Advances in Acute Stroke Treatment 2020

Joseph P. Broderick, MD; Michael D. Hill, MD, MSc, FRCPC

Disclosures

Stroke. 2021;52(2):729-734. 

EVT in Minor Ischemic Stroke, Basilar Artery Occlusion, and Parenteral Antiplatelet Agents

Two cohort studies and a meta-analysis examining whether patients with mild symptoms (typically National Institutes of Health Stroke Scale score 0–5) and a proximal LVO should be treated with EVT reported similar outcomes between patients treated medically and those treated with EVT.[15–17] Randomized trials are underway to assess this question but it will always be more challenging to show a treatment effect on clinical outcomes when symptoms are mild given the ceiling effects on outcome scores. Selection of the specific populations of patients with LVO and only minor symptoms who will benefit from EVT remains an important research goal.

Large registries suggest the EVT is superior to medical therapy for basilar artery occlusion,[18] but this has not yet been shown in trials. The open-label BEST trial (Acute Basilar Artery Occlusion: Endovascular Interventions versus Standard Medical Treatment) randomized patients with basilar artery occlusion to EVT and best medical management versus best medical management alone. The trial was terminated early after 131 patients because of poor recruitment and high frequency of cross-over. In the intention-to-treat analysis, there was no evidence of a difference in the proportion of participants with modified Rankin Scale score of 0 to 3 at 90 days according to treatment (28 [42%] of 66 patients in the intervention group versus 21 [32%] of 65 in the control group; adjusted odds ratio, 1.74 [95% CI, 0.81–3.74]).[19] Further data from the BASICS trial (Basilar Artery International Cooperation Study) have also reported a neutral outcome, with a trend toward better outcomes in the EVT group for those with higher National Institutes of Health Stroke Scale (Schonewille W. Personal communication and presented at ESOC-WSC 2020). Discrepancy in outcomes between cohort studies and randomized trials suggest both that selection bias exists in the cohort studies and that we have yet to identify the target subgroup of patients with basilar artery occlusion who stand to benefit from EVT.

Intravenous or intraarterial tirofiban as an adjunct before or during EVT treatment has received ongoing attention, particularly in Asia but no data from larger randomized trials are available yet.[20,21] Mechanistically, the benefits of parenteral antiplatelet agents may follow the same paradigm as that seen in acute coronary syndromes and be of most utility in LVO stroke due to intracranial atherosclerotic disease.

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