Your study design is completely fucking wrong, you're not measuring 100% recovery. Survivors don't want better functional outcome, THEY WANT 100% RECOVERY. Do you never talk to survivors without using your tyranny of low expectations?
Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design
Translational Stroke Research (2022)
Abstract
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
Introduction
Acute basilar artery occlusion (BAO) results in ischemia in brainstem, occipital lobes, and part of the thalami or cerebellum. Without reperfusion therapy, the rate of mortality or severe disability was as high as 90% [1, 2]. With intravenous or intra-arterial thrombolysis, the rate of death or dependency decreased to 78% and 76%, respectively [2, 3]. Although successful endovascular thrombectomy (EVT) for acute BAO was reported almost 2 decades ago [4, 5], its efficacy remains unproven.
In 2015, 5 landmark randomized controlled trials (RCTs) demonstrated powerful efficacy of EVT in patients with acute ischemic stroke (AIS) from large vessel occlusion in the anterior circulation (AC) within 6–12 h of symptom onset [6,7,8,9,10]. In 2018, DAWN and DEFUSE-3 showed similar efficacy in patients with salvageable ischemic penumbra within 16–24 h after last known well [11, 12]. These studies also revealed that EVT during extended time window was not associated with higher risk of symptomatic intracranial hemorrhage (sICH). The aim of this review was to highlight the latest findings of EVT for acute BAO and critical thinking on future study designs.
No comments:
Post a Comment