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Review
. 2023 Jan;25(1):81-91.
doi: 10.5853/jos.2022.03755. Epub 2023 Jan 31.

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

Mohamad Abdalkader  1 , Stephanos Finitsis  2 , Chuanhui Li  3 , Wei Hu  4 , Xinfeng Liu  4 , Xunming Ji  5 , Xiaochuan Huo  6 , Fana Alemseged  7 , Zhongming Qiu  8 , Daniel Strbian  9 , Volker Puetz  10   11 , James E Siegler  12 , Shadi Yaghi  13 , Kaiz Asif  14 , Piers Klein  1 , Yuyou Zhu  4 , Bruce C V Campbell  7 , Hui-Sheng Chen  15 , Simon Nagel  16   17 , Georgios Tsivgoulis  18 , Zhongrong Miao  6 , Raul G Nogueira  19 , Tudor G Jovin  12 , Wouter J Schonewille  20 , Thanh N Nguyen  1 ; BasilaR Artery Ischemia Network STudy of Endovascular versus Medical Management (BRAINSTEM) Group  1
Affiliations
Review

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

Mohamad Abdalkader et al. J Stroke. 2023 Jan.

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.

Keywords: Acute basilar artery occlusion; Acute stroke; Meta-analysis; Posterior circulation.

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Figures

Figure 1.
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.
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.
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.
See this image and copyright information in PMC

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