The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

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The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

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Wen Sun, Zuowei Duan, Pengfei Xu, ...

First Published August 13, 2022 Research Article 

https://doi.org/10.1177/17562864221114627

Article information

Abstract

Background:

Whether endovascular treatment (EVT) is safe and effective for vertebrobasilar artery occlusion (VBAO) is yet incompletely understood. Two RCTs, the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST) trail and the Basilar Artery International Cooperation Study (BASICS), concentrating on this field were recently reported.

Objective:

We use real-world registry data of VBAO to compare the outcome of EVT inside and outside the inclusion and exclusion criteria of the BEST and BASICS study to testify the feasibility of the selection paradigms of VBAO in these trials.

Methods:

Consecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. The safety outcomes [3-month mortality, symptomatic intracranial hemorrhage (sICH), and effectiveness outcomes (the proportion of 3-month functional independence (mRS of 0–2) and favorable outcome (mRS of 0–3)] were compared between VBAO patients who meet or failed to meet the BEST/BASICS selection criteria for EVT.

Results:

Our study cohort consisted of 577 VBAO patients who underwent EVT. Of them, 446 patients had pc-ASPECTS ≧8. Successful reperfusion (mTICI 2b or 3) was achieved in 85.4% (n = 493). There were 418 patients fulfilling the BEST criterion for EVT and 194 fulfilling the BASICS criterion. Regression analysis indicated that adherence to BEST or BASICS criterion for EVT was not independently related to most of the safety and effectiveness outcome except that adherence to BEST was significantly associated with the 3-month favorable outcome (OR_BEST: 1.742, 95% CI: 1.087–2.790). However, when we put pc-ASPECTS into both criteria with a cut-off value of 8, meeting both BEST criterion plus pc-ASPECTS and BASICS criterion plus pc-ASPECTS was independently related to 3-month functional independence (OR_BEST: 1.687, 95% CI: 1.077–2.644; OR_BASIC: 1.653, 95% CI: 1.038–2.631) and favorable outcome (OR_BEST: 2.280, 95% CI: 1.484–3.502; OR_BASIC: 2.153, 95% CI: 1.372–3.378).

Conclusion:

Our study indicated that, based on real-world data of EVT, adherence to BEST or BASICS criterion for EVT was not independently associated with the safety and effectiveness outcome except that adherence to BEST was significantly related to the 3-month favorable outcome. However, the BEST or BASICS selection criterion and pc-ASPECTS ≧8 might be better paradigms for EVT patient selection.

Keywords

endovascular treatment, inclusive criteria, outcomes, stroke, vertebrobasilar artery occlusions

Introduction

Acute vertebrobasilar artery occlusion (VBAO), accounting for about 1% of all ischemic strokes, is associated with high mortality and disability of up to 70%, which represents the most devastating type of ischemic stroke.^1–4

Previous large trials had indicated an overwhelming benefit of endovascular treatment (EVT) for treating acute anterior circulation ischemic stroke due to emergent large vessel occlusion.^5–8 However, whether EVT is safe and effective for patients with acute VBAO is yet incompletely understood.^9–11

Recently, two multicenter, randomized controlled trials (RCTs), the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion trial (BEST) and the Basilar Artery International Cooperation Study (BASICS), failed to indicate the superiority of EVT over standard medical treatment.^12,13 Despite that, it is still believed in clinical practice that EVT might be helpful for VBAO in case of proper patient selection. We hypothesized that the inclusion and exclusion protocols for EVT in BEST and BASICS are suboptimal for selecting the real patients who need EVT, which might partly explain the negative results of both studies. We therefore use a real-world multicenter database to compare the safety and effectiveness of EVT for patients with VBAO according to the current BEST/BASICS selection criteria for EVT.

Furthermore, the Acute Stroke Prognosis Early Computed Tomography Score (ASPECTS) is a standardized semi-quantitative computed tomographic (CT) grading system used to assess early ischemic changes and predict functional outcomes and ischemic core volumes in patients with acute anterior circulation ischemic stroke.¹⁴ Low ASPECTS has been reported to be associated with poor functional outcome after reperfusion and was adopted as one of the exclusion criteria in several trails in acute anterior circulation ischemic stroke.^6,15–17 The posterior circulation ASPECTS (pc-ASPECTS), first proposed by Puetz et al., was considered as one of the factors associated with functional outcome and mortality in patients with acute VBAO.¹⁸ Several studies have shown that pc-ASPECTS <8 could also identify patients unlikely to achieve favorable outcomes despite successful reperfusion of the basilar artery.^18,19 However, neither the BEST nor the BASICS trial investigators included pc-ASPECTS evaluation in the inclusion criteria. Therefore, we further tried to consider pc-ASPECTS ≧8 as an additional selection criterion and analyzed the safety and effectiveness of EVT divided by the new selection criterion.

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