Revascularization Treatment of Basilar Artery Occlusion in Patients with Mild-to-Moderate Severe Stroke

The 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.

We 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.

Among 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.

In 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.