Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial

Why the fuck are you predicting outcome rather than doing research that will direct the outcome to 100% recovery? Does no one in the stroke medical world have two neurons they can rub together to generate a spark of intelligence? Or any leadership at all?

Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial

Fabricio O. Lima¹Felipe A. Rocha²Henrique C. Silva²Volker Puetz^3,4Diederik Dippel⁵Ido van den Wijngaard⁶Charles Majoie⁷Albert J. Yoo⁸Wim van Zwam⁹Adson F. de Lucena²Diego De Almeida Bandeira²Martin Arndt^3,4Kristian Barlinn^3,4Johannes C. Gerber^4,10Lucianne C. M. Langezaal¹¹Wouter J. Schonewille¹¹Octávio M. Pontes Neto¹²Francisco Antunes Dias¹²Sheila Ouriques Martins¹³Francisco José de A. Mont’Alverne^2* on behalf of BASICS Trial Investigators

• ¹Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
• ²Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
• ³Department of Neurology, Technical University Dresden, Dresden, Germany
• ⁴Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
• ⁵Erasmus MC University Medical Center, Rotterdam, Netherlands
• ⁶Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
• ⁷Academic Medical Center, Amsterdam, Netherlands
• ⁸Texas Stroke Institute, Plano, TX, United States
• ⁹Interventional Radiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
• ¹⁰Institute of Neuroradiology, Dresden Neurovascular Center, Universitätsklinik Dresden, Dresden, Germany
• ¹¹Department of Neurology, University Medical Center, Utrecht, Netherlands
• ¹²Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
• ¹³Department of Neurology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

Introduction and purpose: Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value.

Methods: We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems.

Results: The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11–35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7–9) and 7 (IQR 6–8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55–0.69] and 0.67, 95% CI [0.60–0.74] respectively). Age (OR 0.97, 95% CI [0.95–1.00]), NIHSS (OR 0.91, 95% CI [0.89–0.94]) and collateral score (PC-CS – OR 1.2495% CI [1.02–1.51]) were independently associated with clinical outcome.

Conclusion: The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months.

Introduction

Basilar artery occlusion (BAO) accounts for approximately 10% of strokes due to large vessel occlusion (LVO) and is present in about 8% of patients with symptomatic vertebrobasilar territory ischemia (1–3). Technical developments during the past few years have improved the diagnosis and management of BAO significantly, even so it is still one of the most devastating neurological conditions associated with high morbidity and mortality even in those treated with mechanical thrombectomy (4–7).

Several clinical and imaging predictors of outcome after BAO, such as the National Institutes of Health Stroke Scale (NIHSS) score at admission, age, PC-ASPECTS, and recanalization have been identified in earlier studies (3, 8). Collaterals have been recognized to influence recanalization, reperfusion, hemorrhagic transformation, and subsequent neurological outcomes, and are increasingly assessed in daily clinical practice, in patients with anterior circulation strokes (9). In contrast, the presence of posterior circulation collaterals in BAO patients is a feature that is yet far from being regularly used in clinical practice.

The noninvasive nature of CTA and its wide and rapid availability makes it the preferred diagnostic modality to assess collateral status in the acute stage of BAO. Two main collateral grading system exist for the posterior circulation, the posterior circulation collateral score (PC-CS) and the Basilar Artery on Computed Tomography Angiography (BATMAN) score (10, 11). Only a few studies have examined the role of posterior circulation collaterals as a predictor of outcome and systematically compared the two grading systems (12, 13).

In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare the two systems in terms of prognostic significance.

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