Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: Results From the ATTENTION Multicenter Registry

Abstract

Background: The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO). Methods: The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0–3) at 90 days. We also performed a sensitivity analysis with the propensity score matching–based and the instrumental variable–based analysis. Results: In our primary analysis using the inversed probability of treatment weighting–based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19–1.65]; absolute risk difference, 11.8% [95% CI, 6.9–16.7]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69–0.88]; absolute risk difference, −10.3% [95% CI, −15.8 to −4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching–based and instrumental variable–based analysis. Conclusions: In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed. Registration: URL: www.chictr.org.cn ; Unique identifier: ChiCTR2000041117.

Improving neurological outcome for acute basilar artery occlusion with sufficient recanalization after thrombectomy by intraarterial tenecteplase (INSIST-IT): Rationale and design

“…The secondary efficacy endpoints are a comparison between the active and control groups as follows: (1) the proportion of patients with an improved mTICI score (from 2b/c to 3) after intraarterial TNK administration or at the end of procedure; (2) the proportion of patients with mRS 0-1 at 90 days; (3) the proportion of patients with mRS 0-2 at 90 days; (4) ordinal distribution of mRS at 90 days; (5) change in mRS at 90 days compared with premorbid mRS; (6) change in NIHSS at 24 (−6/ + 24) h, compared with the NIHSS at baseline; (7) the proportion of early neurological improvement (ENI), defined as a NIHSS decrease ⩾4 within 24 (−6/ + 24) h; (8) change in the cerebral circulation time after treatment, defined as the time from the appearance of contrast at the V2 segment of the vertebral artery to the end of the basilar artery during DSA; (9) the composite of recurrent stroke, cardiovascular or cerebrovascular events within 90 days after randomization.…”

“…The primary endpoint in INSIST-IT will be further analyzed by the following subgroups: (1) intravenous thrombolysis (yes vs no); (2) estimated onset of symptoms to TNK time (⩽12 h vs 12-24 h); (3) NIHSS score on admission (4-10 vs >10); (4) age (<60 vs ⩾60); (5) gender (men vs women); (6) stroke etiology (large-artery atherosclerosis vs cardioembolism); (7) baseline pc ASPECTS (6-7 vs 8-10; (8) mTICI (2b vs 2c/3); (9) blood glucose (⩽100 mg/ dl vs >100 mg/dl).…”

“…5,6 Two multicenter, registry studies suggested the benefit of EVT for BAO patients. 7,8 Even so, another challenge that is often encountered in BAO patients receiving EVT is the relatively high rate of reperfusion without functional independence: only about half of patients have a good functional outcome at 90 days (mRS 0-3) although with a > 85% sufficient reperfusion rate. 9,10 Nonetheless, a pharmacological adjunct such as intraarterial thrombolysis that could enhance the clinical benefit of the endovascular procedure is of importance.…”

“…3,4 The benefit of EVT for acute BAO patients was controversial with two early neutral trials (BEST and BASICS). [5][6][7][8] Although, two recent randomized controlled trials (BAOCHE and ATTENTION trials) have demonstrated that EVT was associated with better functional outcomes and survival at 90 days for acute BAO patients, 9,10 only 46% of patients achieved good neurological outcomes (mRS 0-3) at 90 days.…”

Intraarterial thrombolytics as an adjunct to mechanical thrombectomy in patients with basilar artery occlusion

“…We analyzed data from Endovascular Treatment for acute Basilar Artery Occlusion (ATTENTION) registry, which is an ongoing nationwide, prospective, multicenter registry collecting predefined data of acute ischemic stroke patients with basilar artery occlusion who undergo mechanical thrombectomy. The details of the registry are previously published 10 . ATTENTION is registered on the Chinese Clinical Trial Registry (http://www.chictr.org.cn; ChiCTR1800014759).…”