BACKGROUNDThe effectiveness of endovascular therapy in patients with stroke caused by basilarartery occlusion has not been well studied. METHODSWe randomly assigned patients within 6 hours after the estimated time of onset of a stroke due to basilar-artery occlusion, in a 1:1 ratio, to receive endovascular therapy or standard medical care. The primary outcome was a favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 to 6, with 0 indicating no disability, 3 indicating moderate disability, and 6 indicating death) at 90 days. The primary safety outcomes were symptomatic intracranial hemorrhage within 3 days after the initiation of treatment and mortality at 90 days. RESULTSA total of 300 patients were enrolled (154 in the endovascular therapy group and 146 in the medical care group). Intravenous thrombolysis was used in 78.6% of the patients in the endovascular group and in 79.5% of those in the medical group. Endovascular treatment was initiated at a median of 4.4 hours after stroke onset. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (risk ratio, 1.18; 95% confidence interval [CI], 0.92 to 1.50). Symptomatic intracranial hemorrhage occurred in 4.5% of the patients after endovascular therapy and in 0.7% of those after medical therapy (risk ratio, 6.9; 95% CI, 0.9 to 53.0); mortality at 90 days was 38.3% and 43.2%, respectively (risk ratio, 0.87; 95% CI, 0.68 to 1.12). CONCLUSIONSAmong patients with stroke from basilar-artery occlusion, endovascular therapy and medical therapy did not differ significantly with respect to a favorable functional outcome, but, as reflected by the wide confidence interval for the primary outcome, the results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion. (Funded by the Dutch Heart Foundation and others; BASICS ClinicalTrials.gov number, NCT01717755; Netherlands Trial Register number, NL2500.

Background and purpose The role of non-invasive methods in the evaluation of collateral circulation has yet to be defined. We hypothesized that a favorable pattern of leptomeningeal collaterals, as identified by computed tomography angiography (CTA), correlates with improved outcomes. Methods Data from a prospective cohort study at two university based hospitals where CTA was systematically performed in the acute phase of ischemic stroke were analyzed. Patients with complete occlusion of the intracranial internal carotid artery (ICA) and/or the middle cerebral artery (MCA-M1 or M2 segments) were selected. Leptomeningeal collateral pattern was graded as a three category ordinal variable (less, equal, or greater than the unaffected contralateral hemisphere). Univariate and multivariate analyses were performed to define the independent predictors of good outcome at 6 months (mRS≤2). Results 196 patients were selected. The mean age was 69 ±17 years and the median NIHSS score was 13 (IQR 6-17). In the univariate analysis, age, baseline NIHSS, pre-stroke mRS, ASPECT score, admission blood glucose, history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, site of occlusion, and collateral pattern were predictors of outcome. In the multivariate analysis, age (OR 0.95; 95%CI [0.93-0.98], p=0.001), baseline NIHSS (OR 0.75; [0.69-0.83], p<0.001), pre-stroke mRS (OR 0.41; [0.22-0.76], p=0.01), intravenous r-tPA (OR 4.92; [1.83-13.25], p=0.01), diabetes( OR 0.31; [0.01-0.98], p=0.046) and leptomeningeal collaterals (OR 1.93; [1.06-3.34], p=0.03) were identified as independent predictors of good outcome. Conclusion Consistent with angiographic studies, leptomeningeal collaterals on CTA are also a reliable marker of good outcome in ischemic stroke.

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