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Recent randomized trials of endovascular stroke treatment shed little light on the care of patients with basilar artery occlusion because these patients were specifically excluded from these studies. Registries also have failed to provide strong evidence for a clear benefit, although these studies have often been limited by small sample sizes or by the use of intra-arterial thrombolysis only or of earlier-generation mechanical embolectomy devices, rather than newer stent retrievers.
In this study, researchers identified 148 consecutive patients with a demonstrated basilar artery occlusion on an initial catheter angiogram who received endovascular stroke treatment at 11 centers in Germany and Austria from 2011 to 2013. A majority (59%) had already received intravenous thrombolysis, most (84%) were treated with stent retrievers, and most (79%) achieved recanalization. Certain patient- and procedure-related factors that were previously associated with clinical outcomes were also demonstrated here (e.g., stroke severity and age), and collateral status was rigorously determined and associated with improved outcomes as well. Although the use of stent retrievers was associated with good recanalization, recanalization itself was not independently associated with improved outcomes.
Singer OC et al. Mechanical recanalization in basilar artery occlusion: The ENDOSTROKE study. Ann Neurol 2015 Mar; 77:415.
Comment
The failure to identify an independent link between recanalization and clinical outcomes in this study may reflect important limitations of this observational study. Furthermore, nearly one quarter of patients had an unknown time of symptom onset, which could result in ineffective late recanalization, and patients who underwent magnetic resonance imaging before treatment had better outcomes, which could indicate selection bias. The difficulties of interpreting these exploratory analyses and the potential for residual confounding should increase enthusiasm for randomized clinical trials with refined selection criteria, use of newer devices, and rigorous attention to rapid treatment (or, potentially, collaterals or MRI findings) to reevaluate the role of endovascular stroke treatment for basilar artery occlusion.