Written by Clay Smith
There was no statistical difference in endovascular therapy (EVT) compared with usual medical therapy for patients with basilar artery occlusion (BAO).
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Why does this matter?
BAO is a cause of coma, more appropriately, locked-in syndrome. It is a terrible thing for patients, and thrombolysis may be used if it is considered and diagnosed. For other kinds of stroke, particularly anterior circulation stroke, EVT has been shown to be superior to thrombolysis. Would the same hold for BAO?
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This was an open-label, multicenter RCT with 300 patients presenting with BAO who were randomized to usual medical therapy, including thrombolysis within 4.5 hours of onset, (79.5% received thrombolysis) or EVT within 6 hours (78.6% received thrombolysis before EVT). The primary outcome of favorable neurological outcome at 90 days (mRS 0-3) was met in 44.2% in the EVT compared to 37.7% in the usual care group (RR 1.18, 95%CI 0.92-1.50). There were more symptomatic bleeds in the EVT group than the medical therapy group: 4.5% vs 0.7% (RR 6.9, 95%CI 0.9 to 53.0). Malignant brain edema also occurred more often in the EVT group, though this was also not statistically significantly higher. Despite potential bleeding and edema, mortality was statistically the same at 90 days: 38.3% EVT and 43.2% usual care (RR 0.87, 95%CI, 0.68 to 1.12). The authors conclude that a larger study is needed, which is going to be challenging in this rare form of stroke. For now, I think there is clinical equipoise, and I would feel comfortable with my patient receiving either option, although I would lean toward EVT.
Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion. N Engl J Med. 2021 May 20;384(20):1910-1920. doi: 10.1056/NEJMoa2030297