Despite the disappointing results of the BEST and BASICS trials for basilar artery occlusion strokes, in some cases, patients might benefit from endovascular therapy (EVT) after all, according to a closer look at the data.
Raul Nogueira, MD, of Grady Memorial Hospital and Emory University School of Medicine in Atlanta, and colleagues in the VERITAS group, presented their findings at the American Stroke Association virtual International Stroke Conference.
On adjusted intention-to-treat analysis, among the 351 stroke patients with baseline NIH Stroke Scale (NIHSS) scores of ≥ 10, having EVT showed a 38.7% chance of zero-to-moderate disability modified Rankin Scale [mRS] 0-3) at 90 days compared to 26.5% with best medical management (adjusted OR 1.94).
EVT also offered a mortality reduction benefit over controls (40.3% vs 48.2%), although at the risk of increased risk of symptomatic intracranial hemorrhage (5.0% vs 0.6%). Subgroup analysis suggested that older patients tended to have especially good outcomes with EVT.
Based on the study’s results, it does appear “that some patients with basilar artery occlusion strokes benefit from mechanical thrombectomy,” commented Steven Hetts, MD, of UCSF Mission Bay Hospitals in San Francisco.
“The trends do appear to be toward favoring EVT in selected patients, which is consistent with our earlier experience in anterior circulation large vessel occlusion [LVO] strokes,” he noted.
Given how rare they are, posterior circulation LVO strokes are challenging to study, and are also characterised by complex symptoms and severity.
Nogueira noted that the BEST and BASICS were underpowered as they had suffered from poor recruitment, crossovers, and selection issues. Additionally, the BASICS trial had undergone a protocol modification to allow recruitment of people with milder strokes (NIHSS <10), which had potentially diluted the treatment effect. An important point which had been missed was that underlying atrial fibrillation was more prevalent at baseline among the EVT arm than controls.
This implies “that their basilar occlusions may more likely have been from embolization of a clot from the heart to an otherwise normal basilar artery,” according to Dr Hetts. “I would expect that those patients would do better clinically than patients with underlying atherosclerotic disease in the basilar artery itself that leads to basilar artery occlusion.”
Source: MedPage Today
Presentation information: Nogueira RG, et al “Vertebrobasilar occlusion randomization to endovascular reperfusion versus intravenous thrombolysis or medical treatment alone systematic evaluation (VERITAS) collaboration” ISC 2021; Abstract LB 11.
