Acute Basilar Artery Occlusion: Need for an Early Diagnosis in a Devastating Disease
To the Editor:
We read the recent article by Nagel et al1 about intraarterial thrombolysis compared to a combined therapy with abciximab in basilar artery occlusion (BAO) with great interest. They showed a significant increase of recanalization, survival and functional outcome using a combined bridging therapy in their study.
We have to bear in mind, though, that many patients with BAO are primarily admitted in community hospitals without a specialized stroke unit or neurologists on-call. These patients show an extremely high mortality rate if they are secondarily transferred to a stroke center with anticoagulation but without early start of a sufficient treatment.2 Thus, bridging therapies have been started by some stroke centers but adequate results were missing. An early start of intravenous thrombolysis seems justified relating to data from Lindsberg and Mattle.3 The current results also support a bridging attempt using a GP IIb/IIIa antagonist.
Nevertheless, we need to achieve an early diagnosis in BAO patients admitted to community hospitals. This can be achieved by means of telemedicine with transmission of neuroradiological scans to a stroke center, most suitable with a telemedical patient examination.4 These networks represent an important and feasible option but are not often used in treatment of BAO yet. This might become a future option combined with bridging therapies as new strategies are indeed needed. In hospitals without the possibility of CT angiography, a hyperdense basilar artery sign points to a BAO in patients with posterior circulation stroke symptoms.5
Thus, the current results are encouraging in this important battle against an otherwise devastating disease, but our infrastructure needs to be improved to achieve a rapid diagnosis and start of treatment.
Nagel S, Schellinger PD, Hartmann M, Juettler E, Huttner HB, Ringleb P, Schwab S, Köhrmann M. Therapy of acute basilar artery occlusion: intraarterial thrombolysis alone vs bridging therapy. Stroke. 2009; 40: 140–146.
Müller R, Pfefferkorn T, Vatankhah B, Mayer TE, Schenkel J, Dichgans M, Sander D, Audebert HJ. Admission facility is associated with outcome of basilar artery occlusion. Stroke. 2007; 38: 1380–1383.
Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006; 37: 922–928.
Goldmakher GV, Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Halpern EF, Chou MJ, Biagini T, Smith WS, Harris GJ, Dillon WP, Gonzalez RG, Koroshetz WJ, Lev MH. Hyperdense basilar artery sign on unenhanced CT predicts thrombus and outcome in acute posterior circulation stroke. Stroke. 2009; 40: 134–139.