Acute Basilar Artery Occlusion Research Articles

Low neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios predict favorable outcomes after endovascular treatment in acute basilar artery occlusion: subgroup analysis of the BASILAR registry

BackgroundRecently, the BAOCHE trial and ATTENTION trial registry have demonstrated the efficacy of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO), however, the proportion of patients with favorable post-EVT outcomes remains low. The present study aimed to investigate the individual and joint prognostic values of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in patients with acute BAO who have undergone EVT.MethodsWe enrolled patients who underwent EVT from the BASILAR registry. Patients were divided into the following groups based on their modified Rankin Scale (mRS) scores at 90 days: favorable-outcome (mRS score: 0–3) and poor-outcome (mRS score: 4–6) groups. Multivariable logistic regression was performed to analyze the association of NLR and PLR with favorable post-EVT outcomes.ResultsIn total, 585 patients with EVT were recruited. Of these, 189 and 396 patients were in the favorable-outcome and poor-outcome groups, respectively. According to the multivariable logistic regression analyses, both NLR (adjusted odds ratio [aOR], 0.950; 95% confidence interval [CI], 0.920–0.981; P = 0.002) and PLR (aOR, 0.997; 95% CI, 0.995–0.999; P = 0.002) were related to favorable post-EVT outcomes in patients with acute BAO. The optimal cutoff values for the NLR and PLR were 7.75 and 191, respectively. Furthermore, stratified analysis using the multivariable logistic regression model revealed that both NLR and PLR (NLR values ≥ 7.75 and PLR values ≥ 191) were associated with a low rate of favorable outcomes (aOR, 0.292; 95% CI, 0.173–0.494; P < 0.001).ConclusionsLow NLR and PLR were both associated with favorable post-EVT outcomes in patients with acute BAO. Furthermore, the combined value of both inflammatory markers is potentially reliable in predicting clinical post-EVT outcomes.

Patterns of Care in Patients with Basilar Artery Occlusion (BAO): A Population-Based Study

Basilar artery occlusion (BAO) is associated with high morbidity and mortality. Endovascular therapy (EVT) has been shown to be beneficial in acute BAO patients. This retrospective observational study used the National Inpatient Sample (NIS) database to identify BAO patients using the International Classification of Diseases (ICD). Multivariable models were used to evaluate the association of risk factors, comorbidities, length of stay (LOS) in hospital, total cost, disposition, and transfer status. A total of 1120 (447 females, 39.95%) patients were identified, with a higher proportion of White individuals (66.8% vs. 57.6%), atrial fibrillation (31.5% vs. 17.2%; p < 0.0001), and peripheral vascular disease (21.2% vs. 13.7%; p = 0.009). A lower proportion of individuals with diabetes mellitus (32.1% vs. 39.5%; p = 0.05) was found in the EVT group. Majority of the patients (924/1120, 82.5%) were treated at the urban teaching facility, which also performed most of the EVT procedures (164, 89.13%), followed by non-academic urban (166, 14.8%) and rural (30, 2.7%) hospitals. Most patients (19/30, 63%) admitted to rural hospitals were transferred to other facilities. Urban academic hospitals also had the highest median LOS (8.9 days), cost of hospitalization (USD 117,261), and disposition to home (32.6%). This study observed distinct patterns and geographical disparities in the acute treatment of BAO patients. There is a need for national- and state-level strategies to improve access to stroke care.

Abstract Number ‐ 87: Successfull thrombectomy followed by balloon mount stent placement on acute basilar artery occlusion

Introduction Basilar artery occlusion accounts for 10% of all ischemic stroke caused by intracranial large vessel occlusion (LVO) with high morbidity and mortality. Endovascular intervention has been shown effective in the anterior circulation LVO but multiple trials, however a few trials failed to demonstrate the benefit of endovascular intervention over medical therapy, furthermore, there is no trial regarding the benefit of permanent stent deployment in the basilar artery over maximized medical therapy. Here we present a patient who presented with right side hemiplegia, facial droop, and dysmetria with National Institute of Health Stroke Scale of 19. CT head and neck angiography revealed acute basilar occlusion. Endovascular procedure was performed with successful thrombectomy utilizing stent retriever followed by placement of balloon mounted stent due to persistent critical basilar stenosis. Methods A case report Results MRI of the brain revealed acute ischemic stroke of bilateral cerebellar hemisphere, mid and left pons, left cerebral peduncles, and left thalamus. Repeat non‐contrast CT head revealed small bilateral thalamic hemorrhage but due to small size, dual antiplatelet therapy with aspirin and ticagrelor was initiated. After discharge, the patient developed upper extremity deep vein thrombosis for which apixaban was started. Despite dual antiplatelet therapy and anticoagulation, the patient continued to improve. Clinical follow‐up at 6 weeks the patient remained stable with mild residual weakness of the right extremities. Conclusions Thrombectomy with subsequent deployment of permanent stent can be considered as a safe and effective measure of basilar artery occlusion.

Therapeutic strategies for acute basilar-artery occlusion

Therapeutic strategies for acute basilar-artery occlusion

Abstract Number: LBA13 Relationship Between Vertebral Artery Dominance And Incidence Of Embolic Basilar Artery Occlusion

Introduction Vertebral artery asymmetry due to hypoplasia or early termination is common in the general population with 50% left dominance, 25% right dominance, and 25% codominance. Our aim was to identify if an association exists between vertebral artery dominance and incidence of embolic basilar artery occlusion. Methods Retrospective chart review of patients presenting to our comprehensive stroke center with acute ischemic stroke (AIS) secondary to embolic basilar artery occlusion were reviewed. Artery‐to‐artery occlusions related to athersclerotic steno‐occlusive disease or proximal dissection with distal thromboembolism were excluded. Successful recanalization was identified as a modified treatment in cerebral infarction (mTICI) score of 2b and 3. Fisher exact test statistic was used to assess for significant differences in recanalization. Social science statistics software was used for data analysis. Results From May 2017 to November 2019, 29 patients with acute basilar occlusions undergoing thrombectomy were identified. Acute basilar artery occlusion patients had a dominant right vertebral artery (31%, n = 9), codominant vertebral arteries (31%, n = 9) and dominant left vertebral artery (38%, n = 11). Successful recanalization of TICI 2b or higher was achieved in 89.6% (n = 26). Difference between successful recanalization and right or left vertebral artery dominance was not statistically significant (Fisher exact test statistic value 0.48). Conclusions Our study suggests a higher proportion of our patients presenting with basilar artery occlusion had right vertebral artery dominance or codominant pattern. Larger, studies are needed to validate our results.

Endovascular Treatment for Basilar Artery Occlusion: Revisiting Evidence From Randomized Clinical Trials

BACKGROUND Acute ischemic stroke attributed to basilar artery occlusion is known to be associated with high rates of mortality and disability. However, the previous clinical trials did not provide evidence to support the efficacy of endovascular treatment (EVT) in patients with basilar artery occlusion. The purpose of this study was to provide updated evidence about EVT's benefits and safety profile with the recent update from both the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) and the Basilar Artery Occlusion Chinese Endovascular Trial (BAOCHE) trials. METHODS We searched for eligible articles from inception to November 1, 2022, in 5 databases and included all randomized controlled trials with no restrictions on the publication date or language. Meta‐analysis statistics were performed using R software version 4.2.1. RESULTS The rate of modified Rankin scale score of 0 to 3 was significantly higher in the EVT group compared with best medical treatment (risk ratio [RR], 1.54 [95% CI, 1.16–2.04]; P value = 0.002), and the same was observed for the rate of modified Rankin scale score 0 to 2 (RR, 1.83 [95% CI, 1.08–3.08]; P value = 0.024). Moreover, there was a significant reduction in the 90‐day mortality in the EVT group (RR, 0.76 [95% CI, 0.65–0.89]; P value = 0.002). However, there was a significantly higher rate of symptomatic intracerebral hemorrhage in the EVT group compared with best medical treatment (RR, 7.48 [95% CI, 2.27–24.61]; P value &lt;0.001). CONCLUSIONS EVT may confer a clinical benefit to patients with acute ischemic stroke caused by basilar artery occlusion. Because of the small number of included studies and because all of them were conducted in the Chinese population, further trials might be needed to confirm and further investigate the generalizability of these results.

Basilar tip morphology: impact on mechanical thrombectomy for acute distal basilar artery occlusion

BackgroundThe morphology of the basilar artery tip (BAT) varies between patients. The morphologic anatomy of the BAT could affect the efficacy of mechanical thrombectomy (MT).Methods108 patients with acute distal basilar...

Basilar artery occlusion management: Specialist perspectives from an international survey.

Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties. We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Among the 1245 respondents (nINTs=702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5%vs. 95.1%, p<.01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4%vs. 26.7%), or that they would only under specific clinical circumstances (p=.45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p>.05), although nINTs more commonly preferred perfusion imaging (24.2%vs. 19.7%, p=.04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9%vs. 6.9%, p<.01). Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.

A DWI-based radiomics-clinical machine learning model to preoperatively predict the futile recanalization after endovascular treatment of acute basilar artery occlusion patients

ObjectiveTo develop an effective machine learning model to preoperatively predict the occurrence of futile recanalization (FR) of acute basilar artery occlusion (ABAO) patients with endovascular treatment (EVT). Materials and MethodsData from 132 ABAO patients (109 male [82.6 %]; mean age ± standard deviation, 59.1 ± 12.5 years) were randomly divided into the training (n = 106) and test cohort (n = 26) with a ratio of 8:2. FR is defined as a poor outcome [modified Rankin Scale (mRS) 4–6] despite a successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b]. A total of 1130 radiomics features were extracted from diffusion-weighted imaging (DWI) images. The least absolute shrinkage and selection operator (LASSO) regression method was applicated to select features. Support vector machine (SVM) was applicated to construct radiomics and clinical models. Finally, a radiomics-clinical model that combined clinical with radiomics features was developed. The models were evaluated by receiver operating characteristic (ROC) curve and decision curve. ResultsThe area under the receiver operating characteristic (ROC) curve (AUC) of the radiomics-clinical model was 0.897 (95 % confidence interval, 0.837–0.958) in the training cohort and 0.935 (0.833–1.000) in the test cohort. The AUC of the radiomics model was 0.887 (0.824–0.951) in the training cohort and 0.840 (0.680–1.000) in the test cohort. The AUC of the clinical model was 0.746 (0.652–0.840) in the training cohort and 0.766 (0.569–0.964) in the test cohort. The AUC of the radiomics-clinical model was significantly larger than the clinical model (p = 0.016). A radiomics-clinical nomogram was developed. The decision curve analysis indicated its clinical usefulness. ConclusionThe DWI-based radiomics-clinical machine learning model achieved satisfactory performance in predicting the FR of ABAO patients preoperatively.

Endovascular therapy for basilar occlusion: Is there robust evidence?

The combined rate of mortality and severe disability for patients with acute basilar artery occlusion is as high as 90% [1,2]. Observational studies report that with revascularization therapies this rate decreases by about 75% [2,3]. To this regard, four randomized trials were carried out to investigate the association between revascularization therapy and any benefit in patients with basilar artery occlusion and their results were recently published [4–7]. The meta-analysis by Lin et al. [8], published in this issue of the Journal, includes the results of these trials with a total of 988 patients (12 with bilateral vertebral occlusion) and concludes that, in patients with acute basilar occlusion, endovascular therapy, compared with best medical management, might be associated with significant increased rates of ambulation, independence and survival, but also with an increased risk of symptomatic intracranial hemorrhage.

Good collaterals and better outcomes after EVT for basilar artery occlusion: A systematic review and meta-analysis.

Stroke caused by acute basilar artery occlusion (BAO) is devastating with high dependency and mortality. Recent trials have demonstrated the efficacy of endovascular treatment (EVT) for acute BAO, while pretreatment collaterals may be a valuable prognostic indicator for post-EVT outcomes. To systematically review and synthesize evidence on the associations between pretreatment collateral status and outcomes after EVT in acute BAO. We retrieved relevant full-text articles published in English since 1 January 2010, reporting associations between pretreatment collateral status and outcomes after EVT for BAO, by searching MEDLINE and Embase. The primary outcome was favorable or good 90-day functional outcome (modified Rankin Scale [mRS] 0-2 or 0-3); secondary outcomes included successful recanalization, symptomatic intracranial hemorrhage, final infarct volume, and 90-day mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) for good versus poor collaterals on the outcomes were synthesized using random-effects models. Subgroup and sensitivity analyses were conducted for the primary outcome. Overall, 29 primary studies (2995 participants) were included in qualitative review, among which 16 studies (1447 participants) were meta-analyzed. With different imaging modalities and methods to grade the collateral status, good collaterals were found in 33-85% of patients in the individual primary studies (I2 = 95.2%, p < 0.001), with a pooled proportion of 51% (95% CI: 40-62%) across all studies. Good pretreatment collaterals were associated with a doubled rate of favorable/good 90-day functional outcome (RR = 2.03, 95% CI: 1.63-2.51, p < 0.001), a higher rate of successful recanalization (RR = 1.23, 95% CI: 1.04-1.45, p = 0.015), and reduced 90-day mortality (RR = 0.59, 95% CI: 0.43-0.81, p = 0.001) after EVT for BAO. None of the primary studies reported the associations of good collaterals with the other secondary outcomes. Subgroup analyses revealed possibly more prominent protective effect of good pretreatment collaterals over the primary outcome, in studies with longer time windows in patient eligibility criteria for EVT (p = 0.028 for between-subgroup heterogeneity). In patients with BAO receiving EVT, good pretreatment collateral status was associated with a higher chance of favorable 90-day functional outcome, despite the various methods in grading the collateral circulation. Efforts are needed for more standardized collateral assessment in BAO, for more reliable and generalizable investigations of its clinical implications.

Abstract WP12: The Golden 75 Min And Black 120 Min For Acute Basilar Artery Occlusion Intervention: Effect Of Procedure Time On Outcome

Background and Objectives: Previous studies have shown the impact of procedure time (PT) on large vessel occlusion (LVO), however, the relationship for patients with acute basilar artery occlusion (ABAO) was not clear. We aimed to characterize the impact of PT and other procedure-related variables on clinical outcomes among patients with ABAO that underwent mechanical thrombectomy (MT). Methods: Patients with ABAO that underwent MT with a documented PT in the BASILAR study from January 2014 to May 2019 among 47 comprehensive centers in China were included. Multivariable analysis was performed to reveal the association between PT and 90-day modified Rankin Scale score, mortality, complications, and all-cause death at one year. Results: Of the 829 patients from the BASILAR registry, 633 eligible patients were included. A decreased likelihood of favorable outcomes (defined as a modified Rankin Scale score of 0-3 at 90 days) was demonstrated when PT exceeded 60 min (P &lt; 0.001). Additionally, a PT ≤ 75 min independently predicted favorable outcomes (adjusted OR 2.28[95% CI 1.41- 3.68], respectively). The risk of complications and mortality increased by 0.5% and 1.5% with every 10 min increase in PT, respectively (R 2 = 0.64 and R 2 = 0.68, P &lt;0.01). The cumulative rates of favorable outcomes and successful recanalization plateaued after 120 min (2 attempts). Restricted cubic spline regression analysis for the probability of favorable outcomes had an L-shape association (P non-linearity = 0.048) with PT with significant benefit loss before 120 min and then appeared relatively flat. Discussion: For ABAO patients, procedures that exceeded 75 min increased the risk of mortality and decreased the likelihood of a favorable outcome. For procedures exceeding 120 min the benefits and costs of continuing the procedure should be carefully considered. Classification of Evidence: This study provides Class II evidence for ABAO patients undergoing EVT.

Abstract TP153: Basilar Artery Occlusion Management: Specialist Perspectives From After The BEST Of BASICS Study

Background: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to medical management may differ between clinician specialties. Methods: We conducted an international survey (1/1/22-3/31/22) regarding management strategies in acute BAO prior to the announcement of 2 trials indicating superiority of EVT, and compared responses between interventionalists (INT) and non-interventionalists (nINT). Selection practices for routine EVT based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Results: Among the 1245 respondents (nINT=702), INT more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p&lt;0.01). A similar proportion of INT and nINT responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific circumstances (p=0.45). Among respondents who would recommend EVT, there was no difference in the maximum pre-stroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p&gt;0.05), although nINT more commonly preferred perfusion imaging (24.2% vs. 19.7%, p=0.04). Among respondents who indicated they would randomize to medical management, INT were more likely to randomize when the NIHSS was ≥10 (15.9% vs. 6.9%, p&lt;0.01). Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a patient to medical treatment. There were small differences in preference of advanced neuroimaging, although these preferences were unsupported by clinical trial data.

Predictors of delayed reocclusion after successful recanalization in acute basilar artery occlusion patients

BackgroundDelayed reocclusion (DR) after successful recanalization in acute basilar artery occlusion (BAO) patients, which is associated with clinical deterioration and poor outcome, has not been well studied. The current study is aimed to predict DR after successful endovascular therapy in acute BAO patients. Method187 consecutive patients presenting with acute BAO and undergoing endovascular treatment (EVT) were selected in Beijing Tiantan Hospital from January 2012 to July 2018. Computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) within 7 days of the thrombectomy was used to identify reocclusion of the target vessel. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. ResultsDR was observed in 17 of 169 successfully reperfused patients (10.1%). Patients with DR had higher frequency of intracranial atherosclerotic stenosis (ICAS) (94.1% vs. 61.8%; P = 0.01), higher frequency of intracranial angioplasty during EVT (88.2% vs. 57.2%; P = 0.02), lower frequency of stent-retriever use during EVT (52.9% vs. 78.9%; P = 0.03) and a lower proportion of modified Thrombolysis In Cerebral Infarction (mTICI) 3 reperfusion (41.2% vs. 78.3%; P < 0.01). Suggestive predictors were mTICI3 reperfusion (aOR, 0.205; 95% CI, 0.061–0.686) and stent-retriever using (aOR, 0.29; 95% CI, 0.086–0.980). DR was an independent predictor of unfavorable outcome at 90 days (aOR for mTICI ≤3, 5.205; 95% CI, 1.129–24.005). ConclusionsDR within 7 days after successful mechanical thrombectomy in acute BAO patients is rare but associated with poor outcome. Patients without mTICI3 reperfusion and stent-retriever using are at high risk for DR.

Abstract WP146: The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Compares Favorably To The Critical Area Perfusion Score After Basilar Thrombectomy

Introduction: The critical area perfusion score (CAPS) identifies patients with vertebrobasilar occlusions who may benefit from endovascular thrombectomy based on computed tomography perfusion (CTP) regions of severe hypoperfusion. We compared CAPS to the recently described Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS). Methods: Acute basilar artery occlusion (BAO) patients from January 2017-December 2021 with pre-thrombectomy CTP were included in this retrospective analysis from a health system’s stroke registry. CAPS (0-6 points) = CTP Tmax &gt; 10 (cerebellar hemispheres,1 point each; pons, 2 points; midbrain and/or thalamus, 2 points) and CLEOS = (5 x age) + (10 x National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 x CTP cerebral blood volume index). Inter-rater reliability was assessed using light’s kappa for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict the primary outcome, 90-day modified Rankin Scale (mRS) 4-6. Receiver operator characteristics (ROC) curve analyses were performed to evaluate the prognostic ability of each score. Performance of the two scores was assessed among reperfused patients (modified thrombolysis in cerebral infarction 2b-3). Results: 55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.5 (5-24), were included. Light’s kappa among all 6 raters for favorable versus unfavorable CAPS (0-3 versus 4-6) was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio [OR] 1.0010, 95% CI 1.0007-1.0014, p &lt; 0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p = 0.93). In the ROC analysis, a favorable trend was observed for CLEOS (area under the curve [AUC] 0.69, 95% CI 0.54-0.84) compared to CAPS (AUC 0.49, 95% CI 0.34-0.64; p = 0.051). Of the approximately 85% of patients who reperfused, CLEOS had a sensitivity, specificity, positive predictive value, and negative predictive value of 71%, 70%, 74%, and 67%, respectively, compared to 24%, 86%, 67%, and 50% for CAPS. Conclusions: CAPS has fair inter-rater agreement. CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and poor outcomes stratified by reperfusion status after BAO thrombectomy.

Endovascular Therapy for Basilar Artery Occlusion.

Basilar artery occlusion is one of the most devastating neurological conditions with high risks of disability and mortality. Despite the overwhelming benefit of endovascular therapy (EVT) in the anterior circulation and observational data supporting the efficacy of EVT in the posterior circulation, evidence from randomized controlled trials in basilar artery occlusion had been lacking until recently. The BEST (Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment) and BASICS (Basilar Artery International Cooperation Study) randomized trials showed a nonsignificant direction of benefit but failed to demonstrate the superiority of EVT over standard medical therapy in basilar artery occlusion. However, these trials paved the way for 2 subsequent positive trials by highlighting the importance of consecutive recruitment, fast enrollment and avoidance or minimization of cross-over. The recently completed ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) and BAOCHE (Basilar Artery Occlusion Chinese Endovascular Trial) trials showed that EVT is beneficial for basilar artery occlusion within 24 hours of onset, with a treatment effect similar to what has been shown in anterior circulation large vessel occlusion ischemic stroke. In this topical review, we examine and contextualize the current evidence on EVT for basilar artery occlusion.

Abstract TMP7: Efficacy And Safety Of Intravenous Tirofiban Combined With Endovascular Therapy For The Treatment Of Basilar Artery Occlusion Due To Large-artery Atherosclerotic

Background: This study aimed to evaluate whether intravenous tirofiban can improve the functional outcome without promoting risk of intracerebral hemorrhage (ICH) in patients with basilar artery occlusion (BAO) due to large-artery atherosclerotic (LAA) receiving endovascular therapy (EVT). Methods: Consecutive patients with acute BAO duet to LAA within 24 h who underwent EVT and had tirofiban treatment from the BASILAR Registry study were enrolled. All eligible patients were dichotomized into tirofiban and non-tirofiban subgroups according the use of intravenous tirofiban. The primary efficacy outcome was the favorable functional outcome (defined as mRS score of 3 or less), Safety outcomes were mortality within 90 days and intracranial hemorrhage (ICH) within 48 hours. Results: A total of 417 patients were included in this study, of which 275 were in the tirofiban group and 142 were in the non-tirofiban group. After adjusting for multiple factors, patient in the tirofiban group were 1.17 (95% confidence interval [CI], 1.05-1.31) times more likely to achieve favorable outcome at 90 days than those in the non-tirofiban group. The mortality of the tirofiban group was higher than that of the non-tirofiban group (40.7% vs. 58.5%; adjusted risk ratio, 0.61; 95% CI, 0.74-0.89; P &lt;0.001). The 1-year follow-up results were also similar to that at 90 days. Any ICH occurred in 19 (7.1%) patients in the tirofiban group, which was lower than that of 22 (15.8%) in the non-tirofiban group (adjusted risk ratio, 0.45; 95% CI, 0.26-0.68; P=0.004) and symptomatic ICH occurred in 15 (5.2%) patients in the tirofiban group, which was lower than that of 17 (12.2%) in the non-tirofiban group (adjusted risk ratio, 0.40; 95% CI, 0.21-0.76; P=0.005). Conclusions: Tirofiban may associated with improve 90-day favorable outcomes and reduced mortality risk decreased incidence of ICH in patients with BAO due to LAA receiving EVT. The treatment effect of tirofiban may be maintained for one year.

In basilar-artery occlusion stroke, thrombectomy improved functional outcome at 90 d but increased ICH.

Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med. 2022;387:1361-72. 36239644.

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

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). 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. 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. 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.

Endovascular Therapy for Basilar Artery Occlusion: Among the First to Conceptualize, Last to Prove.

In 1981, the dismal outcomes of patients with basilar artery occlusion (BAO) inspired the first reports of intra-arterial thrombolytic treatment in BAO. These reports were among the first to conceptualize that opening an artery could help patients with large vessel occlusion stroke. Whereas multiple anterior circulation LVO trials demonstrated the efficacy of endovascular therapy starting in 2014, proof of benefit for BAO was lacking until 2022. In this commentary, we reflect on how the BASICS (Basilar Artery International Cooperation Study) and BEST (Basilar Artery Occlusion: Endovascular Interventions vs Standard Medical Treatment) trials lay the foundations for clinical trials in BAO, subsequently leading to the positive results of the ATTENTION (Endovascular Treatment for Acute Basilar-Artery Occlusion) and BAOCHE (Basilar Artery Occlusion Chinese Endovascular) trials.