High-Resolution Disconnectome Predicts Outcome and Response to Thrombectomy in Basilar Artery Occlusion

BACKGROUND: Acute basilar artery occlusion causes devastating strokes. Despite the benefit of endovascular treatment, the optimal management remains controversial in specific subgroups, particularly patients with mild deficits, and would benefit from robust prognostic tools. Given the dense white matter networks within the posterior fossa, we tested whether quantifying disconnections from acute diffusion-weighted imaging could improve outcome prediction and identify responders to recanalization compared with conventional metrics. METHODS: We conducted a secondary analysis of a prospective multicenter stroke registry in France, including consecutive patients (2017-2024) with basilar artery occlusion and admission magnetic resonance imaging. Ultra-high-resolution diffusion magnetic resonance imaging was acquired in 2 healthy participants to build normative tractograms with optimized posterior fossa quality. Patient infarcts delineated on diffusion-weighted imaging were projected onto these tractograms to estimate disconnected fiber volume. The primary outcome was 90-day modified Rankin Scale score (0-3 versus 4-6). Predictive performance of disconnected fiber volume was compared with baseline National Institutes of Health Stroke Scale (NIHSS), infarct volume, and posterior circulation Alberta Stroke Program Early Computed Tomography Score using logistic regressions and area under the receiver operating characteristic curves. Ordinal regressions tested associations between dichotomized disconnection status and the full modified Rankin Scale spectrum, stratified by recanalization status. Analyses were repeated in patients with an NIHSS score ≤10. RESULTS: =0.0127). Patients without significant disconnection had better outcomes across the full modified Rankin Scale spectrum (odds ratio, 0.12 [95% CI, 0.065-0.204]) and derived greater benefit from successful recanalization (odds ratio, 0.33 [95% CI, 0.15-0.70]). In patients with an NIHSS score ≤10 (n=102), disconnected fiber volume remained the strongest predictor (area under the receiver operating characteristic curves of 0.83). CONCLUSIONS: Disconnected fiber volume derived indirectly is a robust prognostic marker of basilar artery occlusion outcomes that outperforms conventional predictors and may support future treatment decisions after prospective validation. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT03776877.