Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: A Propensity-Matched Analysis from the Attention Multicentre Registry

Background: Data regarding the comparative efficacy and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes due to acute basilar artery occlusion (BAO) remains controversial. Methods: The present analysis was based on the ongoing prospective multicentre endovascular treatment for acute basilar artery occlusion (ATTENTION) registry in China. We performed a propensity score analysis matching patients treated with BMM with those treated with EVT on a 1:3 ratio. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favourable functional outcome (modified Rankin Score 0-3) at 90 days. We also performed a sensitivity analysis within the inversed propensity of treatment weighting (IPTW) cohort. Findings: Our analytic sample comprised 2,134 patients recruited across 48 sites between 2017 and 2021, including 462 patients received BMM and 1,672 patients who received EVT. Age (median, 65), sex (male, 68%), baseline NIHSS score (median, 21), the proportions of favourable imaging profile (PC-ASPECTS ≥8: ~89%), intravenous alteplase use (~23%) and time from onset to admission (median ~ 333 minutes) were comparable across the PSM groups (n=443 in BMM group; n=1,329 in EVT group). Compared with BMM treated patients, there was a significantly higher rate of favourable outcome at 90 days among EVT patients (adjusted relative risk (1.37 [95% CI: 1.18 to 1.60], absolute risk difference 0.11 [95% CI: 0.06 to 0.15]). The mortality was significantly lower (adjusted relative risk (0.81 [95% CI: 0.72 to 0.91], absolute risk difference -0.09 [95% CI: -0.14 to -0.04]) in patients undergoing EVT. Results were generally consistent across the secondary endpoints. Similar associations were seen in the IPTW cohort. Interpretation: In this large, 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. Clinical Trial Registration Details: ATTENTION is registered on the Chinese Clinical Trial Registry (http://www.chictr.org.cn; ChiCTR2000041117). Funding Information: ATTENTION was an independent, investigator-initiated registry, and no external support was received. Declaration of Interests: RGN reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, Synchron, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse and Perfuze. RGN is one of the Principal Investigators of the “Endovascular Therapy for Low NIHSS Ischemic Strokes (ENDOLOW)” trial. Funding for this project is provided by Cerenovus. RGN is an investor in Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, and Viseon. Other authors have no conflict of interest. Ethics Approval Statement: The study was approved by the ethical committee of the first affiliated hospital of university of science and technology of China. All patients or their legally authorized representatives provided signed informed consent.