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JOURNAL OF LETTER TO THE EDITOR http://dx.doi.org/10.1097/JBR.0000000000000138 Therapeutic strategies for acute basilar-artery occlusion Manyue Ge, Pengfei Yang, Jianmin Liu* To the editor: Two RCTs in China recently published in The New England Acute basilar-artery occlusion (aBAO) is one of the most severe Journal of Medicine provide new evidence for the endovascular [8,9] forms of stroke, with an incidence of severe disability and death treatment of aBAO. [1–3] of up to 80%. Although several previous prospective multi- The Endovascular Treatment for aBAO (ATTENTION) center randomized controlled trials (RCTs) involving patients trial enrolled 340 patients from 36 centers in China within 12 with acute stroke due to large-artery occlusion in the anterior hours after the estimated time of aBAO from 2021 to 2022 and circulation have shown that endovascular thrombectomy (EVT) randomly assigned them into two groups: 226 (31% received dramatically improves prognosis over best medical management thrombolysis) to the EVT group and 114 (34% received throm- [4,5]  (BMM), the efficacy and safety of EVT for aBAO remain bolysis) to the BMM group. All patients had a baseline NIHSS controversial. score of 10 or higher. Good functional status (modified Rankin To date, neither of the two RCTs published has shown scale score, 0–3) at 90 days was observed in 46% of the patients an overwhelming advantage of EVT over BMM for patients in the EVT group and 23% in the BMM group (adjusted rate [6,7] with aBAO. The Basilar Artery Occlusion Endovascular ratio [aRR], 2.06; 95% CI, 1.46–2.91). The incidence of symp- Intervention versus Standard Medical Treatment (BEST) tomatic intracranial hemorrhage was 5% and 0% in the EVT trial was terminated early due to poor recruitment and high and BMM groups, respectively. The mortality at 90 days in these  crossover. Although EVT showed better efficacy compared two groups were 37% and 55%, respectively (aRR, 0.66; 95% with BMM in both per-protocol (44% vs 25%; adjusted CI, 0.52–0.82). odds ratio [aOR], 2.90; 95% confidence interval [CI], In the Basilar Artery Occlusion Chinese Endovascular 1.20–7.03) and as-treated (47% vs 24%; aOR, 3.02; 95% (BAOCHE) trial, a total of 217 patients from multiple cen-  CI, 1.31–7.00) populations, there were no differences in the ters in China underwent randomization from 2016 to 2021. intention-to-treat analysis (42% vs 32%; aOR, 1.74; 95% Enrollment was terminated at a prespecified interim analysis CI, 0.81–3.74). due to marked differences in the primary outcomes between Similarly, the Basilar Artery International Cooperation the two groups. Ultimately, 110 patients were assigned to the Study (BASICS) trial did not indicate any significant differ - EVT group (14% received thrombolysis) and 107 patients to ences between EVT and BMM (44% vs 38%; risk ratio [RR], the BMM group (21% received thrombolysis). All patients  1.18; 95% CI, 0.92–1.50). Only a subgroup analysis in which had a baseline NIHSS score of 6 or higher. Good functional patients’ National Institutes of Health Stroke Scale (NIHSS) status (modified Rankin scale score, 0–3) at 90 days showed score was required to be 10 or above revealed that EVT might that EVT was significantly superior to BMM (46% vs 24%; provide better results. The long duration (2011–2019), slow aRR, 1.81; 95% CI, 1.26–2.60). The incidence of symptom- enrollment, underlying selection bias (29.2% of eligible patients atic intracranial hemorrhage in the EVT and BMM groups were treated outside the trial) of the trial and imbalance of was 6% and 1%, respectively (rate ratio [RR], 5.18; 95% patients with atrial fibrillation in the two treatment groups lim- CI, 0.64–42.18). The mortality at 90 days was 31% in the ited some analyses of the BASICS. EVT group and 42% in the BMM group (aRR, 0.75; 95% CI, However, two real-world cohort studies from China indi- 0.54–1.04). cated that receiving EVT in 24 hours led to better functional Compared with previous trials, possible reasons for the posi- [1,3] outcomes at 90 days than BMM for patients with aBAO. tive outcomes of the ATTENTION and BAOCHE trials are that: Therefore, more well-designed RCTs are necessary to compare (1) Both trials were strictly conducted, which kept the crossover the efficacy of EVT and BMM on basilar-artery stroke. rate low (5/217 for BAOCHE, 6/340 for ATTENTION). (2) The inclusion criteria of both trials were even more stringent. Patients were eligible for the enrollment of ATTENTION only Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, when their NIHSS was 10 or higher. Both trials required the China posterior circulation Alberta Stroke Program Early Computed *Corresponding author: Jianmin Liu, Neurovascular Center, Changhai Hospital, Tomography Score to be 6 or higher; the BAOCHE trial Naval Medical University, Shanghai 200433, China. E-mail: firstname.lastname@example.org restricted enrollment to patients with a Pons-Midbrain Index Copyright © 2023 The Chinese Medical Association, Published by Wolters of more than 2 points, to exclude those with large infarcts in Kluwer Health, Inc. This is an open-access article distributed under the terms of the posterior circulation, particularly in the brain stem. What’s the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 more, both trials extended the time window of aBAO (the time (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially window for BEST and BASICS was 0–6 hours), providing evi- without permission from the journal. dence that allowed more patients to be treated with EVT. Journal of Bio-X Research (2023) 6:1–2 The two trials also had several drawbacks: First, the enrolled Received: 29 November 2022; Accepted: 14 February 2023 populations were all East Asian, with a high prevalence of http://dx.doi.org/10.1097/JBR.0000000000000138 large-artery atherosclerosis stenosis (44% in ATTENTION), 1 LETTER TO THE EDITOR Journal of Bio-X Research leading to high rates of intracranial angioplasty or stenting. Financial support Therefore, caution should be exercised in generalizing these None. findings to a larger population. Second, the limited proportion of patients who received thrombolysis (32% in ATTENTION Conflicts of interest and 18% in BAOCHE) owing to a variety of reasons might have influenced the outcomes in the control group. In a prespecified The authors declare that they have no conflicts of interest. subgroup analysis of 108 patients who received thrombolysis in ATTENTION, no significant differences in the favorable out- References comes were observed between the two treatments (RR, 1.57;  Zi W, Qiu Z, Wu D, et al. Assessment of endovascular treatment for 95% CI, 0.97–2.54). Third, neither trials included patients with acute basilar artery occlusion via a nationwide prospective registry. JAMA Neurol 2020;77:561–573. doi: 10.1001/jamaneurol.2020.0156. mild stroke (NIHSS < 6), for whom EVT should be carefully  Schonewille WJ, Wijman CAC, Michel P, et al. Treatment and outcomes considered. of acute basilar artery occlusion in the Basilar Artery International Despite these limitations, ATTENTION and BAOCHE were the Cooperation Study (BASICS): a prospective registry study. Lancet first to demonstrate the efficacy of endovascular thrombectomy Neurol 2009;8:724–730. doi: 10.1016/S1474-4422(09)70173-5.  Tao C, Qureshi AI, Yin Y, et al. Endovascular treatment versus best med- in the treatment of posterior circulation large-vessel occlusion on ical management in acute basilar artery occlusion strokes: results from a global scale, and provided new strategies for the management of the ATTENTION multicenter registry. Circulation 2022;146:6–17. doi: severe stroke in the posterior circulation. In recent years, Chinese 10.1161/CIRCULATIONAHA.121.058544. neurointerventionalists have published several high-quality RCTs  Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombec- tomy after large-vessel ischaemic stroke: a meta-analysis of individual in major international journals such as The New England Journal patient data from five randomised trials. Lancet 2016;387:1723– of Medicine, The Lancet, and Journal of the American Medical 1731. doi: 10.1016/S0140-6736(16)00163-X. Association, despite their extremely heavy clinical workload.  Jovin TG, Nogueira RG, Lansberg MG, et al. Thrombectomy for anterior Their scientific efforts are to be commended for guiding health circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis. Lancet policy and clinical practice in China, and also for influencing the 2022;399:249–258. doi: 10.1016/S0140-6736(21)01341-6. treatment of stroke in Western countries.  Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard med- ical treatment for vertebrobasilar artery occlusion (BEST): an open-la- bel, randomised controlled trial. Lancet Neurol 2020;19:115–122. doi: Acknowledgments 10.1016/S1474-4422(19)30395-3.  Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. None. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med 2021;384:1910–1920. doi: 10.1056/NEJMoa2030297.  Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of Author contributions acute basilar-artery occlusion. N Engl J Med 2022;387:1361–1372. doi: 10.1056/NEJMoa2206317. MG, PY, and JL designed, wrote and edited the manuscript. JL  Jovin TG, Li C, Wu L, et al. Trial of Thrombectomy 6 to 24 hours after was the corresponding author. All authors approved the final stroke due to basilar-artery occlusion. N Engl J Med 2022;387:1373– version of the manuscript. 1384. doi: 10.1056/NEJMoa2207576.
Journal of Bio-X Research – Wolters Kluwer Health
Published: Mar 7, 2023
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