Core messages
In strokes caused by occlusion of the basilar artery, patients have a clear medical advantage from endovascular thrombectomy. 90-day survival is significantly increased by 25-34% compared to standard therapy without thrombus removal. Thrombectomy also significantly improves functional outcome (1, 2).
Background
Strokes are the leading cause of acquired disability and one of the leading causes of death.In Germany, around 270,000 people have a stroke every year, 85% of which are caused by ischemic (3). If possible, therapy should begin within a time window of 4.5 hours. Pharmacological thrombolysis and mechanical thrombectomy are the methods of choice for large vascular occlusions of the internal carotid artery and/or the media cerebral artery. In the case of acute larger vascular occlusions of the posterior cerebral circulation (vertebral artery/basilar artery), a thrombectomy is also recommended internationally by professional societies, but not on the basis of randomized studies, but only on the basis of registry data. There are now two large, prospectively randomized studies by Chinese researchers on the question of thrombectomy in strokes caused by basilaris occlusion (1, 2).
Design
- Studies: BAOCHE (1) and ATTENTION (2)
- Type of study: multicenter, prospectively randomized open trials
- Participants in
- BAOCHE study: 217 adult patients (O: 64 years) with acute stroke due to occlusion of the A.basilaris that could be treated within 6-24 hours and received either standard therapy plus thrombectomy (n = 117) or standard therapy without thrombectomy (n = 110; control) and the
- ATTENTION study: 340 adult patients (O: 66 years) with moderate or severe stroke due to occlusion of the basilar artery who could be treated within 12 hours and received either standard therapy plus thrombectomy (n = 226; 31% with thrombolysis) or standard non-thrombectomy therapy (n = 114, control; 34% with thrombolysis)
- Primary endpoints In both studies, the proportions of patients with good functional status (modified Rankin Scale [mRS]; 0: no symptoms; 3: good function; 6: death) or death within 90 days
- BAOCHE study: 217 adult patients (O: 64 years) with acute stroke due to occlusion of the A.basilaris that could be treated within 6-24 hours and received either standard therapy plus thrombectomy (n = 117) or standard therapy without thrombectomy (n = 110; control) and the
- ATTENTION study: 340 adult patients (O: 66 years) with moderate or severe stroke due to occlusion of the basilar artery who could be treated within 12 hours and received either standard therapy plus thrombectomy (n = 226; 31% with thrombolysis) or standard non-thrombectomy therapy (n = 114, control; 34% with thrombolysis)
Main results
- The BAOCHE study was stopped after a prespecified interim analysis due to the superiority of thrombectomy.
- A good mRS score (0-3) was achieved by 46% in the thrombectomy group compared to 24% in the control group (adjusted rate ratio [aRR]: 1.81; p <0.001).
- 90-day mortality was 31% in the thrombectomy group and 42% in the control group (aRR: 0.75).
- Symptomatic intracranial haemorrhage occurred in 6% in the thrombectomy group and in 1% in the control group (aRR: 5.18).
- In the ATTENTION study (2), 46% also achieved good functional status after 90 days in thrombectomy (mRS score ≤3), but only 23% in the control group (aRR: 2.06, p <0.001).
- 90-day mortality was 37% after thrombectomy and 55% in the control group (aRR: 0.66).
- Symptomatic intracranial haemorrhage occurred in 5% of the thrombectomy group and in no patients in the control group.There was one death from arterial perforation in thrombectomy.
Clinical significance
«Two relatively large, randomized prospective studies show a significant therapeutic benefit of additional mechanical thrombectomy to standard therapy in acute basilar occlusion,» comments Prof. Dr. Hans-Christoph Diener, Essen (4). «Practically twice as many patients achieved a good functional outcome. However, the 90-day mortality rate remained high at around one third, although significantly lower than with standard therapy alone.»
In both studies, however, the time windows for the start of therapy were more than the otherwise required 4.5 hours. The special patient populations are limiting the transferability of the results: The majority of participants come from Asia, where the prevalence of pre-existing stenosis of the basilar artery is higher than in Caucasians. «It would be desirable to confirm these results in a European population,» says stroke expert Diener.
Funding: public funds/p>
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Source — https://www.univadis.de/viewarticle/schlaganfall-durch-basilaris-verschluss-thrombektomie-senkt-die-sterblichkeit-deutlich