Reperfusion treatment in basilar artery occlusion presenting with mild symptoms

Introduction: Endovascular treatment (EVT) improves outcomes for basilar artery occlusion (BAO) with moderate-to-severe symptoms. However, the best treatment for mild symptoms (NIHSS score 0-10 and 0-5) remains unclear. This study compared EVT +/- IVT to IVT alone in BAO patients with mild symptoms.Patients and Methods: From the SITS-International Stroke Treatment Register, we included BAO patients with available baseline NIHSS score, treated by EVT, IVT, or both within 6 h of symptom onset from 2013 to 2021. Using the Doubly Robust approach (propensity score matching plus multivariable logistic regression), we analyzed efficacy (3-month mRS) and safety (SICH and 3-month death) outcomes for EVT +/- IVT versus IVT alone in BAO patients with NIHSS scores 0-10 and 0-5.Results: 1426 patients were included. For NIHSS scores 0-10 (180 matched, 1:1 ratio), outcomes were similar between EVT +/- IVT and IVT alone groups. For NIHSS scores 0-5 (89 matched, 1:1 ratio), EVT +/- IVT was associated with worse outcomes compared to IVT alone (mRS 0-2, aOR 0.20 [95% CI 0.06-0.61]; p = 0.005; mRS 0-3, aOR 0.27 [95% CI 0.08-0.89]; p = 0.031), but safety outcomes were similar.Discussion: In early-treated BAO patients with mild symptoms, defined as NIHSS 0-10, there were no significant differences in outcomes between EVT +/- IVT and IVT alone. However, for very mild symptoms, defined as NIHSS 0-5, IVT alone was associated with better outcomes compared to EVT +/- IVT.Conclusion: Randomized trials are crucial to determine the optimal reperfusion therapy for BAO patients with mild symptoms. Graphical abstract