Current Opinions on Optimal Management of Basilar Artery Occlusion: After the BEST of BASICS Survey

Abstract

BACKGROUND The best management of basilar artery occlusion (BAO) remains uncertain. The BASICS (Basilar Artery International Cooperation Study) and the BEST (Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment) trials reported neutral results. We sought to understand physicians’ approaches to BAOs and whether further BAO randomized controlled trials were warranted. METHODS We conducted an online international survey from January to March 2022 to stroke neurologists and neurointerventionalists. Survey questions were designed to examine clinical and imaging parameters under which clinicians would offer (or rescind) a patient with BAO to endovascular therapy (EVT) or best medical management versus enrollment into a randomized clinical trial. RESULTS Of >3002 invited participants, 1245 responded (41.4% response rate) from 73 countries, including 54.7% stroke neurologists and 43.6% neurointerventionalists. More than 95% of respondents would offer EVT to patients with BAO, albeit in various clinical circumstances. There were 70.0% of respondents who indicated that the BASICS and BEST trials did not change their practice. Only 22.1% of respondents would perform EVT according to anterior circulation occlusion criteria. The selection of patients for BAO EVT by clinical severity, timing, and imaging modality differed according to geography, specialty, and country income level. Over 80% of respondents agreed that further randomized clinical trials for BAO were warranted. Moreover, 45.6% of respondents indicated they would find it acceptable to enroll all trial‐eligible patients into the medical arm of a BAO trial, whereas 26.3% would not enroll. CONCLUSION Most stroke physicians continue to believe in the efficacy of EVT in selected patients with BAO in spite of BEST and BASICS. There is no consensus on which selection criteria to use, and few clinicians would use anterior circulation occlusion criteria for BAOs. Further randomized clinical trials for BAO are warranted.

Endovascular versus Medical Management of Acute Basilar Artery Occlusion: A Systematic Review and Meta-Analysis of the Randomized Controlled Trials

“…17,18 Perhaps as a result of the neutral trial results, BEST and BASICS provided the foundations to reinforce the concept of equipoise regarding EVT versus MM management of BAO patients. 10,11 BA-OCHE and ATTENTION reinforced consecutive enrolment following the neutral results of BEST and BASICS, resulting in a high inclusion of eligible patients with BAO. In ATTENTION, 342 out of 507 screened patients were enrolled in 1 year compared to 300 patients in 8 years in BASICS.…”

“…Patients with posterior circulation stroke were underrepresented in these trials [ 8 , 9 ]. The efficacy and safety of EVT in posterior circulation stroke has been debated [ 10 , 11 ]. Posterior circulation strokes, particularly those due to acute basilar artery occlusion (BAO), are devastating with high morbidity and mortality rates reaching up to 83%–96% in the absence of reperfusion [ 12 , 13 ].…”

“…8,9 The efficacy and safety of EVT in posterior circulation stroke has been debated. 10,11 Posterior circulation strokes, particularly those due to acute basilar artery occlusion (BAO), are devastating with high morbidity and mortality rates reaching up to 83%-96% in the absence of reperfusion. 12,13 EVT was reported with good clinical outcomes in acute BAO with rates of favorable functional outcome (modified Rankin Scale [mRS] score 0-3) at 90 days ranging between 32% to 40% in two prospective studies.…”

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

“…In patients with symptomatic LVO, if one is presented with a good NCCT in a late window (ie, little early ischemic changes), this raises the question of the reliability of time, particularly in patients with unwitnessed or unknown onset of stroke. Because the notion of time may not be reliable, taking an additional 20 minutes to treat the patient (who may be a fast progressor) 44 may be unacceptable if it can be prevented.…”

“…As it was not possible to dissect response by center, responses from multiple persons from the same center may overestimate (or underestimate) the availability of imaging resources. This survey did not address late window imaging selection for basilar artery occlusion patients to EVT, 44 therefore these findings are not generalizable to the posterior circulation. In ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) 45 and BAOCHE (Basilar Artery Occlusion Chinese Endovascular Trial), 46 patients presenting with basilar artery occlusion were selected mainly by CT with PC ASPECTS in the late window up to 24 hours from estimated symptom onset.…”