Abstract
Endovascular therapy (EVT) has been reported to be safe and effective in improving clinical outcomes among patients with acute basilar artery occlusion (ABAO). The benefits associated with EVT remain uncertain for patients with ABAO with severe symptoms (ie, National Institutes of Health Stroke Scale [NIHSS] score ≥ 21). To assess the outcomes associated with EVT and identify factors associated with outcomes among patients with ABAO and severe symptoms. This prospective, nationwide cohort study was conducted using data from January 2014 to May 2019 in China from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR). Included patients had ABAO and underwent EVT or standard medical treatment (SMT) alone in routine clinical practice. Patients were dichotomized into severe symptoms (ie, NIHSS score ≥ 21) and minor to moderate symptoms (NIHSS score < 21) groups. Patients were followed up for 90 days. Data were analyzed from December 2020 through June 2021. EVT with SMT vs SMT alone. The primary outcome was improvement in modified Rankin Scale (mRS) score at 90 days, defined as a decrease by 1 grade in mRS score. Secondary outcomes included favorable functional outcome (ie, mRS score, 0-3) and mortality. Among 542 patients with ABAO and severe symptoms (median [IQR] age, 65 [57-74] years; 147 [27.1%] women), 431 patients (79.5%) received EVT and 111 patients (20.5%) received SMT. Compared with SMT, EVT was associated with increased odds of improved mRS score (adjusted common odds ratio [OR], 3.44 [95% CI, 2.05-5.78]; P < .001), with increased odds of a favorable functional outcome (ie, mRS score, 0-3; adjusted OR, 4.52 [95% CI, 1.64-12.43]; P = .004) and decreased odds of mortality (adjusted OR, 0.27 [95% CI, 0.15-0.50]; P < .001). Among patients receiving EVT, baseline NIHSS score was associated with decreased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 0.90 [95% CI, 0.85-0.95]; P < .001) and increased odds of mortality (adjusted OR per 1-point increase in score, 1.13 [95% CI, 1.07-1.19]; P < .001), while posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) was associated with increased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 1.71 [95% CI, 1.41-2.07]; P < .001) and decreased odds of mortality (adjusted OR per 1-point increase in score, 0.74 [95% CI, 0.64-0.85]; P < .001). Different occlusion sites, compared with distal basilar artery, were associated with decreased odds of favorable functional outcome (eg, middle basilar artery: adjusted OR vs distal basilar artery, 0.36 [95% CI, 0.17-0.80]; P = .01). This study found that EVT was associated with increased odds of functional favorable outcomes among patients with ABAO and severe symptoms. Baseline NIHSS score, pc-ASPECTS, and occlusion site were independent factors associated with clinical outcomes.
Highlights
Compared with standard medical treatment (SMT), endovascular therapy (EVT) was associated with increased odds of improved modified Rankin Scale (mRS) score, with increased odds of a favorable functional outcome and decreased odds of mortality
Among patients receiving EVT, baseline National Institutes of Health Stroke Scale (NIHSS) score was associated with decreased odds of a favorable functional outcome and increased odds of mortality, while posterior circulation Acute Stroke Prognosis Early Computed Tomography Score was associated with increased odds of a favorable functional outcome and decreased odds of mortality
Outcomes of EVT vs SMT Stratified by Severity EVT was associated with increased rates of favorable functional outcome (93 patients [21.6%] vs 5 patients [4.5%]; odds ratio (OR), 5.83 [95% CI, 2.31-14.72]; P < .001) and decreased rates of mortality (239 patients [55.5%] vs 91 patients [82.0%]; OR, 0.27 [95% CI, 0.16-0.46]; P < .001) at 90 days compared with the SMT group in unadjusted analysis (Figure 1A; eTable 1 in the Supplement)
Summary
Acute basilar artery occlusion (ABAO) is an infrequent ischemic stroke, accounting for a small proportion (approximately 1%) of all ischemic strokes and 5% to 10% of strokes resulting from large vessel occlusion,[1,2] it usually represents a disastrous disease associated with high rates of disability and mortality.[1,2,3] Given that standard medical treatment (SMT) alone is associated with insufficient recanalization rates and poor outcomes among patients with ABAO, endovascular therapy (EVT) has recently been regarded as a promising therapeutic approach for ABAO.[2,4] Since 2006, several studies[5,6,7,8] of the efficacy and safety associated with EVT in ABAO have found results suggesting that EVT may be associated with safe and effective improvements in clinical outcomes and decreased mortality among patients with ABAO.
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