Thrombus enhancement as a predictor of embolic in acute basilar artery occlusion

Thrombus enhancement sign (TES) is a potential imaging biomarker for differentiating embolic large vessel occlusion (embo-LVO) from intracranial atherosclerosis-related LVO (ICAS-LVO) in basilar artery occlusion (BAO). This study evaluates the association between TES and BAO etiology and its predictive value in distinguishing embo-LVO from ICAS-LVO. We conducted a prospective, two-center cohort study of acute ischemic stroke (AIS) patients with BAO who underwent EVT between January 2020 and September 2024. TES was assessed using thin-section maximum intensity projection (TS-MIP) CTA. Patients were classified as embo-LVO or ICAS-LVO based on post-EVT angiography. Logistic regression, receiver operator characteristic curve (ROC) and DeLong test were used to assess TES's diagnostic accuracy. Among 107 patients, TES was detected in 56.1% (60/107). TES was significantly more frequent in embo-LVO (85.2%) than in ICAS-LVO (17.4%) (p < 0.001). TES significantly associated with embo-LVO (OR, 16.136; 95% CI 4.672-55.733; p < 0.001). The area under the curve (AUC) of TES for embo-LVO was 0.839, outperforming distal BAO (AUC = 0.714, p = 0.02). Combining TES with distal BAO improved predictive accuracy (AUC = 0.883). TES is a reliable marker for identifying embo-LVO in BAO and enhancing endovascular treatment strategies for AIS.