Endovascular treatment of acute basilar artery occlusions

Background Since the publication of the large randomized controlled thrombectomy trials, endovascular treatment (EVT) has become the standard of care for acute stroke patients with anterior circulation large vessel occlusion (acLVO); however, the treatment of patients with an intracranial occlusion in the posterior circulation and in particular of the basilar artery has not been proven. Thus, there is uncertainty regarding the indications for EVT due to the poor evidence situation. Objective This review article addresses the current data on EVT in the posterior circulation and the most recent study results. Furthermore, the pathophysiological aspects, indications and specific features in the treatment of these patients are also discussed. Results Despite limited evidence for EVT, this treatment modality has gained significant clinical relevance for the treatment of stroke patients with vascular occlusions in the posterior circulation. From a technical point of view, vascular occlusions in the posterior circulation and particularly of the basilar artery are easily accessible, although the etiology of occlusions and necessary techniques differ compared to occlusions in the anterior circulation. Conclusion Compared to acLVO, EVT in the posterior circulation differs with respect to the current evidence, indications and technique. As current data have not proven its effectiveness for improved clinical outcome, treatment decisions must still be made individually based on institutional protocols, particularly for patients in the late time window or for patients already with signs of extensive infarction on baseline imaging.