Endovascular versus Medical Management of Basilar Artery Occlusion Strokes in Patients with Low Stroke Severity

Background The efficacy and safety of endovascular treatment (EVT) in patients with basilar artery occlusion (BAO) stroke and low (score <10) National Institutes of Health Stroke Scale (NIHSS) score are unclear. Purpose To assess whether EVT improves outcomes in patients with low-scoring NIHSS BAO stroke. Materials and Methods A retrospective cohort study of the Nationwide Re-admissions Database (NRD; January 2016 to December 2022) was conducted. Adults with acute BAO stroke and NIHSS score 1-9 were identified and grouped by EVT (thrombectomy, angioplasty, and/or stenting) versus medical management (MM). Primary outcomes were routine discharge to home with self-care and in-hospital mortality. Propensity score matching was performed to balance EVT and MM cohorts, accounting for demographics, comorbidities, symptoms, stroke etiology, and other factors. Subgroup analyses were performed to identify sources of treatment-effect heterogeneity. χ² tests and logistic regression analyses were used to compare outcomes. Results Among 9461 patients (median age, 68 years; IQR, 58-77 years; 5842 males), 1807 were administered EVT. After propensity score matching, 2888 and 1632 patients with MM and EVT, respectively, remained. Rates of routine discharge were similar (MM vs EVT, 34.0% vs 34.0%; P = .24), but the EVT arm had higher in-hospital mortality (16.0% vs 7.1%; P < .001). In subgroup analyses, EVT was associated with higher odds of routine discharge among patients with NIHSS score of 6-9 (odds ratio [OR], 1.42; 95% CI: 1.07, 1.90; P = .02), whereas it was not associated with higher odds of mortality among those with embolic stroke etiology (OR, 1.42; 95% CI: 0.71, 2.86; P = .32) or those who were 75 years or older (OR, 1.63; 95% CI: 0.79, 3.39; P = .19). Conclusion EVT was not associated with better outcomes but was associated with increased mortality among patients with low-score NIHSS BAO stroke; however, NIHSS score, stroke etiology, and patient age may be sources of clinically significant treatment effect heterogeneity. © RSNA, 2026 Supplemental material is available for this article.