IMPORTANCE After the many positive results in thrombectomy trials in ischemic stroke of the anterior circulation, the question arises whether these positive results also apply to the patient with basilar artery occlusion (BAO). OBJECTIVE To report up-to-date outcome data of intra-arterial (IA) treatment in patients with BAO and to evaluate the influence of collateral circulation on outcome. DESIGN, SETTING, AND PARTICIPANTS Single-center retrospective case series of 38 consecutive patients with BAO who underwent IA treatment between 2006 and 2015 at a comprehensive stroke center.EXPOSURES Intra-arterial treatment by mechanical thrombectomy and/or IA thrombolysis. MAIN OUTCOMES AND MEASURESAdequate recanalization was defined as a score of 2b or 3 on the Thrombolysis in Cerebral Infarction score. Favorable outcome was defined as a modified Rankin Scale of 0 to 3 at first follow-up. Imaging data on the patency of the vertebral arteries and posterior communicating arteries, as well as the presence of cerebellar arterial anastomosis, were recorded and posttreatment imaging results were reviewed. RESULTSOf the 38 patients with BAO, mean (SD) age was 58 (16) years, and 21 (55%) were male. Twenty-seven patients (71%) were treated with intravenous thrombolysis before IA therapy. Mechanical thrombectomy was applied to 30 patients, and 7 patients received local urokinase without thrombectomy. The median National Institutes of Health Stroke Scale score was 21 (interquartile range [IQR], 15-32) points, and median time to IA treatment was 288 (IQR, 216-380) minutes. Adequate recanalization was achieved in 34 of 38 cases (89%). Functional outcome was favorable in 19 (50%) patients. No association between patent collateral circulation and favorable outcome was found. Symptomatic intracranial hemorrhage occurred in 2 patients (5%). CONCLUSIONS AND RELEVANCEThe proportion of patients reaching a favorable outcome in our study is comparable to the IA-treated group of the MR CLEAN trial and better than the results reported in the BASICS registry, suggesting that IA intervention in patients with BAO is an effective and safe treatment modality in daily clinical practice.

Background and Purpose: The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods: We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results: We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%; P =0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52–2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13–2.15]) than patients without stroke. Conclusions: In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

Background and purpose The frequency of ischemic stroke in patients with COVID-19 varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods We included patients with a laboratory confirmed SARS-CoV-2 infection admitted in 16 hospitals participating in the international CAPACITY-COVID registry between March 1st and August 1st, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit (ICU). Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older, but did not differ in sex or cardiovascular risk factors. Median time between onset of COVID-19 symptoms and diagnosis of stroke was two weeks. The incidence of ischemic stroke was higher among patients who were treated at an ICU (16/586; 2.7% versus 22/1561; 1.4%; p=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted RR: 2.08; 95%CI:1.52-2.84). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functional dependent at discharge and in-hospital mortality. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted RR 1.56; 95%CI:1.13-2.15) than patients without stroke. Conclusions In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was approximately 2%, with a higher risk in patients treated at an ICU. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

To the Editor We thank van Houwelingen et al 1 for their retrospective study exploring the efficacy and safety of intraarterial (IA) treatment in basilar artery occlusion (BAO). They reported adequate recanalization and favorable outcomes in the cohort receiving IA therapy after BAO.We commend the authors' stringent diagnostic workup to confirm the presence of BAO. However, we note that the mean age of the patient cohort was younger than 60 years, and given that this age demographic harbors fewer comorbidities compared with the older than 65 age group where stroke incidence is higher, this confers a favorable outcome regardless of the intervention. Furthermore, although some prestroke comorbidities have been accounted for, atrial fibrillation has not been considered. In patients with atrial fibrillation receiving systemic antithrombotic therapy, IA thrombolysis is contraindicated owing to the increased risk for an adverse intracranial hemorrhage, 2 thus leaving stenting as the only suitable option. Therefore, the very nature of judgement-based treatment allocation leaves the door open for potential selection bias that may significantly affect outcome measures.Although effort has been taken to categorize patency according to vessel subtype, inclusion of multiple criteria within the same category overlooks the varying pathophysiology underlying reduced patency. For example, no patency of vertebral arteries was defined as either complete occlusion, posterior inferior cerebellar artery termination, aplasia or vessel hypoplasia, or high-grade stenosis of more than 70%. Stenotic vessels are commonly caused by platelet plugs associated with atherosclerotic plaque rupture and are less likely to be successfully managed by IA urokinase alone. 2 Alternative methods of stratification may eliminate this bias.This retrospective study 1 covers a period of 9 years, a time in which stent retriever technology has considerably evolved. In particular, the Trevo device has been associated with better recanalization rates and fewer complications compared with Merci. 3 Given the inconsistencies in the device used and the fact that the Trevo device was used in most cases in this study, there may be an overestimation of benefit derived from this treatment modality as a consistent single device was not used.Restoration of cerebral perfusion alone may be insufficient to produce favorable outcomes 4 ; thus, while initial results from this study are promising, it should prompt prospective trials with a larger patient cohort to evaluate the longterm benefit of IA therapy in acute BAO.