by Isabella Colonna
For November’s research paper of the month we have selected Tao C, Nogueira RG, Zhu Y, Sun J, Han H, Yuan G, Wen C, Zhou P, Chen W, Zeng G, Li Y, Ma Z, Yu C, Su J, Zhou Z, Chen Z, Liao G, Sun Y, Ren Y, Zhang H, Chen J, Yue X, Xiao G, Wang L, Liu R, Liu W, Liu Y, Wang L, Zhang C, Liu T, Song J, Li R, Xu P, Yin Y, Wang G, Baxter B, Qureshi AI, Liu X, Hu W; ATTENTION Investigators. Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022 Oct 13;387(15):1361-1372. doi: 10.1056/NEJMoa2206317. PMID: 36239644.
Stroke due to basilar artery occlusion has been associated with high rates (>80%) of death or remaining disability, despite the best medical care. So far, limited evidence supports the use of endovascular thrombectomy in patients with acute basilar artery occlusion.
This paper presents the results of the Endovascular Treatment for Acute Basilar-Artery Occlusion (ATTENTION) trial; this is a multicentre, prospective, randomised and open-label trial, conducted in 36 Chinese centres, aiming to investigate whether endovascular treatment in addition to the best medical care would be superior to the best medical care alone in patients with moderate-to-severe acute ischaemic stroke (NIHSS >10), within 12 hours from the estimated time of the basilar-artery occlusion.
After screening for eligibility, 340 patients were enrolled in the study (226 assigned to the endovascular treatment group and 114 to the control group). Good functional status, defined as a score of 0 to 3 on the modified Rankin scale at 90 days, was achieved by 46% of patients in the thrombectomy group and by 23% of those in the control group (95% CI: 1.46-2.91; p<0.001). Similarly, the percentage of individuals presenting excellent functional status at 90 days (modified Rankin scale score from 0 to 2) was significantly higher in the thrombectomy group. Moreover, the patency of the basilar artery at 24 to 72 hours, assessed by CTA or MRA, was found in the 91% and in the 38% of patients included in the thrombectomy and in the control group, respectively.
Concerning safety outcomes, higher rates of mortality at 90 days were observed in the control cohort than in the intervention group (55% versus 37%). Symptomatic intracranial haemorrhage occurred in the 5% of patients who underwent thrombectomy and in none of the control group. In the thrombectomy group, there were 32 procedural complications (14%), including one fatal arterial perforation.
In conclusion, the results of this trial show that in patients with moderate to severe symptoms due to acute basilar artery presenting within 12 hours, endovascular thrombectomy led to better functional outcomes at 90 days but was associated with procedural complications and intracerebral haemorrhages.