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Medical Hypothesis
November 16, 2015

Time window for recanalization in basilar artery occlusion
Speculative synthesis

Perttu J. Lindsberg, MD, Johanna Pekkola, MD, Daniel Strbian, MD, MSc (Stroke Med), Tiina Sairanen, MD, MSc (Stroke Med), Heinrich P. Mattle, MD, and Gerhard Schroth, MDAuthors Info & Affiliations
November 17, 2015 issue
85 (20) 1806-1815
https://doi.org/10.1212/WNL.0000000000002129
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Abstract

Basilar artery occlusion (BAO) is one of the most devastating forms of stroke and few patients have good outcomes without recanalization. Most centers apply recanalization therapies for BAO up to 12–24 hours after symptom onset, which is a substantially longer time window than the 4.5 hours used in anterior circulation stroke. In this speculative synthesis, we discuss recent advances in BAO treatment in order to understand why and under which circumstances longer symptom duration might not necrotize the brainstem and turn therapeutic attempts futile. We raise the possibility that distinct features of the posterior circulation, e.g., highly developed, persistent collateral arterial network, reverse filling of the distal basilar artery, and delicate plasma flow siding the clot, might sustain brittle patency of brainstem perforators in the face of stepwise growth of the thrombus. Meanwhile, the tissue clock characterizing the rapid necrosis of a typical anterior circulation penumbra will not start. During this perilous time period, recanalization at any point would salvage the brainstem from eventual necrosis caused by imminent reinforcement and further building up of the clot.

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Information & Authors

Information

Published In

Neurology®
Volume 85 • Number 20 • November 17, 2015
Pages: 1806-1815
PubMed: 26574535

Copyright

© 2015 American Academy of Neurology.

Publication History

Received: March 25, 2015
Accepted: July 20, 2015
Published online: November 16, 2015
Published in print: November 17, 2015

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Disclosure

P. Lindsberg reports no commercial disclosures. Financial resources from governmental and nonprofit foundations have been received from the Helsinki University Central Hospital governmental subsidiary funds for clinical research, the Finnish Academy, the Sigrid Jusélius Foundation, the Maire Taponen Foundation, and the Paavo Nurmi Foundation. J. Pekkola reports no disclosures relevant to the manuscript. D. Strbian reports no commercial disclosures. Financial resources from governmental and nonprofit foundations have been received from the Helsinki University Central Hospital governmental subsidiary funds for clinical research and the Finnish Medical Foundation. T. Sairanen has received travel expenses to a scientific conference with the support of Boehringer Ingelheim Pharmaceuticals Inc. Financial resources from nonprofit foundations have been received from the Maire Taponen Foundation. H. Mattle has received outside of the submitted work honoraria for speaking or advisory boards from the following companies: speaker's fees from Bayer, Biogen, Covidien, Daiichi Sankyo, Neuravi, Novartis, Sanofi/Genzyme, Serono, and Teva; and consulting fees from AstraZeneca, Bayer, Biogen, Boehringer Ingelheim, Covidien, Daiichi Sankyo, Genzyme, Merck-Serono, Neuravi, Novartis, Pfizer, Sanofi/Genzyme, Servier, and Teva. G. Schroth reports no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Perttu J. Lindsberg, MD
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Medical journal DUODECIM, Assistant Editor, since 2000
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Helsinki University Hospital District research funding 2013-2015
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Sigrid Jus?lius foundation 2013-2015
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Johanna Pekkola, MD
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Daniel Strbian, MD, MSc (Stroke Med)
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) The Helsinki University Central Hospital (HUCH) governmental subsidiary (EVO) funds for clinical research, minor role, 2015-2016. (2) The Finnish Medical Foundation, funds for clinical research 2014-2016
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
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Tiina Sairanen, MD, MSc (Stroke Med)
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
received consultancy fees from Boehringer Ingelheim; participation in scientific meetings as representative of Dept. neurology, HUCH funded by Bayer Inc.,Orion Pharma inc., Teva Inc .
Editorial Boards:
1.
Member of the Editorial Board of Experimental & Translational Stroke Medicine
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Heinrich P. Mattle, MD
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
Servier, St. Jude Medical, Neuravi
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Servier, Sanofi, Bayer, Biogen, B?hringer-Ingelheim, Merck, MSD, Neuravi, Teva, St. Jude Medical, Novartis, Pfizer
Editorial Boards:
1.
Stroke, International Journal of Stroke, Swiss Medical Weekly, Practical Neurology
Patents:
1.
NONE
Publishing Royalties:
1.
Neurologie, Kurzlehrbuch Neurologie, Neurology, Fundamentals of Neurology, DGN Leitlinien, all Thieme Publisher, Stuttgart
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Servier, Sanofi, Bayer, Biogen, Genzyme, Merck, MSD, Neuravi, Pfizer, Teva, AGA Medical, Novartis, Pfizer, Daiichi-Sankyo
Speakers' Bureaus:
1.
Servier, Sanofi, Bayer, Biogen, Merck, Teva, St. Jude Medical, Novartis, Pfizer, B?hringer-Ingelheim,Daiichi-Sankyo
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Servier, Sanofi, Bayer, Biogen, Merck, Teva, St. Jude Medical, Novartis, Pfizer, Daiichi-Sankyo
Research Support, Government Entities:
1.
Swiss National Science Foundation
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Swiss Heart Foundation
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author
Gerhard Schroth, MD
From Neurology, Clinical Neurosciences (P.J.L., D.S., T.S.), and Research Programs Unit, Molecular Neurology (P.J.L.), Biomedicum Helsinki, University of Helsinki and Helsinki University Hospital; the Department of Radiology (J.P.), HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Finland; and the Departments of Neurology (H.P.M.) and Diagnostic and Interventional Neuroradiology (G.S.), Inselspital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
View all articles by this author

Notes

Correspondence to Dr. Lindsberg: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Drs. Lindsberg and Schroth conceptualized and designed the study. Drs. Schroth, Mattle, Pekkola, Strbian, and Sairanen collected data and participated in data analysis. Drs. Schroth and Pekkola analyzed all radiologic data. Dr. Lindsberg made the first draft and all others wrote parts of it and/or reviewed it critically.

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