EVT Benefits Persist up to 3 Years After Stroke due to BAO

 If it wasn't 100% recovery then it wasn't a favorable outcome to the survivor!  Your tyranny of low expectations should be rooted out of stroke.

EVT Benefits Persist up to 3 Years After Stroke due to BAO

Favorable functional outcomes after endovascular thrombectomy (EVT) in patients with ischemic stroke due to care(NOT RECOVERY!)r artery occlusion were sustained up to 3 years, but only in those younger than 70, new research showed.

Investigators found that more than twice as many stroke patients who received EVT were ambulatory and capable of self-care at 3 years compared to those who got best medical management alone.

Patients receiving EVT also had lower mortality and higher rates of other functional outcomes.

“These findings reinforce EVT as the standard of care and support broader implementation and timely access to thrombectomy services for posterior circulation stroke,” lead author Wei Hu, MD, PhD, Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China, and colleagues wrote.

The findings were published online on December 29 in JAMA Neurology.

Standard of Care

Basilar artery occlusion is an uncommon but devastating subtype of ischemic stroke. As previously reported by Medscape Medical News, earlier results from the ATTENTION trial showed that EVT improves 3-month functional outcomes compared to best medical management in affected patients.

However, data regarding the longer-term efficacy of thrombectomy have been limited.

The new 3-year follow-up extension of the ATTENTION trial included 307 adults (mean age, 68 years) who were treated between February 2021 and January 2022 across 36 stroke centers in China. Participants had presented with moderate to severe ischemic stroke (National Institutes of Health Stroke Scale score of 10 or greater) due to basilar artery occlusion within 12 hours of the estimated time of onset.

Patients were randomly assigned to receive either EVT plus best medical management (thrombectomy group) or best medical management alone (control group).

Clinical assessments were conducted at baseline, 24 hours, 7 days or at hospital discharge, 90 days, 12 months, and 3 years.

The primary endpoint was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-3. Researchers adjusted for age, prestroke mRS score, time from symptom onset to randomization, and stroke severity.

Follow-up data for the new study were collected through January 2025.

Excellent Functional Outcome

At 3 years, 38.4% of the thrombectomy group had achieved ambulatory and self-care capable status (mRS score, 0-3) vs 18.3% in the control group (adjusted risk ratio [RR], 2.05; 95% CI, 1.35-3.11; P  = .001).

An excellent functional outcome (mRS score, 0-1) was observed in 30.5% of patients in the thrombectomy group vs 9.6% in the control group (adjusted RR, 3.03; 95% CI, 1.69-5.44).

More subjects in the thrombectomy group than in the control group had an mRS score of 0-2, indicating functional independence (35.5% vs 12.5%; adjusted RR, 2.71; 95% CI, 1.62-4.54).

“Among every 100 patients treated with EVT rather than medical management, 20 more would be ambulatory and self-care capable, and 23 more would be functionally independent at 3 years,” wrote the authors.

Quality of life, as measured by the European Quality of Life 5-Dimension 5-Level questionnaire, was higher in the thrombectomy group. And more patients in this group achieved independence in instrumental activities of daily living as measured by the Barthel Index.

The mortality rate steadily increased and was relatively high at 3 years in both the EVT group (55.7%) and the control group (73.1%), but it was significantly lower in the thrombectomy group.

A prespecified subgroup analysis found that patients younger than 70 benefited from the treatment (adjusted RR, 2.70; 95% CI, 1.52-4.78), but those aged 70 or older did not.

Important Insights

In extending the follow-up period to 3 years, the study “offers important insights into the long-term trajectory of recovery after endovascular thrombectomy in patients with basilar artery occlusion,” wrote the authors.

The study didn’t include patients on the more extreme spectrum of stroke severity (mild or very severe). It also didn’t correct for multiple testing, so analyses should be considered exploratory, the authors noted.

In addition, the trial wasn’t powered to assess differences in treatment effects across subgroups, and researchers didn’t record medication compliance, vascular risk factor control benchmarks, interim adverse events, or the rate of recurrent stroke, all of which could affect long-term functional outcomes, they added.

Also, the relatively low use of thrombolysis may have contributed to poorer outcomes in the control group and to the clinical magnitude between groups.

'Solid Evidence' 

Reached for comment, Johanna Ospel, MD, PhD, neuroradiology fellow and stroke researcher at University of Calgary, Canada, said the 3-year results are “important because they show that the benefit of EVT is sustained over the long-term: EVT benefit in the EVT arm is long-lasting, beyond the standard 3-months outcome assessment.”

Ospel said she personally was not surprised by the long-term data, “but, in some ways, these results, together with the BAOCHE trial, did turn the evidence for basilar occlusion EVT upside down because we really did not have a good evidence basis for treating these occlusions with EVT,” she told Medscape Medical News.

“Most of us probably did offer EVT for some basilar occlusion patients even before ATTENTION and BAOCHE, but this was really not based on solid data and [was] off-label,” Ospel added.

“Thanks to these two trials, we now can say that basilar occlusion EVT is based on solid evidence from randomized trials, and that has important implications for systems of care, guidelines, insurance providers and procedural reimbursement,” she concluded.

The study was funded by the Fundamental Research Funds for Central Universities and the Program for Innovative Research Team of The First Affiliated Hospital of the University of Science and Technology of China. The study authors reported no conflicts of interest. Ospel reports being co-author of the American Heart Association (AHA)/American Stroke Association(ASA) 2022 scientific statement “Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment.”