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Endovascular Treatment vs. Best Medical Management in Basilar Artery Occlusion
Quick Takes
- It remains uncertain whether endovascular treatment or best medical therapy is superior for patients with acute basilar artery occlusion (BAO).
- In this observational, registry-based study, patients with acute BAO who underwent endovascular treatment had better functional outcomes and less death at 90 days than patients who received best medical management.
- The results of this observational study will not change recommendations/guidelines, nor will clinical practice change, as most stroke physicians are already biased toward endovascular treatment for BAO.
Study Questions:
In stroke patients with acute basilar artery occlusion (BAO), are outcomes better with best medical management (BMM) or with endovascular treatment (EVT)?
Methods:
This is a prospective observational study of consecutive patients who presented to 1 of 48 hospitals in China between 2017–2021 with BAO >24 hours from last known normal. The specifics of BMM or EVT were left to the treating teams. For the primary analysis, modeling by inverse probability of treatment weighting was performed to account for treatment selection bias in this nonrandomized study. The primary outcome was favorable functional outcome (modified Rankin scale score 0-3) at 90 days. Endpoint assessment was not blinded.
Results:
A total of 2,134 patients were included in the final analysis. After adjustment for potential confounders (age, sex, blood pressure, baseline National Institutes of Health Stroke Scale [NIHSS] score, etc.) in the primary analysis, a favorable functional outcome was observed more frequently in the EVT group (adjusted relative risk [aRR], 1.42; 95% confidence interval [CI], 1.19-1.65) and 90-day mortality was lower in the EVT than BMM group (aRR, 0.78; 95% CI, 0.69-0.88). Symptomatic intracranial hemorrhage was higher in the EVT than BMM group (aRR, 7.77; 95% CI, 2.56-23.49). An interaction was observed such that patients with NIHSS <10 did not appear to benefit as much from EVT compared to BMM as did patients with NIHSS ≥10.
Conclusions:
In this observational, registry-based study, patients with acute BAO who underwent EVT had better functional outcomes and less death at 90 days than patients who received BMM.
Perspective:
Because this is an observational study, causality (EVT leading to better outcomes in BAO patients) cannot be assumed. It is likely that patients more likely to do well with EVT (those who were younger, with fewer medical comorbidities, etc.) were selected for EVT more frequently than patients unlikely to do well. The study design (using inverse probability of treatment weighting) attempted to account for this selection bias, but residual bias may exist. Randomized controlled trials are required to determine which treatment approach (EVT vs. BMM) is superior in BAO. However, because BAO is so frequently catastrophic for patients, stroke physicians tend to favor EVT (rather than “doing nothing”). As a result, randomized controlled trials are limited by pursuit of EVT for patients outside of trials, significantly complicating interpretation of the results. The results of this observational study will not change guidelines or clinical practice, particularly given that most stroke physicians are already biased toward EVT for BAO.
Clinical Topics: Prevention
Keywords: Basilar Artery, Coronary Occlusion, Endovascular Procedures, Intracranial Hemorrhages, Patient Outcome Assessment, Stroke, Treatment Outcome, Secondary Prevention, Vascular Diseases
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