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. 2024 Dec;9(4):835-884.
doi: 10.1177/23969873241257223. Epub 2024 Jul 22.

European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion

Daniel Strbian  1 , Georgios Tsivgoulis  2 , Johanna Ospel  3 , Silja Räty  1 , Petra Cimflova  4 , Georgios Georgiopoulos  5   6 , Teresa Ullberg  7 , Caroline Arquizan  8 , Jan Gralla  9 , Kamil Zeleňák  10 , Salman Hussain  11 , Jens Fiehler  12 , Patrik Michel  13 , Guillaume Turc  14 , Wim Van Zwam  15
Affiliations

European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion

Daniel Strbian et al. Eur Stroke J. 2024 Dec.

Abstract

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Keywords: Guideline; acute management; basilar artery occlusion; endovascular treatment; posterior circulation; stroke; systematic review; thrombolysis.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in Supplemental Table 1.

Figures

Figure 1.1.
Figure 1.1.
PICO 1 – Bias evaluation for the observational studies.
Figure 2.1.
Figure 2.1.
PICO 2 – Risk of bias for RCTs included in PICO 2.
Figure 2.2.
Figure 2.2.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: favourable functional outcome (mRS scores of 0–2 at 3 months) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis, p = 0.12).
Figure 2.3.
Figure 2.3.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: favourable functional outcome (mRS scores of 0–2 at 3 months) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone, and stratified by high versus low proportion of IVT-treated patients in the BMT arm (pooled adjusted RR, random-effects meta-analysis, p = 0.003 for interaction). The BEST trial was excluded from this interaction analysis due to its extremely high rate of crossovers (22.5%) from EVT into BMT arm.
Figure 2.4.
Figure 2.4.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: Good functional outcome (mRS scores of 0–3 at 3 moths) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis, p = 0.04).
Figure 2.5.
Figure 2.5.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: Good functional outcome (mRS scores of 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone, and stratified by high versus low proportion of IVT-treated patients in the BMT arm (pooled adjusted RR, random-effects meta-analysis, p = 0.02 for interaction). The BEST trial was excluded from this interaction analysis due to its extremely high rate of crossovers (22.5%) from EVT into BMT arm.
Figure 2.6.
Figure 2.6.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: Distribution of mRS scores at 3 months (shift analysis) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis, p = 0.03).
Figure 2.7.
Figure 2.7.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: mortality at 90 days in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis, p = 0.01).
Figure 2.8.
Figure 2.8.
PICO 2 – Meta-analysis of randomised-controlled clinical trials: symptomatic ICH in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis, p = 0.003).
Figure 2.9.
Figure 2.9.
PICO 2 – Risk of bias for registry studies.
Figure 2.10.
Figure 2.10.
PICO 2 – Meta-analysis of registry studies: Good functional outcome (mRS scores 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone, and stratified by high versus low proportion of IVT-treated patients in the BMT arm (pooled adjusted RR, random-effects meta-analysis, p = 0.0001 for interaction).
Figure 2.11.
Figure 2.11.
PICO 2 – Forest plot showing differential effect of reperfusion therapy stratified by high versus low proportion of IVT-treated patients in the BMT arm (p = 0.03 for interaction), including data from randomised-controlled clinical trials (RCTs) and one registry study. Distribution of mRS scores at 3 months (shift analysis) in patients with acute ischaemic stroke presenting within 6 h from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (Cochran’s Q-test for interaction testing).
Figure 3.1.
Figure 3.1.
PICO 3 – Risk of bias in randomised-controlled clinical trials.
Figure 3.2.
Figure 3.2.
PICO 3 – Meta-analysis of randomised-controlled clinical trials (RCTs): Good functional outcome (mRS scores 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6–24 h from time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled adjusted RR, random-effects meta-analysis).
Figure 3.3.
Figure 3.3.
PICO 3 – Risk of bias in observational studies.
Figure 3.4.
Figure 3.4.
PICO 3 – Meta-analysis of observational studies: Good functional outcome (mRS scores 0–3 at 3 months, except for the BASICS registry: 1 month) in patients with acute ischaemic stroke presenting within 6–24 h from time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled RR, random-effects meta-analysis).
Figure 3.5.
Figure 3.5.
PICO 3 – Sensitivity analysis of observational studies after inclusion of the studies that presented raw data regarding good functional outcome (mRS scores 0–3 at 3 months, except for the BASICS registry: 1 month) in patients with acute ischaemic stroke presenting within 6–24 h from time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (RR, random-effects meta-analysis).
Figure 3.6.
Figure 3.6.
PICO 3 – Forest plot showing differential effect of reperfusion therapy stratified by geographical regions including RCTs and observational studies: Good functional outcome (mRS scores 0–3 at 3 months, except for the BASICS registry: 1 month) in patients with acute ischaemic stroke presenting within 6–24 h from time last known well treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (p-value for interaction <0.0001, Cochran’s Q-test for interaction testing).
Figure 4.1.
Figure 4.1.
PICO 4 – Risk of bias in observational studies.
Figure 4.2.
Figure 4.2.
PICO 4 – Meta-analysis of randomised-controlled clinical trials (RCTs) stratified by clinical severity at baseline (p-value for interaction 0.03): Good functional outcome (mRS scores of 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6 h (BASICS), within 12 h (ATTENTION), or within 6–24 h (BAOCHE) from time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled RR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). Only a minor proportion of patients randomised to ATTENTION and BAOCHE received IVT as part of the BMT.
Figure 4.3.
Figure 4.3.
PICO 4 – Meta-analysis of randomised-controlled clinical trials (RCTs): Symptomatic intracranial haemorrhage in patients with acute ischaemic stroke presenting with <10 NIHSS, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (RR, random-effects meta-analysis).
Figure 4.4.
Figure 4.4.
PICO 4 – Forest plot showing differential effect of reperfusion therapy stratified by NIHSS cutoff 10, including data from randomised-controlled clinical trials (RCTs) and registry studies. Good functional outcome (mRS scores of 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6 h (BASICS), within 12 h (ATTENTION), within 6–24 h (BAOCHE), or 24 h (RESCUE Japan Registry 2, ATTENTION registry) from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (p-value for interaction 0.0004, Cochran’s Q-test for interaction testing). Only a minor proportion of patients randomised to ATTENTION and BAOCHE received IVT as part of the BMT.
Figure 4.5.
Figure 4.5.
PICO 4 – Meta-analysis of randomised-controlled clinical trials (RCTs) stratified by occlusion location at baseline (p-value for interaction 0.01): Good functional outcome (mRS scores of 0–3 at 3 months) in patients with acute ischaemic stroke presenting within 6 h (BASICS), within 12 h (ATTENTION), or within 6–24 h (BAOCHE) from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (pooled RR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). Only a minor proportion of patients randomised to ATTENTION and BAOCHE received IVT as part of the BMT.
Figure 4.6.
Figure 4.6.
PICO 4 – Forest plot showing differential effect of reperfusion therapy stratified by NIHSS cutoff 10, including data from randomised-controlled clinical trials (RCTs) and registry studies. Good functional outcome (mRS scores of 0–3 at 3 months in all except BASICS prospective registry, where it was assessed at 1 month) in patients with acute ischaemic stroke presenting within 6 h (BASICS), within 12 h (ATTENTION), within 6–24 h (BAOCHE), or 24 h (RESCUE Japan Registry 2), or no time limit (BASICS prospective registry) from the time last known well, treated with endovascular treatment plus best medical treatment (BMT) versus BMT alone (p-value for interaction <0.00001, Cochran’s Q-test for interaction testing). Only a minor proportion of patients randomised to ATTENTION and BAOCHE received IVT as part of the BMT.
Figure 4.7.
Figure 4.7.
PICO 4 – Interaction testing for treatment effect between EVT ± IVT and no EVT (100% IVT) in patients with GCS 3–7 and 8–15.
Figure 5.1.
Figure 5.1.
PICO 6 – Risk of bias in an observational study.
Figure 6.1.
Figure 6.1.
PICO 7 – Risk of bias for the non-randomised trials included in PICO 7.
Figure 6.2.
Figure 6.2.
PICO 7 – Meta-analysis of observational studies: Good functional outcome (mRS scores 0–3 at 90 days) in adults with acute ischaemic stroke due to BAO, treated with direct endovascular thrombectomy versus intravenous thrombolysis and endovascular thrombectomy (pooled OR, random-effects meta-analysis).
Figure 6.3.
Figure 6.3.
PICO 7 – Meta-analysis of observational studies: Good functional outcome (mRS scores of 0–2 at 3 months) in adults with acute ischaemic stroke due to BAO, treated with direct endovascular thrombectomy vs. intravenous thrombolysis and endovascular thrombectomy (pooled OR, random-effects meta-analysis).
Figure 6.4.
Figure 6.4.
PICO 7 – Meta-analysis of observational studies: Good functional outcome (shift mRS scores of at 3 months) in adults with acute ischaemic stroke due to BAO, treated with direct endovascular thrombectomy versus intravenous thrombolysis and endovascular thrombectomy (pooled adjusted OR, random-effects meta-analysis).
Figure 6.5.
Figure 6.5.
PICO 7 – Meta-analysis of observational studies: Symptomatic intracranial haemorrhage post treatment in adults with acute ischaemic stroke due to BAO, treated with direct endovascular thrombectomy versus intravenous thrombolysis and endovascular thrombectomy (pooled adjusted OR, random-effects meta-analysis).
Figure 6.6.
Figure 6.6.
PICO 7 – Meta-analysis of observational studies: Favourable recanalisation (mTICI 2b/3 post treatment) in adults with acute ischaemic stroke due to BAO, treated with intravenous thrombolysis and endovascular thrombectomy versus direct endovascular thrombectomy (pooled adjusted OR, random-effects meta-analysis).
Figure 7.1.
Figure 7.1.
PICO 8 – Risk of bias of the studies.
Figure 7.2.
Figure 7.2.
PICO 8 – Meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Good functional outcome (mRS scores of 0–3 at 3 months) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.3.
Figure 7.3.
PICO 8 – Meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Favourable functional outcome (mRS scores of 0–2 at 3 months) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.4.
Figure 7.4.
PICO 8 – Meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Successful recanalisation (mTICI 2B-3) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.5.
Figure 7.5.
PICO 8 – Meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Symptomatic ICH in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.6.
Figure 7.6.
PICO 8 – Meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Mortality at 90 days in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.7.
Figure 7.7.
PICO 8 – Sensitivity meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Good functional outcome (mRS scores of 0–3 at 3 months) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration vs. stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.8.
Figure 7.8.
PICO 8 – Sensitivity meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Favourable functional outcome (mRS scores of 0–2 at 3 months) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration vs. stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.9.
Figure 7.9.
PICO 8 – Sensitivity meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Successful recanalisation (mTICI 2B-3) in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.10.
Figure 7.10.
PICO 8 – Sensitivity meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Symptomatic intracranial haemorrhage in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration versus stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 7.11.
Figure 7.11.
PICO 8 – Sensitivity meta-analysis of observational studies (except for *post hoc analysis of the BASICS RCT): Mortality at 90 days in adults with acute ischaemic stroke due to acute BAO, treated with EVT using direct aspiration vs. stent retriever as the first-line strategy (pooled OR, random-effects meta-analysis).
Figure 8.1.
Figure 8.1.
PICO 9 – Bias evaluation of the observational studies.
Figure 9.1.
Figure 9.1.
PICO 10 – Risk of bias of the studies included.
Figure 9.2.
Figure 9.2.
PICO 10 – Metanalysis of observational studies comparing add-on antithrombotic treatment versus no add-on antithrombotic medication stratified by studies with only basilar or dominant vertebral artery occlusion versus studies, where basilar artery occlusion was a subgroup of patients: mRS score of 0–2 at 3 months (pooled OR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). *Unadjusted studies.
Figure 9.3.
Figure 9.3.
PICO 10 – Metanalysis of observational studies comparing add-on antithrombotic treatment versus no add-on antithrombotic medication stratified by studies with only basilar or dominant vertebral artery occlusion versus studies, where basilar artery occlusion was a subgroup of patients: Mortality (pooled OR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). *Unadjusted studies.
Figure 9.4.
Figure 9.4.
PICO 10 – Metanalysis of observational studies comparing add-on antithrombotic treatment versus no add-on antithrombotic medication stratified by studies with only basilar or dominant vertebral artery occlusion versus studies, where basilar artery occlusion was a subgroup of patients: sICH (pooled OR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). *Unadjusted studies
Figure 9.5.
Figure 9.5.
PICO 10 – Metanalysis of observational studies comparing add-on antithrombotic treatment versus no add-on antithrombotic medication stratified by studies with only basilar or dominant vertebral artery occlusion versus studies, where basilar artery occlusion was a subgroup of patients: recanalisation TICI 2B-3 (pooled OR, random-effects meta-analysis, Cochran’s Q-test for interaction testing). *Unadjusted studies.
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