Clinical Pearls & Morning Reports
Langezaal et al. conducted a randomized trial involving patients with strokes due to basilar-artery occlusion. They compared the efficacy and safety of endovascular therapy initiated within 6 hours after the estimated time of basilar-artery occlusion with those of medical therapy. Read the NEJM Original Article here.
Q: What percentage of all ischemic strokes caused by intracranial proximal large-vessel occlusion are due to basilar-artery occlusion?
A: Basilar-artery occlusion accounts for approximately 10% of all ischemic strokes caused by intracranial proximal large-vessel occlusion, and is associated with high morbidity and mortality.
Q: Have major trials of endovascular therapy for stroke included patients with basilar-artery occlusion?
A: Few patients with basilar-artery occlusion have been included in major trials of endovascular therapy, which have mainly enrolled patients with strokes in the anterior cerebral circulation. The vascular anatomy, clinical presentation, and severity of neurologic deficit in patients with basilar-artery occlusion differ from those in patients with anterior-circulation strokes. These differences suggest that trials of endovascular treatment should be conducted independently for patients with strokes in the basilar-artery territory.
A: The primary outcome of the trial was a favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. In this trial, there was not a statistically significant difference in the primary outcome between the group of patients who received endovascular therapy for basilar-artery occlusion initiated within 6 hours after the time of stroke and those who received medical therapy. In the intention-to-treat analysis, 68 of 154 patients (44.2%) in the endovascular treatment group had a favorable functional outcome, as compared with 55 of 146 patients (37.7%) in the medical treatment group (risk ratio, 1.18; 95% confidence interval [CI], 0.92 to 1.50; P=0.19). The trial did not show an advantage of endovascular therapy over medical therapy, but these findings may be inconclusive. The results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion.
A: The primary safety outcomes were symptomatic intracranial hemorrhage detected on neuroimaging within 3 days after the initiation of treatment and mortality at 90 days. Mortality at 90 days was 38.3% in the endovascular group and 43.2% in the medical care group (risk ratio, 0.87; 95% CI, 0.68 to 1.12; P=0.29). The risk of symptomatic intracranial hemorrhage within 3 days after the initiation of treatment was 4.5% in the endovascular group and 0.7% in the medical care group (risk ratio, 6.9; 95% CI, 0.9 to 53.0; P=0.06).