Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion

Abstract

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.

Predictors of Early Neurological Deterioration in Stroke Due to Vertebrobasilar Occlusion

“…The rate of ENDs that occurred in the two groups was similar (24.1 vs. 25.8%, p = 0.945). Functional outcome, represented by 3 months mRS, was poorer (5 [2][3][4][5] vs. 2 [1][2][3][4][5], p < 0.001) in the primary EVT group.…”

“…Among imaging parameters, more truncal-type occlusions (77.8 vs. 47.0%, p < 0.001) and incomplete occlusions (33.3 vs. 10.6%, p = 0.001) were seen, with a higher proportion of intracranial atherosclerotic occlusions (71.3 vs. 47.0%, p < 0.001) in the MM group. Larger initial infarct volumes represented by PC-ASPECTS (8 [7][8][9] vs. 9 [8][9][10], p < 0.001), poorer collateral status represented by BATMAN collateral score (5 [3-6] vs. 6.5 [5][6][7][8], p < 0.001), and absent fetal-type posterior cerebral arteries (PCA) were observed in the primary EVT group.…”

“…Identification of factors predictive of END in VBO patients with medical management may provide keys to expand the pool of patients that may benefit from EVT. Currently, there is no successful clinical trial that shows the superiority of EVT for VBO (5), but it is likely that through reasonable patient selection, EVT for VBO will result in good outcomes (6). However, patient selection by strict NIHSS scores and time parameters is more difficult to apply in VBO for a few reasons.…”

Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices

“…There is much uncertainty related to treating posterior circulation stroke caused by basilar artery occlusion (BAO) with mechanical thrombectomy. The Basilar Artery International Cooperation study (BASICS) and endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion (BEST) clinical trials are the only randomized clinical trials to date designed specifically to study the outcome of EVT in patients with basilar stroke within 6-8 h of onset (84,85). However, the benefits of thrombectomy in the anterior circulation have not been replicated in basilar occlusions.…”

Association of Regular Thrombus Surface Phenotype With Complete Recanalization in First-Line Contact Aspiration Thrombectomy for Basilar Artery Occlusion

“…Endovascular thrombectomy (EVT) is the standard of care for anterior circulation large vessel occlusion (acLVO) demonstrating high rates of recanalization and favorable outcome (2). In contrast, randomized controlled trials have not confirmed a benefit of EVT and best medical management (BMM) compared with BMM alone for patients with BAO (3,4).…”