J Stroke.  2023 Jan;25(1):81-91. 10.5853/jos.2022.03755.

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

Affiliations
  • 1Departments of Radiology and Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
  • 2Department of Radiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
  • 3Stroke Center and Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
  • 4Department of Neurology and Stroke Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
  • 5Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
  • 6Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
  • 7Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
  • 8Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
  • 9Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
  • 10Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
  • 11Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
  • 12Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
  • 13Rhode Island Hospital, Brown University, Providence, RI, USA
  • 14Amita Health and University of Illinois-Chicago, Chicago, IL, USA
  • 15Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
  • 16Neurology, Heidelberg University Hospital, Heidelberg, Germany
  • 17Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
  • 18Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
  • 19Department of Neurology, Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
  • 20Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands

Abstract

Background and Purpose
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).
Methods
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.
Results
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.
Conclusion
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.

Keyword

Acute stroke; Acute basilar artery occlusion; Posterior circulation; Meta-analysis

Figure

  • Figure 1. PRISMA 2020 flow diagram for systematic reviews [42] which included searches of PubMed, EMBASE, Cochrane, and Web of Science databases, registers and other sources.

  • Figure 2. Forest plots for (A) favorable functional outcome (mRS 0–3) at 3 months, (B) excellent clinical outcome (mRS 0–2) at 3 months, (C) symptomatic intracranial hemorrhage, and (D) mortality odds ratio for pooled patient groups treated with EVT or MM. mRS, modified Rankin Scale; EVT, endovascular thrombectomy; MM, medical management; CI, confidence interval; BAOCHE, Basilar Artery Occlusion Chinese Endovascular Trial; ATTENTION, Endovascular Treatment For Acute Basilar Artery Occlusion: A Multicentre Randomised Clinical Trial; BASICS, Basilar Artery International Cooperation Study; BEST, Basilar Artery Occlusion Endovascular Intervention versus Standard Medical Treatment; REML, random effect restricted maximum likelihood.

  • Figure 3. Forest plots for the (A) primary outcome data (mRS 0–3), (B) secondary endpoints of excellent clinical outcome (mRS 0–2), (C) symptomatic intracranial hemorrhage, and (D) mortality for patients with acute basilar occlusion and NIHSS <10 treated with EVT or MM. mRS, modified Rankin Scale; EVT, endovascular thrombectomy; MM, medical management; CI, confidence interval; BAOCHE, Basilar Artery Occlusion Chinese Endovascular Trial; BASICS, Basilar Artery International Cooperation Study; REML, random effect restricted maximum likelihood.


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Ji Hoe Heo, Jaeseob Yun, Kwang Hyun Kim, Jae Wook Jung, Joonsang Yoo, Young Dae Kim, Hyo Suk Nam
J Stroke. 2024;26(2):164-178.    doi: 10.5853/jos.2023.03279.


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