcid.org/0000-0002-8749-6066
Christian Maegerlein https://orcid.org/0000-0003-4885-7671
Cornelius Deuschl https://orcid.org/0000-0001-9262-7289
Maximilian Thormann https://orcid.org/0000-0003-3822-8871
Supplemental material: Supplemental material for this article is available online.
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Supplementary Materials
Supplemental material, sj-docx-1-ine-10.1177_15910199241240045 for Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience by Tomas Klail, Eike I. Piechowiak, Nadja Krug, Christian Maegerlein, Volker Maus, Sebastian Fischer, Donald Lobsien, Daniel Pielenz, Hanna Styczen, Cornelius Deuschl, Maximilian Thormann, Elie Diamandis, Mirjam R. Heldner, Johannes Kaesmacher and Pasquale Mordasini in Interventional Neuroradiology
Supplemental material, sj-docx-2-ine-10.1177_15910199241240045 for Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience by Tomas Klail, Eike I. Piechowiak, Nadja Krug, Christian Maegerlein, Volker Maus, Sebastian Fischer, Donald Lobsien, Daniel Pielenz, Hanna Styczen, Cornelius Deuschl, Maximilian Thormann, Elie Diamandis, Mirjam R. Heldner, Johannes Kaesmacher and Pasquale Mordasini in Interventional Neuroradiology