No superior treatment for acute basilar artery occlusion

In patients with acute basilar artery occlusion, intra-arterial therapy is not superior to primary intravenous thrombolysis, a study published online in The Lancet Neurology finds. Published online in The Lancet Neurology the study compared outcomes in 592 patients with recent symptomatic basilar artery occlusion who were enrolled at 48 centres in Europe, America, Australia, and the Middle East. Nearly a third of the patients were treated with antithrombotic therapy (AT), 30% with intra-arterial throbolysis (IAT), 14% with intravenous thrombolysis (IVT), 5% with mechanical thrombectomy, 13% with a combination of intra-arterial thrombolysis and thrombectomy, and 7% with IAT and IVT. After one month, 402 patients had a poor outcome, which was defined as a modified Rankin scale score of four or five (for severe disability), or death. In patients with a mild-to-moderate deficit, IVT and IAT were associated with a similar risk of poor outcome (adjusted RR, 0.94 and 1.29, respectively), as compared with outcome following AT. IAT was associated with worse outcomes compared to IVT (adjusted RR, 1.49). In patients with a severe deficit, compared with outcome following AT, treatment with either IVT or IAT was associated with a lower risk of poor outcome (adjusted RR, 0.88 and 0.94, respectively), and outcomes were similar for IAT compared to IVT (adjusted RR, 1.06). "The often-held assumption that IAT is superior to IVT in patients with an acute symptomatic basilar artery occlusion is challenged by our observations," the authors concluded. The results should encourage clinicians to treat patients who have acute symptomatic BAO and a mild-to-moderate deficit with IVT, they said. In an accompanying editorial, Graham Hankey, a neurologist from Royal Perth hospital, said the findings cannot be explained by dramatic systematic differences in treatment allocation according to baseline clinical and prognostic factors. The variations show widespread uncertainty about the relative risks and benefits of the various treatments, he said. “This uncertainty… is the ideal platform from which to launch a large multicentre, randomised trial of the most promising treatment options for basilar artery occlusion,” he concluded. The Lancet Neurology 2009; 8: 724-730....