Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion

Tudor G Jovin ¹, Chuanhui Li ¹, Longfei Wu ¹

¹From the Department of Neurosurgery (T.G.J., Jian Chen, L.J., H.Z., X.J.), the Department of Neurology (C.L., L.W., C.W., W.Z., Q.M., Y.Z., H.S.), the Stroke Center (C.L.), the Department of Emergency Medicine (J.D.), and the Center for Evidence-Based Medicine (C.H.), Xuanwu Hospital, and the Department of Radiology, Beijing Chaoyang Hospital (Q.Y.), Capital Medical University, and Peking University Clinical Research Institute, Peking University First Hospital (C.Y.), Beijing, the Department of Neurology, Baotou Central Hospital of Inner Mongolia Medical University (C.J.), Baotou, the Department of Neurosurgery, the 904th Hospital of the People's Liberation Army (PLA), Wuxi (Z.S.); the Department of Neurology, Central Hospital of Shengli Oil Field, Dongying (Z.G.), the Department of Neurology, Liaocheng Third People's Hospital, Liaocheng (C.S.), the Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou (W.C.), the Department of Neurosurgery, the First People's Hospital of Changzhou, Changzhou (Y.P.), the Department of Neurosurgery, Tianjin Huanhu Hospital (M.W.), the Department of Neurosurgery, Binhai Hospital of Beijing University (W.S.), and the Department of Neurosurgery, Tianjin Teda Hospital (Z.G.), Tianjin, the Department of Neurology, Nanning Second People's Hospital, Nanning (T.L.), the Department of Radiology, Luoyang Central Hospital of Zhengzhou University, Luoyang (L.W.), the Department of Neurology and the Clinical Research Center of Neurologic Disease, Second Affiliated Hospital of Soochow University, Suzhou (G.X.), the Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guiyang (H.Y.), the Department of Neurology, Shanghai Blue Cross Hospital, Shanghai (M.R.), the Department of Neurology (X.L.), and the Department of Critical Care Medicine, Data and Statistics Division (Y.L.), Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, the Department of Neurology, Xinqiao Hospital and Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing (Q.Y.), the Department of Neurosurgery, 985th Hospital of the PLA, Taiyuan (Qingfeng Zhu), the Department of Neurology, Linyi People's Hospital, Linyi (Qiyi Zhu), the Department of Neurology, Subei People's Hospital, Yangzhou (X.L.), the Department of Neurology, Yantaishan Hospital of Shandong First Medical University, Yantai (H.L.), the Department of Neurology, Nanyang Central Hospital of Xinxiang Medical University, Nanyang (C.W.), the Cerebrovascular Center, Henan Provincial People's Hospital, Zhengzhou (L.Z.), the Department of Neurosurgery, Hospital of Baoan People's Hospital, Shenzhen (H.Y.), and the Department of Neurology, Xi'an No.3 Hospital, Xi'an (M.C.), - all in China; Cooper University Healthcare and Cooper Medical School of Rowan University (T.G.J.), Camden, NJ; the Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (D.S.L.); the Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.); Altair Biostatistics, Mooresville, NC (S.B.); the Stroke Unit, Hospital Vall d'Hebrón, Barcelona (M.R.); and the Department of Neurology, Pittsburgh Institute of Brain Disorder and Recovery, University of Pittsburgh Medical Center and Veterans Affairs Pittsburgh Health Care System, Geriatric Research Education and Clinical Center, Pittsburgh (Jun Chen).

⁰From the Department of Neurosurgery (T.G.J., Jian Chen, L.J., H.Z., X.J.), the Department of Neurology (C.L., L.W., C.W., W.Z., Q.M., Y.Z., H.S.), the Stroke Center (C.L.), the Department of Emergency Medicine (J.D.), and the Center for Evidence-Based Medicine (C.H.), Xuanwu Hospital, and the Department of Radiology, Beijing Chaoyang Hospital (Q.Y.), Capital Medical University, and Peking University Clinical Research Institute, Peking University First Hospital (C.Y.), Beijing, the Department of Neurology, Baotou Central Hospital of Inner Mongolia Medical University (C.J.), Baotou, the Department of Neurosurgery, the 904th Hospital of the People's Liberation Army (PLA), Wuxi (Z.S.); the Department of Neurology, Central Hospital of Shengli Oil Field, Dongying (Z.G.), the Department of Neurology, Liaocheng Third People's Hospital, Liaocheng (C.S.), the Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou (W.C.), the Department of Neurosurgery, the First People's Hospital of Changzhou, Changzhou (Y.P.), the Department of Neurosurgery, Tianjin Huanhu Hospital (M.W.), the Department of Neurosurgery, Binhai Hospital of Beijing University (W.S.), and the Department of Neurosurgery, Tianjin Teda Hospital (Z.G.), Tianjin, the Department of Neurology, Nanning Second People's Hospital, Nanning (T.L.), the Department of Radiology, Luoyang Central Hospital of Zhengzhou University, Luoyang (L.W.), the Department of Neurology and the Clinical Research Center of Neurologic Disease, Second Affiliated Hospital of Soochow University, Suzhou (G.X.), the Department of Neurosurgery, Affiliated Hospital of Guizhou Medical University, Guiyang (H.Y.), the Department of Neurology, Shanghai Blue Cross Hospital, Shanghai (M.R.), the Department of Neurology (X.L.), and the Department of Critical Care Medicine, Data and Statistics Division (Y.L.), Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, the Department of Neurology, Xinqiao Hospital and Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing (Q.Y.), the Department of Neurosurgery, 985th Hospital of the PLA, Taiyuan (Qingfeng Zhu), the Department of Neurology, Linyi People's Hospital, Linyi (Qiyi Zhu), the Department of Neurology, Subei People's Hospital, Yangzhou (X.L.), the Department of Neurology, Yantaishan Hospital of Shandong First Medical University, Yantai (H.L.), the Department of Neurology, Nanyang Central Hospital of Xinxiang Medical University, Nanyang (C.W.), the Cerebrovascular Center, Henan Provincial People's Hospital, Zhengzhou (L.Z.), the Department of Neurosurgery, Hospital of Baoan People's Hospital, Shenzhen (H.Y.), and the Department of Neurology, Xi'an No.3 Hospital, Xi'an (M.C.), - all in China; Cooper University Healthcare and Cooper Medical School of Rowan University (T.G.J.), Camden, NJ; the Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (D.S.L.); the Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.); Altair Biostatistics, Mooresville, NC (S.B.); the Stroke Unit, Hospital Vall d'Hebrón, Barcelona (M.R.); and the Department of Neurology, Pittsburgh Institute of Brain Disorder and Recovery, University of Pittsburgh Medical Center and Veterans Affairs Pittsburgh Health Care System, Geriatric Research Education and Clinical Center, Pittsburgh (Jun Chen).

The New England Journal of Medicine +

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October 14, 2022

View abstract on PubMed

Summary

Endovascular thrombectomy significantly improved functional outcomes for basilar-artery occlusion stroke patients presenting 6-24 hours after symptom onset. While effective, this stroke treatment also increased risks of hemorrhage and procedural complications.

Area Of Science

Neurology
Interventional Cardiology
Vascular Surgery

Background

Basilar-artery occlusion (BAO) stroke presents a significant clinical challenge.
The efficacy and safety of endovascular thrombectomy (EVT) in later time windows (6-24 hours) for BAO remain understudied.

Purpose Of The Study

To evaluate the effectiveness and safety of EVT compared to medical therapy alone in patients with BAO presenting 6-24 hours after symptom onset.

Main Methods

A randomized controlled trial (RCT) in China enrolled 217 patients with BAO stroke.
Patients were randomized 1:1 to receive either medical therapy plus EVT or medical therapy alone.
The primary outcome was good functional status (modified Rankin Scale score 0-3) at 90 days.

Main Results

EVT resulted in a significantly higher rate of good functional status at 90 days (46% vs. 24%, adjusted rate ratio 1.81).
The EVT group experienced a higher incidence of symptomatic intracranial hemorrhage (6% vs. 1%) and procedural complications (11%).
Mortality at 90 days was lower in the EVT group (31% vs. 42%).

Conclusions

Endovascular thrombectomy is superior to medical therapy alone for improving functional outcomes in BAO stroke patients presenting 6-24 hours after onset.
The benefits of EVT must be weighed against an increased risk of cerebral hemorrhages and procedural complications.

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