Outcomes and Safety of Revascularization Approaches for Stroke Related to Isolated Vertebral Artery Occlusions (BRAVO)

 'Better' and 'may' signify COMPLETE FUCKING FAILURE OF 100% RECOVERY! Don't you even know that is the only goal in stroke and you aren't even measuring that. With NO measurements, you'll never get there! 

Here is your business101 requirements. Not measuring 100% recovery is the height of incompetence!

“What's measured, improves.” So said management legend and author Peter F. Drucker ) 

The latest here:

Outcomes and Safety of Revascularization Approaches for Stroke Related to Isolated Vertebral Artery Occlusions (BRAVO)

Alexander Salerno, MD, PhD https://orcid.org/0000-0001-8494-5527 alexander.salerno@chuv.ch, 

Vincent Dunet, MD https://orcid.org/0000-0002-9897-4561, 

Marek Sykora, MD, PhD https://orcid.org/0000-0003-3508-2176, 

Philipp Baumgartner, MD https://orcid.org/0000-0003-1525-2019, 

Visnja Padjen, MD, PhD https://orcid.org/0000-0002-6126-8305, 

Guido Bigliardi, MD https://orcid.org/0000-0001-5312-7206, 

Dylan Ryan, MD https://orcid.org/0000-0001-7254-0020, … Show All … on behalf of the EVA-TRISP and BRAVO Investigators

Abstract

BACKGROUND:

The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear.

METHODS:

This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW).

RESULTS:

Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80–2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, −1 [95% CI, −2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36–13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35–0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86–28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14–32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90–11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT (Pinteraction=0.025).

CONCLUSIONS:

IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

Graphical Abstract

Despite robust evidence demonstrating the benefits of revascularization treatments for large vessel occlusions in anterior circulation strokes, the optimal acute management of occlusive posterior circulation (PC) acute ischemic strokes (AISs) other than basilar artery occlusion (BAO) remains less clear.