Occlusion of the basilar artery is the most serious cause of stroke with very high disability and mortality. Although current clinical practice at many stroke centers includes endovascular treatment for basilar artery occlusion, evidence from large randomized trials is lacking. Recently, two new randomized controlled trials on endovascular treatment in basilar artery occlusion (ATTENTION - Endovascular Treatment for Acute Basilar Artery Occlusion and BAOCHE - Basilar Artery Occlusion Chinese Endovascular) were published. Both included patients with basilar artery occlusion and severe neurological deficits, although the time windows differed (ATTENTION: 0-12 hours, BAOCHE: 6-24 hours) and patients with evidence of a large brainstem or other posterior circulation infarct were excluded from the study. Patients were randomized 2:1 (ATTENTION) and 1:1 (BAOCHE) to endovascular treatment versus not.
Both studies showed much better functional outcomes in the endovascular treatment group (modified Rankin Scale 0-3 in 46% vs 23% in the ATTENTION trial and 46% vs 24% in the BAOCHE trial). Mortality was also significantly lower in the treatment group. Symptomatic intracranial hemorrhage occurred in few patients with endovascular treatment (5%/6%).
Despite the positive results of these trials, an important limitation is that both studies were conducted in the Chinese population, which is known to have a higher prevalence of cerebral atherosclerosis. While the likely larger proportion of patients with large-vessel-associated strokes may be associated with more difficulties in endovascular treatment (angioplasty and stenting were very frequently performed in both studies), it may also be associated with better collateralization and therefore increase the time window for successful endovascular treatment. Important unanswered questions include the utility of endovascular treatment in basilar artery occlusions with more modest neurological deficits.
Key Points:
- Two randomized controlled trials showed better outcomes in patients with basilar artery occlusion treated with endovascular therapy
- These trials were limited to the Chinese population, which is known to have a higher prevalence of large artery atherosclerosis
- Open questions include the use of endovascular therapy in basilar artery occlusion with less severe neurological deficits
References:
- Tao C, Nogueira RG, Zhu Y, et al. Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022;387(15):1361-1372. doi:10.1056/NEJMoa2206317 https://pubmed.ncbi.nlm.nih.gov/36239644/
- Jovin TG, Li C, Wu L, et al. Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion. N Engl J Med. 2022;387(15):1373-1384. doi:10.1056/NEJMoa2207576 https://pubmed.ncbi.nlm.nih.gov/36239645/
Author:
Dmitrii Khutorov
Co-author:
Simon Fandler-Höfler, Medical University of Graz, Austria
Publish on behalf of the Scientific Panel on Stroke