Endovascular treatment for basilar artery occlusion: A systematic review and meta-analysis

Meta-analysis of clinical and safety profiles after reperfusion therapy in acute posterior circulation strokes: insights and implications

BACKGROUND

Posterior circulation stroke (PCS) accounts for approximately 20% of all acute ischemic strokes. The optimal reperfusion therapy for PCS management remains uncertain.

PURPOSE

To evaluate the prevalence and outcomes of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and bridging therapy in PCS patients.

MATERIAL AND METHODS

We conducted a meta-analysis of 19 studies examining reperfusion therapy outcomes in PCS patients, including 9765 individuals. We pooled prevalence data and assessed associations between reperfusion therapies and clinical, safety, and recanalization outcomes using random-effects models.

RESULTS

The pooled prevalence of reperfusion therapies post-acute PCS was 39% for IVT, 54% for EVT, and 48% for bridging therapy. EVT was associated with significantly higher odds of favorable functional outcomes (modified Rankin Score [mRS] 0-3) at 90 days compared to standard medical therapy (odds ratio [OR] = 5.68; 95% confidence interval [CI]=2.07-15.59; P = 0.001). Conversely, bridging therapy was linked to reduced odds of favorable functional outcomes at 90 days compared to EVT (OR = 0.35; 95% CI=0.26-0.47; P < 0.001). Bridging therapy was also significantly associated with lower odds of good functional outcomes (mRS 0-2) (OR = 0.25; 95% CI=0.11-0.54; P < 0.001), reduced risk of symptomatic intracranial hemorrhage (OR = 0.26; 95% CI=0.07-0.68; P = 0.009), lower mortality (OR = 0.13; 95% CI=0.04-0.44; P = 0.001), and less successful recanalization (OR = 0.35; 95% CI=0.13-0.94; P = 0.038) relative to EVT.

CONCLUSION

Our meta-analysis underscores the favorable outcomes associated with EVT in PCS cases. With notable reperfusion rates, understanding factors influencing PCS outcomes can inform patient selection and prognostic considerations.

Overview of systematic reviews comparing endovascular to best medical treatment for large-vessel occlusion acute ischaemic stroke: an umbrella review

Background

The literature on endovascular treatment (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) has been rapidly increasing after the publication of positive randomized-controlled clinical trials (RCTs) and a plethora of systematic reviews (SRs) showing benefit compared to best medical therapy (BMT) for LVO.

Objectives

An overview of SRs (umbrella review) and meta-analysis of primary RCTs were performed to summarize the literature and present efficacy and safety of EVT.

Design and methods

MEDLINE via Pubmed, Embase and Epistemonikos databases were searched from January 2015 until 15 October 2023. All SRs of RCTs comparing EVT to BMT were included. Quality was assessed using Risk of Bias in Systematic Reviews scores and the RoB 2 Cochrane Collaboration tool, as appropriate. GRADE approach was used to evaluate the strength of evidence. Data were presented according to the Preferred Reporting Items for Overviews of Reviews statement. The primary outcome was 3-month good functional outcome [modified Rankin scale (mRS) score 0-2].

Results

Three eligible SRs and 4 additional RCTs were included in the overview, comprising a total of 24 RCTs, corresponding to 5968 AIS patients with LVO (3044 randomized to EVT versus 2924 patients randomized to BMT). High-quality evidence shows that EVT is associated with an increased likelihood of good functional outcome [risk ratio (RR) 1.78 (95% confidence interval (CI): 1.54-2.06); 166 more per 1000 patients], independent ambulation [mRS-scores 0-3; RR 1.50 (95% CI: 1.37-1.64); 174 more per 1000 patients], excellent functional outcome [mRS-scores 0-1; RR 1.90 (95% CI: 1.62-2.22); 118 more per 1000 patients] at 3 months. EVT was associated with reduced 3-month mortality [RR 0.81 (95% CI: 0.74-0.88); 61 less per 1000 patients] despite an increase in symptomatic intracranial haemorrhage [sICH; RR 1.65 (95% CI: 1.23-2.21); 22 more per 1000 patients].

Conclusion

In patients with AIS due to LVO in the anterior or posterior circulation, within 24 h from symptom onset, EVT improves functional outcomes and increases the chance of survival despite increased sICH risk.

Registration

PROSPERO Registration Number CRD42023461138.

Endovascular thrombectomy for basilar-artery occlusion: A meta-analysis with trial sequential analysis

Background and purpose

Basilar-artery occlusion (BAO) usually accounts for devastating neurologic sequelae, poor prognosis, and even death. While endovascular thrombectomy (EVT) is the most successful treatment for anterior circulation stroke with large vessel occlusion, its effectiveness in treating acute BAO is still debatable. Our aim is to compare the efficacy and safety between EVT and conservative medical treatment (CMT) in BAO.

Methods

Up until May 2022, relevant literature was gathered using searches in Embase, PubMed, and the Cochrane Library. The primary outcomes were defined as good functional outcome (modified Rankin Scale 0-2) and favorable functional outcome (modified Rankin Scale 0-3) at 3 months between EVT and CMT groups. The secondary outcomes included mortality at 3 months, symptomatic intracerebral hemorrhage (ICH), and any ICH.

Results

Eight studies involving 3733 patients with BAO were enrolled 2573 individuals underwent EVT, and the remaining 1160 patients received CMT. Compared with CMT, EVT achieved more favorable functional outcome (odds ratio (OR) 1.26, 95% CI 1.03-1.55, I2 = 54%, p = 0.05) in BAO. The good functional outcome showed a similar tendency (OR 1.23, 95% CI 0.97-1.57, I2 = 63%, p = 0.02) as well. EVT decreased mortality at 3 months (OR 0.81, 95% CI 0.70-0.93, I2 = 31 %, p = 0.19), although having a tendency to cause symptomatic ICH (OR 2.91, 95% CI 1.38-6.18, I2 = 22 %, p = 0.27).

Conclusions

EVT in BAO provides superior functional outcomes and less mortality compared with CMT. Even though EVT has the propensity to cause symptomatic ICH, EVT nevertheless improved posterior circulation stroke.

Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.

United States regulatory approval of medical devices used for endovascular neurosurgery: A two-decade review of FDA regulatory files

BACKGROUND

The evolution of neuroendovascular technologies has progressed substantially. Over the last two decades, the introduction of new endovascular devices has facilitated treatment for more patients, and as a result, the regulatory environment concerning neuroendovascular devices has evolved rapidly in response.

OBJECTIVE

To examine trends in the approval of neuroendovascular devices by the United States Food and Drug Administration (FDA) over the last 20 years.

METHODS

Open-access US FDA databases were queried between January 2000 and December 2022 for all devices approved by the Neurological Devices Advisory Committee. Neuroendovascular devices were manually classified and grouped by category. Device approval data, including approval times, approval pathway, and presence of predicate devices, were examined.

RESULTS

A total of 3186 neurological devices were approved via various US FDA pathways during the study period. 320 (10.0%) corresponded to neuroendovascular devices, of which 301 (94.1%) were approved via the 510(k) pathway. The percentage of 510(k) pathway neuroendovascular devices increased from 6.9% to 14.3% of all neuro devices before and after 2015, respectively. There was an increase in approval times for neuroendovascular devices cleared after 2015.

CONCLUSION

Over the last two decades, the neuroendovascular device armamentarium has rapidly expanded, especially after positive stroke trials in 2015. Regulatory approval times are significantly affected by device category, generation, company size, and company location, and a vast majority are approved by the 510(k) pathway. These results can guide further innovation in the endovascular device space and may act as a roadmap for future regulatory planning.

A meta-analysis and systematic review of endovascular thrombectomy versus medical management for acute basilar artery occlusion

OBJECTIVE

Acute basilar artery occlusion (BAO) is a devastating neurologic event. As endovascular thrombectomy (EVT) became more prevalent for anterior circulation strokes, investigations were conducted in the posterior circulation. Its success in improving outcomes compared to standard medical therapy (SMT) after BAO has been debated.

METHODS

We conducted a systematic review and meta-analysis of all randomized controlled trials (RCTs) and observational cohort studies evaluating EVT compared to SMT in acute BAO. We queried PubMed, Embase, and Cochrane for studies. Primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 3). We analyzed studies for risk of bias (ROB) and calculated pooled risk ratios (RRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (95%CI) using the random effects model for our primary outcome and secondary positive outcomes and harms.

RESULTS

We identified four RCTs (991 patients randomized) and three cohort studies (1030 patients treated in-trial) that fit inclusion criteria. Three RCTs had low ROB, one had serious ROB. One cohort study had high ROB, one had moderate ROB, and one had low ROB. EVT was statistically significantly more associated with good functional outcome than SMT in RCTs (RR=1.54, 95%CI=1.16-2.04, p = 0.003) and trended towards significance in cohort studies (RR=2.64, 95%CI=0.87-8.00, p = 0.09). Mean mRS at 90 days was lower in EVT patients in RCTs (MD=-0.65, 95%CI=-1.07--0.22, p = 0.003) though not cohort studies (MD =-0.84, 95%CI=-2.48-0.79, p = 0.31). Symptomatic intracerebral hemorrhage (sICH) was statistically significantly associated with EVT in RCTs (OR=6.36, 95%CI=2.24-18.07, p < 0.001) and statistically non-significantly in cohort studies (OR=4.51, 95CI=1.00-20.33, p = 0.05). Mortality at 90 days was statistically lower with EVT than with SMT in both RCTs (OR=0.76, 95%CI=0.65-0.88, p < 0.001) cohort studies (OR=0.36, 95%CI=0.26-0.50, p < 0.001) CONCLUSION: EVT is associated with greater rates of good functional outcomes and lower rates of death and disability despite higher rates of periprocedural sICH.

Reocclusion after successful endovascular treatment in acute ischemic stroke: systematic review and meta-analysis

BACKGROUND

Endovascular treatment (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO).

OBJECTIVE

To systematically review the available data on: (1) incidence, predictors, and outcomes of patients with reocclusion after successful EVT for AIS and, (2) the characteristics, complications, and outcomes of patients with reocclusion treated with repeated EVT (rEVT) within 30 days of the first procedure.

METHODS

PubMed was searched (between January 2012 and April 2021) to identify studies reporting reocclusion following successful EVT (Thrombolysis in Cerebral Infarction ≥2b) in patients with AIS due to LVO. Pooled incidence of reocclusion per 100 patients with successful recanalization following EVT was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Extracted incidences of reocclusion according to etiology and use of intravenous thrombolysis were pooled using random-effects meta-analytic models.

RESULTS

A total of 840 studies was identified and seven studies qualified for the quantitative analysis, which described 91 same-vessel reocclusions occurring within the first 7 days after treatment among 2067 patients (4.9%; 95% CI 3% to 7%, I2=70.2%). Large vessel atherosclerosis was associated with an increased risk of reocclusion (OR=3.44, 95% CI 1.12 to 10.61, I2=50%). We identified 90 patients treated with rEVT for recurrent LVO, described in five studies. The rates of procedural complications, mortality, and unfavorable functional outcome at 3 months were 18.0%, 18.9%, and 60.3%, respectively.

CONCLUSION

In cohorts of patients with AIS due to LVO, 5% of patients experienced reocclusion within 7 days after successful EVT. Repeated EVT can be a safe and effective treatment for selected patients with reocclusion.

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16–2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08–3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26–3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36–25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50–5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65–0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.

A Case of Sudden Cardiac Arrest After Brainstem Infarction

Research on the causes of sudden cardiac arrest (CA) after ischemic stroke, especially disruption of the autonomic nervous system's central control, has recently focused more on the widespread cortical and subcortical network than on autonomic circuits at the spinal and brainstem level. However, no clinical case of sudden CA requiring cardiopulmonary resuscitation (CPR) after brainstem infarction has been reported. We report a case of a 78-year-old woman who died suddenly from a brainstem infarction. Her husband heard a falling sound and found her unresponsive and lying with agonal breathing. The initial cardiac rhythm was pulseless electrical activity confirmed by emergency medical technicians. Recovery of spontaneous circulation was achieved after CPR. Basilar artery occlusion was shown on computed tomography, but no other findings that could have caused CA were found. Targeted temperature management was initiated, but she died on hospital day 22. Brainstem infarction may cause sudden CA; therefore, definitive treatment may achieve better outcomes.

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

BACKGROUND AND PURPOSE

The optimal management of patients with acute basilar artery occlusion (BAO) is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared to medical management (MM) for acute BAO through a meta-analysis of randomized controlled trials (RCTs).

METHODS

We performed a systematic review and meta-analysis of RCTs of patients with acute BAO. We analyzed the pooled effect of EVT compared to MM on the primary outcome (modified Rankin Scale [mRS] of 0-3 at 3 months), secondary outcome (mRS 0-2 at 3 months), symptomatic intracranial hemorrhage (sICH), and 3-month mortality rates. For each study, effect sizes were computed as odds ratios (ORs) with random effects and Mantel-Haenszel weighting.

RESULTS

Four RCTs met inclusion criteria including 988 patients. There were higher odds of mRS of 0-3 at 90 days in the EVT versus MM group (45.1% vs. 29.1%, OR 1.99, 95% confidence interval [CI] 1.04-3.80; P=0.04). Patients receiving EVT had a higher sICH compared to MM (5.4% vs. 0.8%, OR 7.89, 95% CI 4.10-15.19; P<0.01). Mortality was lower in the EVT group (35.5% vs. 45.1%, OR 0.64, 95% CI 0.42-0.99; P=0.05). In an analysis of two trials with BAO patients and National Institutes of Health Stroke Scale (NIHSS) <10, there was no difference in 90-day outcomes between EVT versus MM.

CONCLUSION

In this systematic review and meta-analysis, EVT was associated with favorable outcome and decreased mortality in patients with BAO up to 24 hours from stroke symptoms compared to MM. The treatment effect in BAO patients with NIHSS <10 was less certain. Further studies are of interest to evaluate the efficacy of EVT in basilar occlusion patients with milder symptoms.

Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion

BACKGROUND

Data from trials investigating the effects and risks of endovascular thrombectomy for the treatment of stroke due to basilar-artery occlusion are limited.

METHODS

We conducted a multicenter, prospective, randomized, controlled trial of endovascular thrombectomy for basilar-artery occlusion at 36 centers in China. Patients were assigned, in a 2:1 ratio, within 12 hours after the estimated time of basilar-artery occlusion to receive endovascular thrombectomy or best medical care (control). The primary outcome was good functional status, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]), at 90 days. Secondary outcomes included a modified Rankin scale score of 0 to 2, distribution across the modified Rankin scale score categories, and quality of life. Safety outcomes included symptomatic intracranial hemorrhage at 24 to 72 hours, 90-day mortality, and procedural complications.

RESULTS

Of the 507 patients who underwent screening, 340 were in the intention-to-treat population, with 226 assigned to the thrombectomy group and 114 to the control group. Intravenous thrombolysis was used in 31% of the patients in the thrombectomy group and in 34% of those in the control group. Good functional status at 90 days occurred in 104 patients (46%) in the thrombectomy group and in 26 (23%) in the control group (adjusted rate ratio, 2.06; 95% confidence interval [CI], 1.46 to 2.91, P<0.001). Symptomatic intracranial hemorrhage occurred in 12 patients (5%) in the thrombectomy group and in none in the control group. Results for the secondary clinical and imaging outcomes were generally in the same direction as those for the primary outcome. Mortality at 90 days was 37% in the thrombectomy group and 55% in the control group (adjusted risk ratio, 0.66; 95% CI, 0.52 to 0.82). Procedural complications occurred in 14% of the patients in the thrombectomy group, including one death due to arterial perforation.

CONCLUSIONS

In a trial involving Chinese patients with basilar-artery occlusion, approximately one third of whom received intravenous thrombolysis, endovascular thrombectomy within 12 hours after stroke onset led to better functional outcomes at 90 days than best medical care but was associated with procedural complications and intracerebral hemorrhage. (Funded by the Program for Innovative Research Team of the First Affiliated Hospital of USTC and others; ATTENTION ClinicalTrials.gov number, NCT04751708.).

Outcome of endovascular treatment in acute basilar artery occlusion with National Institutes of Health Stroke Scale score 10-19

OBJECTIVE

Authors of this study aimed to investigate the efficacy and safety of endovascular treatment (EVT) versus standard medical treatment (SMT) alone in patients with acute basilar artery occlusion (BAO) and moderate deficit (National Institutes of Health Stroke Scale [NIHSS] score 10-19).

METHODS

Patients with moderate deficit caused by acute BAO in the period from January 2014 to May 2019 were included in the study. The patients were divided into groups based on treatment: EVT plus SMT group or SMT-alone group. The primary outcome was favorable functional outcome (modified Rankin Scale score 0-3) at 90 days, and safety outcomes were symptomatic intracerebral hemorrhage (sICH) and mortality at 90 days.

RESULTS

A total of 173 patients had moderate deficits, 128 of whom had been treated with EVT and 45 with SMT alone. EVT was associated with a significant higher proportion of 90-day favorable outcomes compared with SMT (adjusted odds ratio [aOR] 4.09, 95% CI 1.39-12.04, p = 0.011). Younger age (aOR 0.96, 95% CI 0.92-0.99, p = 0.017), absence of diabetes mellitus (aOR 0.35, 95% CI 0.12-0.99, p = 0.048), higher baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS; aOR 1.48, 95% CI 1.07-2.05, p = 0.018), and modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b-3 (aOR 15.15, 95% CI 3.07-74.72, p = 0.001) were independent factors for a favorable outcome in the EVT group. Rates of mortality and sICH were comparable in the EVT and SMT groups.

CONCLUSIONS

EVT leads to improved outcomes compared to those with SMT alone. Younger age, absence of diabetes mellitus, higher baseline pc-ASPECTSs, and mTICI score of 2b-3 were associated with better functional outcome in the EVT group.

Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: Results From the ATTENTION Multicenter Registry

BACKGROUND

The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO).

METHODS

The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0-3) at 90 days. We also performed a sensitivity analysis with the propensity score matching-based and the instrumental variable-based analysis.

RESULTS

In our primary analysis using the inversed probability of treatment weighting-based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19-1.65]; absolute risk difference, 11.8% [95% CI, 6.9-16.7%]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69-0.88]; absolute risk difference, -10.3% [95% CI, -15.8 to -4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching-based and instrumental variable-based analysis.

CONCLUSION

In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed.

REGISTRATION

URL: www.chictr.org.cn Unique identifier: ChiCTR2000041117.

Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Aims

Whether endovascular treatment (EVT) can further improve the prognosis of patients with posterior circulation ischemic stroke (PCIS) is unclear. This meta-analysis aims to compare the efficacy and safety of PCIS patients treated with EVT plus standard medical treatment (SMT) and SMT alone.

Methods

We systematically searched for relevant randomized controlled trials (RCTs) and prospective cohort trials in MEDLINE, EMBASE, and the Cochrane Library up to February 2022. The primary outcome was favorable functional outcome of the modified Rankin Scale (mRS) with scores of 0-2 or 0-3; secondary outcomes included successful recanalization rate, intracranial hemorrhage (ICH), or symptomatic intracranial hemorrhage (sICH) after treatment and 90-day mortality.

Results

We identified six studies including 1, 385 PCIS patients (957 with EVT plus SMT; 428 with SMT alone). EVT plus SMT substantially improved 90-day functional outcomes compared with SMT alone [mRS score of 0-2: RR=1.95, 95% CI (1.52 - 2.51), P < 0.001; mRS score of 0-3: RR = 1.85, 95% CI (1.49 - 2.30), P < 0.001, respectively]. Moreover, compared with SMT, combined treatment significantly improved the rate of successful recanalization [RR = 5.03, 95% CI (3.96-6.40), P < 0.001] and reduced 90-day mortality [RR = 0.71, 95% CI (0.63-0.79), P < 0.001] despite a higher risk of ICH [RR = 6.13, 95% CI (2.50-15.02), P < 0.001] and sICH [RR = 10.47, 95% CI [2.79-39.32), P = 0.001].

Conclusion

Low-to-moderate evidence from RCTs and non-RCTs showed that increased ICH and sICH risk of EVT plus SMT did not translate to a higher risk of unfavorable outcomes compared with SMT and could even promote independence at 90 days in a real-world cohort.

Endovascular thrombectomy versus standard medical treatment for stroke patients with acute basilar artery occlusion: a systematic review and meta-analysis

BACKGROUND

Whether endovascular thrombectomy (EVT) is superior to standard medical treatment (SMT) for stroke patients with acute basilar artery occlusion (BAO) is uncertain. This systematic review and meta-analysis aimed to compare the safety and efficacy of EVT with SMT for treating BAO patients.

METHODS

Papers were retrieved from PubMed, Embase, and the Cochrane Library databases. The primary outcome of this meta-analysis was favorable functional outcomes at 3 months (defined as a modified Rankin Scale (mRS) score of ≤3). A random effect model was used to calculate risk ratios (RR) with 95% confidence intervals (CIs) per outcome.

RESULTS

Five articles, including two randomized controlled trials (RCTs) and four observational cohort studies, comprising 1484 patients (1024 in the EVT group and 460 in the SMT group), were included in the meta-analysis. The pooled results demonstrated no significant differences between the EVT and SMT groups in achieving favorable functional outcomes at 3 months (RR=1.63, 95% CI 0.90, 2.96; p=0.11). However, patients in the EVT group had higher rates for symptomatic intracerebral hemorrhage (RR=6.22, 95% CI 2.06 to 18.76; p=0.001) but lower mortality at 3 months (RR=0.72, 95% CI 0.56 to 0.91; p=0.007) than patients in the SMT group.

CONCLUSION

Among patients with BAO, EVT and SMT did not differ significantly in achieving favorable functional outcomes at 3 months, but BAO patients treated with EVT might have lower mortality at 3 months. RCTs are warranted to further assess the efficacy and safety of EVT for BAO patients.

Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design

Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.

Endovascular treatment for acute Basilar Artery Occlusion - a multicenter randomized controlled trial (ATTENTION)

BACKGROUND AND HYPOTHESIS

Recently, two multicenter randomized controlled trials (RCT) failed to show a significantly beneficial effect of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO). However, both trials suffered from equipoise issues which may have hindered the validity of the trial results. Therefore, additional RCT studies are needed to explore the potential benefit of EVT in patients presenting with BAO.

STUDY DESIGN

ATTENTION is an investigator-initiated, multicenter, prospective, randomized, controlled clinical trial with open-label treatment and blinded outcome assessment (PROBE) of EVT versus best medical management (BMM). The primary effect parameter is a modified Rankin Score of 0-3 at day 90.

DISCUSSION

ATTENTION will provide evidence for the efficacy and safety of EVT in stroke patients within 12 hours after BAO.

First-Line Stent Retriever versus Direct Aspiration for Acute Basilar Artery Occlusions: A Systematic Review and Meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) for anterior circulation stroke has been proven to be highly effective. In comparison, MT for basilar artery occlusion (BAO) continues to lack definitive evidence of efficacy. The main MT modalities are stent retriever (SR) and direct aspiration (DA). Several studies have been published comparing the 2 approaches.

OBJECTIVE

We sought to directly compare and synthesize safety and efficacy outcomes with SR versus DA for acute BAO.

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Overall, 8 studies comprising 693 patients with BAO were included (SR: 457; DA: 236). The SR group was associated with statistically significant lower odds of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.31-0.94) and mTICI3 (OR: 0.47; 95% CI: 0.23-0.95) compared with DA. Favorable outcome rates were similar between the 2 groups (OR: 0.83; 95% CI: 0.60-1.16). The rates of symptomatic intracerebral hemorrhage (OR: 3.57; 95% CI: 0.75-16.95), subarachnoid hemorrhage (SAH) (OR: 4.71; 95% CI: 0.82-26.90), and vessel perforation (OR: 2.64; 95% CI: 0.43-16.33) were higher in the SR group, but statistical significance was not reached. The rates of 90-day mortality were similar between the 2 groups (OR: 1.07; 95% CI: 0.67-1.70). Procedure duration was significantly shorter when DA was used compared with SR (weighted mean difference: 26.10 minutes; 95% CI: 13.28-38.92).

CONCLUSIONS

SR is associated with statistically significant lower odds of mTICI 2b/3 and mTICI 3 recanalization rates compared with DA. SR appears to be associated with a higher complication rate, but significance was not reached.

Endovascular therapy in basilar artery occlusion in Sweden 2016-2019-a nationwide, prospective registry study

Purpose

We present the first nationwide study on endovascular therapy for basilar artery occlusion (BAO) from early hospital management to 3-month outcome.

Methods

Data were collected on all acute ischaemic stroke patients registered 2016–2019 in the two national quality registers for stroke care and endovascular therapy (EVT), receiving EVT for BAO and subclassified into proximal, middle and distal.

Results

In all, 251 patients were included: 69 proximal, 73 middle and 109 distal BAO. Patients with proximal BAO were younger (66, middle 71, distal 76, p < 0.0001), less often female (27.5%, middle 47.9%, distal 47.7%, p = 0.015), more often smokers (28.6%, middle 20.3%, distal 11.5%, p < 0.0001), and fewer had atrial fibrillation (13.2%, middle 24.7%, distal 48.6%, p < 0.0001). Level of consciousness and NIHSS score did not differ by BAO subtype and 52.2% were alert on admission. Time from groin puncture to revascularization was significantly longer in patients with proximal BAO (71, middle 46, distal 42 min, p < 0.0001), and angioplasty and/or stenting was more often performed in patients with proximal (43.4%) and middle (27.4%) than distal (6.4%) BAO (p < 0.0001). Cumulative 90-day mortality was 38.6% (proximal 50.7%, middle 32.9%, distal 34.9%, p = 0.02). Older and pre-stroke dependent patients had higher mortality, as did patients in whom angioplasty/stenting was performed.

Conclusion

We confirm a serious outcome in BAO despite endovascular therapies, and demonstrate important differences relating to occlusion location in baseline characteristics, procedural time, therapeutic measures and outcome. Further in-depth analyses of factors affecting outcome in BAO are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00234-021-02843-3.

Effects of and prognostic factors affecting endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion

PURPOSE

To investigate the clinical outcome and factors affecting the prognosis of endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion.

MATERIALS AND METHODS

Eighty-three patients with acute vertebrobasilar artery occlusion were treated with endovascular mechanical thrombectomy, and the recanalization rate, clinical outcomes at three months, modified DWI-PC-ASPECTS, and MRA-BATMAN scores were analyzed.

RESULTS

Following acute mechanical thrombectomy, the TICI 2B-3 score was achieved in all patients (100%). At three-month evaluation, 56 (67.5%) patients had good prognosis with the mRS score of 0-2, including 13 (23.2%) patients who had arterial occlusion caused by emboli and 43 (76.8%) who had atherosclerotic stenosis. In analyzing factors affecting the prognosis, a significant difference (P < 0.05) existed between patients with good (mRS 0-2) and poor (mRS 3-6) prognosis in the NIHSS (17.3 vs. 31.2, P = 0.000001), modified DWI-PC-ASPECTS (10.4 vs. 7.8, P = 0.021), and MRA-BATMAN (6.3 vs. 4.6, P = 0.003) scores. Univariate Logistic regression analysis demonstrated NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 to be the risk factors for poor prognosis. Multivariate Logistic regression analysis revealed NIHSS score ≥ 21 as an independent risk factor for poor prognosis.

CONCLUSION

Endovascular mechanical thrombectomy is safe and effective in recanalizing occluded vertebrobasilar artery occlusion, and NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 are the risk factors for poor prognosis.

RAPID Software to the Clinical Application Value of Acute Basilar Artery Occlusion with Endovascular Treatment

OBJECTIVE

To investigate the clinical application value of RAPID software based on computed tomography perfusion imaging (CTP) in the endovascular treatment of acute basilar artery occlusion (BAO).

MATERIALS AND METHODS

The data of patients with acute basilar artery occlusion who received endovascular treatment in Taizhou Hospital, Zhejiang Province, between January 2020 and April 2021 were retrospectively analysed. The patients were divided into a perfusion imaging and a no-perfusion imaging group based on whether the image analysis results were obtained by RAPID software. Age, preoperative National Institute of Health stroke scale (NIHSS) score, onset to puncture time (OPT), operation methods, good prognosis at 3 months after surgery (modified Rankin scale (mRS) score ≤3), symptomatic intracranial haemorrhage (sICH) and other clinical data were compared between the two groups. Multivariate logistic regression analysis was used to identify the independent factors affecting the prognosis of BAO patients.

RESULTS

In total, 61 patients with acute BAO were included: 31 patients in the perfusion imaging group and 30 patients in the no-perfusion imaging group. There were no statistically significant differences between the two groups in age, NIHSS score or operation methods (all P >0.05). However, OPT and the good prognosis rate were significantly higher in the perfusion imaging group than in the no-perfusion imaging group (χ²=8.176, 5.003, P < 0.05). SICH was significantly lower in the perfusion imaging group than in the no-perfusion imaging group (χ²=5.628, P < 0.05). Logistic regression analysis showed that the image analysis results of RAPID software influenced the prognosis of EVT in patients with acute BAO (OR=4.048, 95%CI: 1.276-12.840).

CONCLUSIONS

RAPID software based on CTP can be used for preoperative screening of patients with acute basilar artery occlusion to identify those suitable for endovascular treatment, which is worthy of clinical promotion.

Tenecteplase Thrombolysis in Posterior Circulation Stroke

One in five ischaemic strokes affects the posterior circulation. Basilar artery occlusion is a type of posterior circulation stroke associated with a high risk of disability and mortality. Despite its proven efficacy in ischaemic stroke more generally, alteplase only achieves rapid reperfusion in ~4% of basilar artery occlusion patients. Tenecteplase is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, which can be administered by intravenous bolus. The single-bolus administration of tenecteplase vs. an hour-long alteplase infusion is a major practical advantage, particularly in "drip and ship" patients with basilar artery occlusion who are being transported between hospitals. Other practical advantages include its reduced cost compared to alteplase. The EXTEND-IA TNK trial demonstrated that tenecteplase led to higher reperfusion rates prior to endovascular therapy (22 vs. 10%, non-inferiority p = 0.002, superiority p = 0.03) and improved functional outcomes (ordinal analysis of the modified Rankin Scale, common odds ratio 1.7, 95% CI 1.0-2.8, p = 0.04) compared with alteplase in large-vessel occlusion ischaemic strokes. We recently demonstrated in observational data that tenecteplase was associated with increased reperfusion rates compared to alteplase prior to endovascular therapy in basilar artery occlusion [26% (n = 5/19) of patients thrombolysed with TNK vs. 7% (n = 6/91) thrombolysed with alteplase (RR 4.0 95% CI 1.3-12; p = 0.02)]. Although randomized controlled trials are needed to confirm these results, tenecteplase can be considered as an alternative to alteplase in patients with basilar artery occlusion, particularly in "drip and ship" patients.