Incidence, predictors, and outcomes of malignant cerebral edema after acute basilar artery occlusion thrombectomy

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BACKGROUND: Malignant cerebral edema (MCE) following basilar artery occlusion (BAO) thrombectomy is a critical, yet understudied, complication. OBJECTIVE: To investigate the incidence, predictors, and clinical impact of MCE in patients with BAO after endovascular thrombectomy (EVT). METHODS: In this retrospective analysis of the national multicenter PERSIST Registry (2422 patients with BAO treated with EVT recruited from 65 Chinese centers, 2015-2022), MCE was defined as Jauss score ≥4 on follow-up imaging. Multivariable logistic regression identified predictors of MCE and its association with 90-day outcomes. A favorable outcome was defined as achieving a modified Rankin Scale score of 0-3 at 90 days. RESULTS: A total of 1883 patients who met the eligibility requirements were included. MCE occurred in 39.6% (746/1883) of patients. Independent predictors included admission systolic blood pressure ≥160 mm Hg (aOR=1.26, 95% CI 1.02 to 1.54), prolonged procedure time (aOR=1.01, 95% CI 1.01 to 1.01), BATMAN score ≥7 (aOR=0.68, 95% CI 0.55 to 0.84), and vertebral V4 occlusion (vs proximal BA: aOR=0.68, 95% CI 0.52 to 0.89). Successful reperfusion reduced MCE risk (aOR=0.57, 95% CI 0.42 to 0.75). Diabetes mellitus exhibited an inverse association (aOR=0.78, 95% CI 0.61 to 0.99). MCE predicted lower odds of favorable outcome (aOR=2.41, 95% CI 1.94 to 3.01; P<0.001) and higher mortality (aOR=1.85, 95% CI 1.51 to 2.27; P<0.001) at 90 days. CONCLUSIONS: MCE complicates 39.6% of patients with BAO after EVT and portends catastrophic outcomes despite successful recanalization. Shortening the procedure time, increasing the likelihood of first-pass success, and optimal admission blood pressure management might be targets to decrease MCE for patients with BAO undergoing EVT.

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