Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion

Therapeutic strategies for acute basilar-artery occlusion

Endovascular thrombectomy (EVT) has been established as an effective treatment for acute basilar artery occlusion (BAO) in the short term. However, the durability of these benefits over the long term has not been well characterized. To determine whether the clinical benefits of EVT for acute BAO are sustained at 3 years, with a primary focus on functional outcomes and mortality compared with best medical management alone. This study is a 3-year follow-up extension of a multicenter randomized clinical trial conducted between February 2021 and January 2022, with follow-up data collected through January 2025. The study was designed as an open-label, assessor-blinded trial to evaluate the long-term efficacy of EVT. The trial was conducted at 36 comprehensive stroke centers across China, representing a diverse, population-based setting that enhances the generalizability of the results. A total of 340 patients with acute BAO within 12 hours of estimated symptom onset were randomly assigned to the thrombectomy or control group. Eligible participants were adults with imaging-confirmed BAO and without contraindications to endovascular therapy. Of the randomized patients, 307 (90.3%) completed 3-year follow-up-203 in the thrombectomy group and 104 in the control group. Participants in the thrombectomy group received EVT in combination with best medical management, while the control group received best medical management alone. EVT procedures were performed according to institutional protocols using stent retrievers, aspiration devices, balloon angioplasty, stent deployment, intra-arterial thrombolysis, or combinations of these approaches that were left to the discretion of the treating team. The primary outcome was a modified Rankin Scale (mRS) score of 0 to 3 at 3 years, representing the ability to walk and perform self-care. Secondary outcomes included a mRS score of 0 to 2, distribution across the mRS score categories, and quality of life. These outcomes were prespecified prior to data analysis. Among 307 patients (median [IQR] age, 68 [59-75]; 211 [69%] male) with available data, an mRS score of 0 to 3 at 3 years was observed in 78 patients (38.4%) in the thrombectomy group and in 19 patients (18.3%) in the control group (adjusted risk ratio, 2.05; 95% CI, 1.35-3.11; P = .001). The distribution of mRS scores favored the thrombectomy group over the control group (adjusted common odds ratio, 2.60; 95% CI, 1.53-4.43). The cumulative 3-year mortality increased from 36.7% (n = 83) at 90 days to 55.7% (n = 113) in the thrombectomy group and 55.3% (n = 63) to 73.1% (n = 76) in the control group (adjusted risk ratio, 0.76; 95% CI, 0.65-0.89). On prespecified subgroup analysis, benefit was observed in patients younger than 70 years; a treatment effect was not demonstrated in patients aged 70 years and older. At 3 years, the clinical benefit of EVT in patients with acute BAO was durable, with substantially better functional outcomes and reduced mortality compared with medical management. These results reinforce EVT as the standard of care for BAO and support broader implementation and timely access to thrombectomy services. ChiCTR.org.cn Identifier: ChiCTR2400082236.

BackgroundThe effects and risks of endovascular thrombectomy 6 to 24 hours after stroke onset due to basilar-artery occlusion have not been extensively studied.MethodsIn a trial conducted over a 5-year period in China, we randomly assigned, in a 1:1 ratio, patients with basilar-artery stroke who presented between 6 to 24 hours after symptom onset to receive either medical therapy plus thrombectomy or medical therapy only (control). The original primary outcome, a score of 0 to 4 on the modified Rankin scale (range, 0 to 6, with a score of 0 indicating no disability, 4 moderately severe disability, and 6 death) at 90 days, was changed to a good functional status (a modified Rankin scale score of 0 to 3, with a score of 3 indicating moderate disability). Primary safety outcomes were symptomatic intracranial hemorrhage at 24 hours and 90-day mortality.ResultsA total of 217 patients (110 in the thrombectomy group and 107 in the control group) were included in the analysis; randomization occurred at a median of 663 minutes after symptom onset. Enrollment was halted at a prespecified interim analysis because of the superiority of thrombectomy. Thrombolysis was used in 14% of the patients in the thrombectomy group and in 21% of those in the control group. A modified Rankin scale score of 0 to 3 (primary outcome) occurred in 51 patients (46%) in the thrombectomy group and in 26 (24%) in the control group (adjusted rate ratio, 1.81; 95% confidence interval [CI], 1.26 to 2.60; P<0.001). The results for the original primary outcome of a modified Rankin scale score of 0 to 4 were 55% and 43%, respectively (adjusted rate ratio, 1.21; 95% CI, 0.95 to 1.54). Symptomatic intracranial hemorrhage occurred in 6 of 102 patients (6%) in the thrombectomy group and in 1 of 88 (1%) in the control group (risk ratio, 5.18; 95% CI, 0.64 to 42.18). Mortality at 90 days was 31% in the thrombectomy group and 42% in the control group (adjusted risk ratio, 0.75; 95% CI, 0.54 to 1.04). Procedural complications occurred in 11% of the patients who underwent thrombectomy.ConclusionsAmong patients with stroke due to basilar-artery occlusion who presented 6 to 24 hours after symptom onset, thrombectomy led to a higher percentage with good functional status at 90 days than medical therapy but was associated with procedural complications and more cerebral hemorrhages. (Funded by the Chinese National Ministry of Science and Technology; BAOCHE ClinicalTrials.gov number, NCT02737189.)

In several randomized clinical trials, endovascular thrombectomy led to better functional outcomes than conventional treatment at 90 days poststroke in patients with acute basilar artery occlusion. However, the long-term clinical outcomes of these patients have not been well delineated. To evaluate 1-year clinical outcomes in patients with acute basilar artery occlusion following endovascular thrombectomy vs control. This study is an extension of the ATTENTION trial, a multicenter, randomized clinical trial. Patients were included between February 2021 and January 2022, with 1-year follow-up through April 2023. This multicenter, population-based study was conducted at 36 comprehensive stroke sites. Patients with acute basilar artery occlusion within 12 hours of estimated symptom onset were included. Of the 342 patients randomized in the ATTENTION trial, 330 (96.5%) had 1-year follow-up information available. Endovascular thrombectomy (thrombectomy group) vs best medical treatment (control group). The primary outcome was defined as a score of 0 to 3 on the modified Rankin Scale (mRS) at 1 year. Secondary outcomes were functional independence (mRS score 0-2), excellent outcome (mRS score 0-1), level of disability (distribution of all 7 mRS scores), mortality, and health-related quality of life at 1 year. Among 330 patients who had 1-year follow-up data, 227 (68.8%) were male, and the mean (SD) age was 67.0 (10.7) years. An mRS score 0 to 3 at 1 year was achieved by 99 of 222 patients (44.6%) in the thrombectomy group and 21 of 108 (19.4%) in the control group (adjusted rate ratio, 2.23; 95% CI, 1.51-3.29). Mortality at 1 year compared with 90 days was more frequent in both the thrombectomy group (101 of 222 [45.5%] vs 83 of 226 [36.7%]) and the control group (69 of 108 [63.9%] vs 63 of 114 [55.3%]). Excellent outcome (mRS score 0-1) at 1 year compared with 90 days increased in the thrombectomy group (62 of 222 [27.9%] vs 45 of 226 [19.9%]) but not in the control group (9 of 108 [8.3%] vs 9 of 114 [7.9%]) resulting in a magnified treatment benefit. Among patients with basilar artery occlusion within 12 hours of onset, the benefits of endovascular thrombectomy at 1 year compared with 90 days were sustained for favorable (mRS score 0-3) outcome and enhanced for excellent (mRS score 0-1) outcome.

Advances in Stroke: Treatments-Interventional.

Background Previous clinical trials have supported the use of endovascular therapy (EVT) for basilar artery occlusion (BAO) stroke within 24 hours of symptom onset. However, the safety and effectiveness of EVT in patients with BAO treated beyond 24 hours remains unclear. Purpose To compare clinical outcomes and safety following EVT combined with standard medical care versus medical care alone in patients with acute ischemic stroke due to BAO treated beyond 24 hours from symptom onset. Materials and Methods This multicenter retrospective study enrolled patients between March 2017 and April 2024 across China. Eligible patients had BAO and were treated with EVT or standard medical care beyond 24 hours from symptom onset. The primary outcome was the proportion of patients achieving good functional status (modified Rankin Scale score, 0-3). Primary safety outcomes included 90-day mortality and symptomatic intracranial hemorrhage. Inverse probability-weighted regression was performed to adjust for prespecified clinical characteristics, and instrumental variable analysis was repeated as sensitivity analysis. Results Among 217 patients (median age, 66 years [IQR, 58-73 years]; 160 men), good functional status at 90 days was achieved in 35.7% (46 of 129) of patients who underwent EVT and 26.1% (23 of 88) of controls (inverse probability of treatment weighting [IPTW]-adjusted risk ratio [RR], 1.67; P = .008), which was confirmed by instrument variable analysis (adjusted RR, 2.18; P = .04). There was no evidence of a difference in mortality at 90 days between EVT and control groups (48.1% [62 of 129 patients] vs 54.6% [48 of 88 patients]; IPTW-adjusted RR, 0.80; P = .10). Risk of symptomatic intracranial hemorrhage was higher in EVT compared with control groups (11.9% [15 of 126 patients] vs 1.3% [one of 80 patients]; IPTW-adjusted RR, 11.01; P = .02). Conclusion In this study of patients with BAO treated beyond 24 hours from symptom onset, EVT was associated with higher odds of good functional status at 90 days compared with standard medical care, albeit with increased odds of symptomatic intracranial hemorrhage. Chinese Clinical Trial Registry no. ChiCTR2000041117 © RSNA, 2026 Supplemental material is available for this article.

Background:Randomized controlled trials have demonstrated an improved outcome of basilar artery occlusion (BAO) with endovascular thrombectomy (EVT) compared to best medical treatment. However, a minority of the patients recruited up to 12–24 h from onset in the positive trials received intravenous thrombolysis (IVT), and a trial with a higher IVT rate did not show superiority of EVT. Thus, the efficacy and safety of EVT compared to IVT for BAO remain less clear.Aims:We aimed to compare outcomes after IVT alone to EVT with or without IVT for acute BAO.Methods:This international, observational, retrospective study included patients who received recanalization therapy for BAO at six centers between January 2010 and March 2024. The primary outcome was 3-month modified Rankin Scale (mRS) score 0–3, and secondary outcomes comprised mRS 0–2, ordinal mRS, mortality, and symptomatic intracranial hemorrhage. Outcomes after IVT versus EVT ± IVT were compared using inverse probability-weighted regression adjustment models adjusting for known predictors of outcome in BAO and baseline variables differing between the treatment groups. Interaction of the treatment group with symptom severity and onset-to-treatment time was tested.Results:Of 523 patients with BAO (median age 69, 35.2% women), 28.9% received IVT and 71.1% EVT ± IVT. The IVT-alone group had a lower baseline National Institutes of Health Stroke Scale score (median 11 vs 15) but equally extensive ischemic changes in baseline imaging. After inverse probability-weighted regression adjustment, the IVT-alone group had higher odds of mRS 0–3 (adjusted odds ratio (aOR) = 2.33 [95% confidence interval (CI) = 1.31–4.12]), mRS 0–2 (aOR = 1.93 [95% CI = 1.12–3.30]), lower median mRS (aOR = 1.81 [95% CI = 1.21–2.71]), and lower mortality (aOR = 0.53 [95% CI = 0.29–0.97]), but no difference in symptomatic intracranial hemorrhage (aOR = 0.81 [95% CI = 0.28–2.36]). No interactions for the primary outcome were found.Conclusion:In this study, patients with BAO had better outcome after IVT than EVT ± IVT independent of symptom severity and time from onset. Although the non-randomized design of the study warrants caution, the results encourage further trials comparing EVT and IVT to guide recanalization therapy in BAO patients.Data access statement:Anonymized data are available upon reasonable request to the corresponding author following the national legislation.

Objective To investigate the efficacy and safety of mechanical thrombectomy for cardioembolic stroke (CES) due to atrial fibrillation. Methods Patients with CES admitted to Nanjing First Hospital from January 2015 to September 2017 were enrolled retrospectively. They were divided into the thrombectomy group and the intravenous thrombolysis alone group. The baseline data, the National Institutes of Health Stroke Scale (NIHSS) score at 24 h after treatment, rates of good outcome (defined as the modified Rankin Scale score 0-2) at 90 d after onset, hemorrhagic transformation and death between the two groups were compared. Multivariate logistic regression analysis was used to determine the independent factors for the outcomes in patients with CES. Results A total of 117 patients with CES were enrolled, including 65 (55.6%) in the thrombectomy group and 52 (44.4%) in the intravenous thrombolysis alone group. Sixty-two patients (53.0%) had good outcome and 55 (47.0%) had poor outcome. The proportion of patients whose NIHSS score decreased >4 within 24 h after treatment (58.4% vs. 26.9%; χ2=6.254, P=0.007), rates of good recanalization (78.5% vs. 57.7%; χ2=5.850, P=0.016), and good outcome at 90 d (63.1%vs. 40.4%; χ2=5.972, P=0.015) in the thrombectomy group were significantly higher than those in the intravenous thrombolysis alone group, while there were no significant differences in the incidences of hemorrhagic transformation, symptomatic intracerebral hemorrhage and gastrointestinal bleeding, as well as mortality at 90 d. Multivariate logistic regression analysis showed that good recanalization (odds ratio [OR] 0.371, 95% confidence interval [CI] 0.157-0.876; P=0.024) and thrombectomy (OR 0.398, 95% CI 0.179-0.883; P=0.024) were the independent factors for good outcome, while diabetes (OR 6.572, 95% CI 1.684-25.641; P=0.007) was the independent factor for poor outcome. Conclusion The efficacy of mechanical thrombectomy for patients with CES due to atrial fibrillation is superior to intravenous thrombolysis alone, and it dose not increase the mortality and complications. Good recanalization and mechanical thrombectomy are the independent factors for good outcome, while diabetes is an independent factor for poor outcome in patients with CES due to atrial fibrillation. Key words: Stroke; Brain Ischemia; Intracranial Embolism; Atrial Fibrillation; Thrombectomy; Endovascular Procedures; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Outcome

BackgroundThe role of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) remains controversial, particularly for patients with acute large vessel occlusion (LVO) due to atrial fibrillation (AF), who may have a poor response to thrombolysis. Furthermore, robust evidence is lacking regarding the benefits of bridging therapy in patients with AF-related AIS-LVO. Accordingly, this study aimed to assess whether patients with AF benefit from bridging thrombectomy.MethodsWe performed a retrospective, observational, single-center study from January 2020 to June 2025. Patients meeting the inclusion criteria for both IVT and EVT were enrolled and dichotomized based on thrombectomy type: the bridging thrombectomy (IVT + EVT) group versus the direct thrombectomy (EVT alone) group. After 1:1 propensity score matching (PSM), the outcome measures, including the proportions of patients with modified Rankin scale (mRS) scores of 0–2 at 90 days, the number of retrieval attempts, successful recanalization, door-to-recanalization time, symptomatic intracranial hemorrhage, and mortality within 90 days, were compared. Finally, an exploratory subgroup analysis was performed, stratifying the cohort by age.ResultsA total of 221 patients who underwent EVT were included (125 with bridging IVT and 96 with direct EVT). After PSM, there were no significant differences in 90-day functional independence (mRS 0–2) between the two groups (59.0% versus 50.0%; p = 0.158). Furthermore, direct EVT was associated with a shorter median door-to-recanalization time (125.5 versus 135.5 min; p = 0.015) and fewer median thrombectomy passes (1 versus 2, p = 0.003). The rates of successful recanalization, symptomatic intracranial hemorrhage, and 90-day mortality were comparable. A significant interaction effect between age and treatment modality was observed for the primary outcome of a 90-day mRS score of 0–2 (p for interaction = 0.048). Among patients aged ≥85 years, those receiving EVT alone had a significantly higher rate of functional independence than those in the combined IVT and EVT groups (50.0% versus 12.5%, p = 0.041).ConclusionIn this real-world, matched-control study, EVT alone demonstrated comparable efficacy to combined IVT + EVT for AF-related LVO. However, in patients aged ≥85, EVT alone significantly improved functional independence and reduced mortality.

BackgroundEndovascular thrombectomy for acute ischemic stroke due to medium-vessel occlusion has had varying results across trials. Whether thrombectomy improves functional outcomes in patients with medium-vessel occlusion and moderate-to-severe deficits is unclear.MethodsWe conducted an open-label, randomized trial with blinded outcome assessment at 48 centers in China. Eligible patients were adults who presented within 24 hours after the onset of a moderate-to-severe stroke (National Institutes of Health Stroke Scale [NIHSS] score, ≥6; scale, 0 to 42, with higher scores indicating greater neurologic deficits) due to occlusion of a medium vessel. Patients were assigned in a 1:1 ratio to thrombectomy plus medical management (thrombectomy group) or medical management alone (control group). The primary outcome was functional disability as measured by the shift in the modified Rankin scale score (scale, 0 [no disability] to 6 [death]) at 90 days. Violation of the proportional-odds assumption precluded the use of shift in the modified Rankin scale score, so as prespecified, functional independence (modified Rankin scale score of 0, 1, or 2) at 90 days was used as the primary outcome. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality.ResultsAmong 280 patients in the thrombectomy group and 283 in the control group, the median age was 71 years, the median NIHSS score was 10 (range, 3 to 36), and 42.8% were women; 36.6% received intravenous thrombolysis. Functional independence at 90 days was seen in 58.6% of the patients in the thrombectomy group and in 46.6% of those in the control group (adjusted rate ratio, 1.24; 95% confidence interval, 1.07 to 1.44; P=0.004). The incidence of symptomatic intracranial hemorrhage was 4.7% in the thrombectomy group and 2.2% in the control group; 90-day mortality was 11.1% and 10.2%, respectively.ConclusionsAmong patients with acute ischemic stroke due to medium-vessel occlusion and moderate-to-severe deficits, thrombectomy led to a greater likelihood of functional independence than medical management alone but also to a higher risk of symptomatic intracranial hemorrhage. (Funded by the National Natural Science Foundation of China and the Noncommunicable Chronic Diseases–National Science and Technology Major Project; ORIENTAL-MeVO ClinicalTrials.gov number, NCT06146790.)

Recanalization is considered a prerequisite for favorable outcome in basilar artery occlusion (BAO). Intravenous thrombolysis (IVT) has been successfully used for eligible patients with BAO well beyond the 4.5-hour time window but has been largely underrepresented in the best medical management arms in recent randomized controlled trials of recanalization therapy in BAO. We aimed to analyze the outcomes of patients with BAO treated with IVT only and to compare IVT with endovascular thrombectomy (EVT). This observational single-center, retrospective cohort study included consecutive patients with BAO treated with IVT and/or EVT up to 48 hours of symptom onset during 1995-2022. The primary outcome was favorable functional outcome (modified Rankin Scale 0-3) at 3 months collected by a stroke physician by phone. In the first part, we described the outcomes and factors associated with functional outcome in the IVT-only cohort during 1995-2022. In the second part, we used doubly robust inverse probability-weighted regression adjustment models to compare functional outcome of patients treated with IVT vs EVT+/-IVT during 2010-2022. In the whole cohort of 376 patients with acute BAO treated with recanalization therapy, 245 (65.2%) received only IVT. In the IVT-only cohort, most patients had moderate-to-severe clinical presentation (median NIH Stroke Scale 18) but no extensive early ischemic changes in the posterior circulation on admission. Half of them had onset-to-treatment time over 6 hours. 46.5% of the IVT-treated patients achieved 3-month favorable functional outcome, whereas mortality was 35.9%. sICH occurred in 11.1%. In a multivariable analysis, younger age, milder symptom severity, and less baseline ischemic changes predicted favorable functional outcome. In the 2010-2022 cohort, when compared with patients treated with EVT+/-IVT (n = 121), the IVT-only cohort (n = 122) had higher odds for favorable functional outcome (IVT 58.2% vs EVT 43.0% (aOR 2.82 [95% CI 1.31-6.05]). IVT alone produced outcomes comparable with those in recent trials of endovascular BAO recanalization. Furthermore, in head-to-head comparison in our cohort, the IVT-only approach was more often associated with favorable outcome than EVT+/-IVT. Thus, it should not be overlooked as the first-line recanalization therapy in acute BAO, even in longer time windows. This study provides Class IV evidence that tPA is as effective as thrombectomy for basilar artery thrombosis.

BACKGROUNDThe benefit of endovascular thrombectomy (EVT) in patients with basilar artery occlusion and severe neurological deficits is well established. However, its effectiveness in those with mild‐to‐moderate deficits remains uncertain. This study compared outcomes of EVT(±intravenous thrombolysis [IVT]) versus IVT alone in patients with basilar artery occlusion and mild‐to‐moderate stroke severity.METHODSWe used data from the international multicenter EVA‐TRISP (Endovascular Treatment and Thrombolysis for Ischemic Stroke Patients) and TRISP (Thrombolysis for Ischemic Stroke Patients) collaboration. All patients with radiologically confirmed basilar artery occlusion, National Institutes of Health Stroke Scale score <10, and a time to first treatment within 6 hours were included. Main outcomes of interest were favorable (functional) outcome (modified Rankin Scale [mRS] score 0—2), overall distribution of mRS, mortality at 3 months, and symptomatic intracranial hemorrhage. We applied binary logistic and ordinal regression using covariate adjustment and inverse probability of treatment weighting.RESULTSAmong 274 patients from 18 centers, 176 (64.3%) received EVT (mean age 68±15 years, 38% female, median [interquartile range] National Institutes of Health Stroke Scale score 5 [3—8], 34% with bridging IVT) and 98 (35.8%) received IVT alone (mean age 70±13 years, 43% female, median National Institutes of Health Stroke Scale score 5 [4–8]). Favorable outcome occurred in 63.6% of patients with EVT(±IVT) and in 64.3% of patients with IVT alone (adjusted odds ratio [OR] 0.89, 95% CI 0.46–1.72). There was an association of EVT(±IVT) with unfavorable distribution of the mRS (adjusted OR 1.83, 95% CI 1.10–3.06), and mortality was higher in the EVT(±IVT) group (15.9% versus 6.1%, adjusted OR 3.38, 95% confidence interval 1.30–8.75). Rates of symptomatic intracranial hemorrhage did not differ between groups (2.0% versus 0%). The results remained unchanged after additional inverse probability of treatment weighting analyses.CONCLUSIONSIn this multicenter observational cohort study, EVT(±IVT) in patients with basilar artery occlusion with mild‐to‐moderate stroke, was not associated with improved clinical outcome but higher mortality compared with IVT‐treatment. Our findings underscore equipoise and the need for prospective trials in this population.

The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients. We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale at 90days. The safety outcome was mortality at 90days and symptomatic intracranial hemorrhage within 48h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293). A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68-0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82-0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08-1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74-1.71, p = 0.58). Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.

Background The clinical benefit of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) in patients with mild symptoms remains controversial. Purpose To evaluate the efficacy and safety of EVT versus intravenous thrombolysis (IVT) in patients with BAO with National Institutes of Health Stroke Scale (NIHSS) scores of 0-9 or 0-5. Materials and Methods In a multicenter retrospective study between January 2018 and January 2024, outcomes in patients with BAO with NIHSS scores of 0-9 or 0-5 who underwent EVT or IVT were compared using inverse probability weighting (IPW) methods. In a meta-analysis, studies (published until April 1, 2025) comparing EVT and medical management (ie, control treatment) in BAO were identified. Results The retrospective study included 200 patients (median age, 69 years [IQR, 60-76 years]; 137 men), and the meta-analysis included six studies encompassing 3014 patients. Among patients with NIHSS scores of 0-9, after IPW, EVT was associated with a higher likelihood of excellent functional outcome (modified Rankin Scale [mRS] score of 0-1) compared with IVT (adjusted odds ratio [OR], 2.02 [95% CI: 1.05, 3.86]; P = .04). In contrast, among patients with NIHSS scores of 0-5 (n = 52), EVT was associated with a lower likelihood of independent ambulation (mRS score of 0-3) than IVT (adjusted OR, 0.19 [95% CI: 0.05, 0.80]; P = .02). Meta-analysis indicated that in patients with NIHSS scores of 0-9, EVT was associated with a higher likelihood of excellent functional outcome compared with control treatment (adjusted OR, 2.15 [95% CI: 1.60, 2.91]; P < .001). However, among patients with NIHSS scores of 0-5, EVT was associated with a reduced likelihood of independent ambulation compared with control treatment (adjusted OR, 0.23 [95% CI: 0.09, 0.59]; P = .002). Conclusion Compared with IVT, EVT was associated with a higher likelihood of excellent functional outcome in patients with BAO with NIHSS scores of 0-9 but a lower likelihood of independent ambulation in patients with NIHSS scores of 0-5. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Kallmes and Rabinstein in this issue.

BackgroundThe use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied.MethodsWe assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage.ResultsA total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group.ConclusionsIn patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.)