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Endovascular therapy is effective for basilar artery occlusion in patients with moderate/severe symptoms (ATTENTION)
Clinical Question
For patients with an acute basilar artery occlusion, is endovascular thrombectomy safer and more effective than standard medical therapy?
Bottom line
In patients with acute basilar artery occlusion causing moderate to severe symptoms, endovascular thrombectomy significantly reduced the likelihood of disability (NNT = 4) and mortality (NNT = 5) at 90 days. The authors note that Chinese patients have a high prevalence of intracranial large artery atherosclerosis, and that the results may not generalize. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
Previous studies have been inconclusive regarding the value of endovascular thrombectomy for the treatment of acute basilar artery occlusion, a condition with high morbidity and mortality. This study from China identified 342 adults (of the 507 screened) with a moderate to severe ischemic stroke and moderate to severe symptoms (NIH Stroke Scale score of 10 or higher) that were consistent with basilar artery occlusion. Patients with previous stroke-related disability and those with intracranial hemorrhage were excluded. After confirming basilar artery occlusion on imaging, patients were randomized in a 1:2 ratio to receive best medical care or best medical care plus endovascular therapy, which could include stent retrievers, thromboaspiration, balloon angioplasty, stent deployment, intraarterial thrombolysis, or combinations of those therapies. Approximately one-third underwent intravenous thrombolysis, as well. All patients were treated within 12 hours of when they were last well. The mean age at baseline was slightly older than 66 years, 68% were men, and groups appeared to be balanced at baseline. The average time from stroke onset to revascularization was 6.9 hours. The primary outcome of having a modified Rankin score of 0 to 3 at 90 days was more likely in the intervention group (46% vs 23%; relative risk [RR] 2.06; 95% CI 1.46 - 2.91; number needed to treat [NNT] = 4). Although 90-day mortality was also lower in the intervention group (37% vs 55%; RR 0.66; 0.52 - 0.82; NNT = 5), intracranial hemorrhage occurred in 12 patients (5%) in the intervention group compared with none in the usual care group (P = 0.13 by my calculation using Fisher’s exact test).
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Thrombectomy for basilar artery occlusion
Maybe not quite ready for prime time in a North American setting but the results of this study are impressive. This has important implications for paramedic management since currently, paramedics are trained to identify patients with suspected LVO occlusion (i.e. MCA) who are then are preferentially transported to a thrombectomy centre even if it means bypassing other non-thrombectomy capable stroke centres. Stroke recognition guidelines for paramedics are not designed, nor has significant research been done, to assist paramedics to identify patients with basilar artery occlusion. Now is the time to start researching this aspect of stroke management.
Endovascular treatment
Good presentation of the data.
thrombectomy for acute basilar artery occlusion
surgery better outcomes