ATTENTION RCT – Thrombectomy Benefits Basilar Artery Occlusion Stroke?

Written by Sam Parnell

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Endovascular thrombectomy was associated with improved functional neurologic outcomes compared to best medical care for patients with basilar-artery occlusion who presented within 12 hours of stroke onset. However, thrombectomy was also associated with significant procedural complications and an increased risk of intracranial hemorrhage.

Why does this matter?
Up to 80% of patients with basilar-artery occlusions who present with moderate to severe symptoms will die or develop severe disability despite optimal medical care.1-3 BEST and BASICS RCTs, did not show that endovascular therapy was associated with improved clinical outcomes compared to medical therapy. However, there were several limitations with both studies, and the study authors recommended additional, larger trials to better assess the efficacy and safety of endovascular therapy for basilar-artery occlusion.4,5

Pay ATTENTION to Basilar-Artery Strokes
The ATTENTION study was a multi-center, prospective, randomized, open-label trial at 36 medical centers in China comparing endovascular thrombectomy to best medical care for adult patients with basilar-artery occlusion who presented within 12 hours from last known well. Patients were randomly assigned in a 2:1 ratio to undergo endovascular therapy plus best medical care or to receive only best medical care. Best medical care was defined as patients receiving thrombolytic agents, antiplatelet medications, anticoagulation, and supportive care according to national and institutional guidelines.

A total of 340 patients were included in the intention-to-treat analysis. Patient characteristics and demographics were similar between the two groups. A comparable number of patients in each group received intravenous thrombolysis (31% in the thrombectomy group vs 34% in the control group).

Good functional neurologic outcomes (modified Rankin score of 0-3) at 90 days were observed in 46% of patients in the thrombectomy group and 23% in the control group (aRR 2.06 (95%CI 1.46 to 2.91, p<0.001). Furthermore, patients in the thrombectomy group had lower 90-day mortality: 37% in the thrombectomy group vs 55% in the control group, aRR 0.66 (95%CI 0.52 to 0.82). See figure from the article below for a graphical representation of the results.

From cited article

However, adverse events were more common in the thrombectomy group. Symptomatic intracranial hemorrhage occurred in 12 patients (5%) in the thrombectomy and no patients in the control group. Overall, there were 32 procedural complications (14%) associated with thrombectomy, including 6 arterial dissections and 5 vessel perforations with 1 patient dying after arterial perforation.

This suggests that endovascular therapy is associated with better neurologic outcomes compared to best medical therapy alone for patients with basilar-artery occlusion. However, these improved functional outcomes must be weighed against the higher risk of intracranial hemorrhage and procedural complications.

Source
Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022 Oct 13;387(15):1361-1372. doi: 10.1056/NEJMoa2206317.

Works Cited

  1. Writing Group for the BASILAR Group. Assessment of endovascular treatment for acute basilar artery occlusion via a nationwide prospective registry. JAMA Neurol 2020; 77: 561-73.
  2. Schonewille WJ, Wijman CAC, Michel P, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol 2009; 8: 724-30.
  3. Tao C, Qureshi AI, Yin Y, et al. Endovascular treatment versus best medical management in acute basilar artery occlusion strokes: results from the ATTENTION multicenter registry. Circulation 2022; 146: 6-17.
  4. Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial. Lancet Neurol 2020; 19: 115-22.
  5. Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med 2021; 384: 1910-20.

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