Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

Lina Palaiodimou; Andreas Eleftheriou; Aristeidis H Katsanos; Apostolos Safouris; Georgios Magoufis; Stavros Spiliopoulos; Georgios Velonakis; Sofia Vassilopoulou; Diana Aguiar de Sousa; Guillaume Turc; Daniel Strbian; Georgios Tsivgoulis

doi:10.3390/jcm12072617

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

J Clin Med. 2023 Mar 30;12(7):2617. doi: 10.3390/jcm12072617.

Authors

Lina Palaiodimou¹, Andreas Eleftheriou¹, Aristeidis H Katsanos², Apostolos Safouris^{1

3

4

5}, Georgios Magoufis³, Stavros Spiliopoulos⁶, Georgios Velonakis⁷, Sofia Vassilopoulou⁸, Diana Aguiar de Sousa^{9

10}, Guillaume Turc^{11

12

13

14}, Daniel Strbian¹⁵, Georgios Tsivgoulis^{1

16}

Affiliations

¹ Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 15784 Athens, Greece.
² Division of Neurology, McMaster University and Population Health Research Institute, Hamilton, ON L8L2X2, Canada.
³ Stroke Unit, Metropolitan Hospital, 18547 Piraeus, Greece.
⁴ Aktios Rehabilitation Center, 15341 Athens, Greece.
⁵ Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Section of Neurointervention, Department of Neurosurgery, Semmelweis University, 1085 Budapest, Hungary.
⁶ Interventional Radiology Department, "Attikon" University Hospital, 12462 Athens, Greece.
⁷ Research Unit of Radiology, 2nd Department of Radiology, Eginition Hospital, National and Kapodistrian University of Athens, 15784 Athens, Greece.
⁸ First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 15784 Athens, Greece.
⁹ Stroke Center, Lisbon Central University Hospital, 1649-024 Lisbon, Portugal.
¹⁰ Institute of Anatomy and CEEM, Faculdade de Medicina, Universidade de Lisboa, 1649-004 Lisbon, Portugal.
¹¹ Department of Neurology, GHU Paris Psychiatrie et Neurosciences, 75014 Paris, France.
¹² Department of Neurology, Faculty of Medicine, Université Paris Cité, 75006 Paris, France.
¹³ INSERM U1266, 75014 Paris, France.
¹⁴ FHU NeuroVasc, 75010 Paris, France.
¹⁵ Department of Neurology, Helsinki University Hospital and University of Helsinki, 00029 Helsinki, Finland.
¹⁶ Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.

Abstract

Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs).

Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest.

Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16-2.05; I² = 60%), functional independence (RR: 1.83; 95% CI: 1.08-3.08; I² = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26-3.05; I² = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36-25.61; I² = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50-5.44; I² = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65-0.89; I² = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China.

Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.

Keywords: acute basilar artery occlusion; acute ischemic stroke; basilar stroke; endovascular treatment; mechanical thrombectomy; meta-analysis; posterior circulation; randomized controlled clinical trials.

Publication types

Review

Grants and funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.