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  • Updated 02.26.2024
  • Released 10.28.1997
  • Expires For CME 02.26.2027

Basilar artery stroke



Basilar artery brainstem infarctions are perhaps the most feared and devastating of all ischemic strokes. With the development of advanced high-resolution MRI wall imaging, our understanding of symptomatic intracranial atherosclerotic disease has expanded beyond the presence of luminal diameter stenosis. Basilar arterial wall remodeling and symptomatic non-stenosing intracranial atherosclerotic disease (and its significant contribution to embolic stroke of undetermined source) are presented. The latest basilar artery mechanical thrombectomy randomized controlled trial data, bridging intravenous thrombolysis prior to mechanical thrombectomy, intra-arterial thrombolysis, and basilar artery percutaneous angioplasty and stent randomized controlled trial evidence, are discussed.

Key points

• Basilar artery stroke can be a grave condition.

• Basilar artery stroke is most commonly caused by atherothrombosis and cardioembolism.

• Patients with acute ischemic stroke in the basilar artery territory should receive intravenous thrombolytic therapy with tenecteplase or alteplase, even if mechanical thrombectomy is planned.

• Mechanical thrombectomy has been proven to be beneficial in basilar artery thrombosis.

• Current evidence does not support the use of percutaneous angioplasty and stent in the intracranial posterior circulation.

• Arteriographic absence of arterial luminal imaging is no longer the “gold standard” in ruling out symptomatic intracranial atherosclerosis. Symptomatic non-stenosing intracranial atherosclerosis appears to play a substantial role in stroke.

Historical note and terminology

The first clinico-pathologic report of basilar artery occlusion appeared in 1868 by Hayem (80). In 1882, Leyden reviewed prior cases of basilar artery occlusion, reported two additional clinico-pathologic cases of his own, described aneurysmal dilation of the basilar artery, and discussed the differential diagnosis between atherosclerotic basilar artery disease and superimposed thrombosis, embolism to the basilar artery, and syphilitic basilar artery endarteritis with thrombosis (106). His discussion of three patients who presented with sudden (but nonfatal) bulbar signs, presumed to have basilar artery thrombosis, probably represents the first recorded instance of basilar artery stroke. Charles Dana, in an extensive review of infarctions and hemorrhages of the pons and medulla surveyed 39 autopsied cases of lower brainstem infarction and noted that many patients had prodromal transient attacks of hemiparesis, vertigo, dysarthria, and double vision during the months or years preceding their major strokes (43). He divided the clinical presentation into two major categories: (1) long tract motor and sensory dysfunction and (2) bulbar symptoms and signs. Foix and Hillemand published a detailed review of pontine infarcts and the anatomy of the basilar artery and its branches (63).

Kubik and Adams's classic report on basilar artery occlusion in 1946 shaped modern conceptions of pathology and pathogenesis of basilar artery steno-occlusive disease (96). They analyzed 18 necropsy cases, concluding that basilar artery occlusions are characterized by frequent early loss of consciousness, common bilateral involvement, and combinations of pupillary disturbance, ocular and other cranial nerve palsies, dysarthria, extensor plantar responses, hemiplegia or quadriplegia, and often a marked remission of symptoms. Biemond emphasized amnesia, hemianopsia, and other posterior cerebral artery manifestations of basilar artery distribution ischemia (23). Millikan and Siekert detailed vertebrobasilar transient ischemic attacks ("vertebrobasilar insufficiency") and advocated anticoagulants as therapy. Kemper and Romanul described a patient with the loss of the ability to communicate due to limb and bulbar paralysis, a condition later coined "locked-in syndrome." A public light was shed on this rare and devastating disorder with the 1997 publication and film of the same name in 2007, Le Scaphandre et le Papillon (The Diving Bell and The Butterfly) a moving, first-person account by Jean-Dominique Bauby, former Editor-in-Chief of the French magazine Elle and a victim of a basilar artery stroke. The locked-in syndrome had already been depicted in Alexandre Dumas’ novel The Count of Monte Cristo, when he created Monsieur Noirtier de Villefort. Dumas described his character as a “corpse with living eyes” (188). Caplan described the "top of the basilar syndrome” and attributed it to embolic occlusion of the distal basilar artery producing ischemia of the rostral brainstem and the posterior cerebral artery territories (35).

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