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

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.