Usefulness of CT angiography for therapeutic decision making in thrombolyzing intubated patients with suspected basilar artery thrombosis

Kay W P Ng, N Venketasubramanian, Leonard L L Yeo, Aftab Ahmad, Pei K Loh, Raymond C S Seet, Hock L Teoh, Bernard P L Chan, Vijay K Sharma
Journal of Neuroimaging: Official Journal of the American Society of Neuroimaging 2012, 22 (4): 351-4

BACKGROUND AND AIMS: Acute ischemic stroke (AIS) due to basilar artery thrombosis (BAT) causes high mortality and severe disability. Early neurological assessment and timely thrombolysis might improve outcome. BAT is difficult to diagnose due to wide spectrum of presentation and decreased conscious level. Emergency physicians often intubate BAT patients with airway compromise before arrival of stroke neurologist. We evaluated role of computerized tomography (CT) angiography (CTA) of brain and cervical arteries in early diagnosis of acute BAT in intubated patients and facilitating decision for thrombolysis.

METHODS: Consecutive AIS patients presenting between 2007 and 2009 within 6 hours of symptom onset, with sudden deterioration in conscious level and intubation before assessment by neurologist, were included. All patients underwent brain CT and CTA. Outcomes were assessed at 3 months.

RESULTS: Thrombolytic therapy, mainly intravenous tissue plasminogen activator (IV-TPA), was administered to 161 (8.4%) of 1,917 AIS patients during the study period. Acute BAT contributed 10.9% of our cohort. CTA was performed in 152 (94.4%) patients and the rest were excluded due to their impaired renal functions. Five patients (3 males, mean age 72 years) presenting with acute obtundation and airway compromise were intubated, sedated, and paralyzed before assessment by neurologist. CTA showed BAT in all. IV-TPA was initiated at 213 ± 59 minutes in 4 patients while 1 received intraarterial thrombolysis at 13 hours. There was no intracranial hemorrhage. Mean length of hospital stay was 11.8 days. Despite severe stroke at presentation, good functional recovery at 3 months (modified Rankin scale [mRS] 1) occurred in 2 patients; mRS 4 in 1, and 2 died.

CONCLUSION: In patients with BAT, intubated before assessment by neurologist, CTA might help in confirming the diagnosis and facilitating therapeutic decision making for initiating thrombolysis.

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