Chiang Chia-Chun, Dumitrascu Oana M, Wingerchuk Dean M, O'Carroll Cumara B
Department of Neurology, Mayo Clinic, Phoenix, AZ.
Neurologist. 2018 Mar;23(2):71-74. doi: 10.1097/NRL.0000000000000156.
Acute basilar artery occlusion (BAO) is a devastating, life-threatening condition that accounts for approximately 1% of all strokes. Currently, there is no consensus on the best treatment strategy for patients with BAO. Whereas endovascular reperfusion therapy is proven to improve outcomes in anterior circulation stroke, its benefit in acute BAO has not been confirmed in randomized controlled trials.
To critically assess the current evidence regarding recanalization in acute BAO, and to discuss the outcomes of different treatment strategies in the management of acute BAO.
The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, and content experts in the field of vascular and hospital neurology.
A recent meta-analysis was selected for critical appraisal to assess the recanalization hypothesis in acute BAO. The authors performed a systematic literature search through August 2013 and pooled in the analysis of 45 studies and 2056 patients. The overall recanalization rate was 75% in this meta-analysis. The authors concluded that recanalization was associated with a 1.5-fold reduction in the risk of death or dependency, and a 2-fold reduction in the risk of mortality. Subgroup analysis comparing different modes of intervention revealed data that favor endovascular intervention over intravenous thrombolysis (IVT). However, the authors were not able to obtain a statistically valid direct comparison of the 2 therapies as their meta-analysis included observational studies. Subgroup analysis on the treatment window revealed that onset-to-treatment time of <12 hours was associated with a higher recanalization rate (81%) and a lower intracranial hemorrhage rate (10%) compared with onset-to-treatment time >12 hours.
IVT is the standard of care for BAO patients presenting within 4.5 hours of symptom onset, whereas recanalization is associated with better outcomes regardless of how recanalization is achieved. Randomized controlled trials comparing IVT plus endovascular treatment versus IVT in the treatment of acute BAO are needed to provide evidence-based management guidance.
急性基底动脉闭塞（BAO）是一种严重的、危及生命的疾病，约占所有中风的1%。目前，对于BAO患者的最佳治疗策略尚无共识。虽然血管内再灌注治疗已被证明可改善前循环中风的预后，但其在急性BAO中的益处尚未在随机对照试验中得到证实。
严格评估关于急性BAO再通的现有证据，并讨论不同治疗策略在急性BAO管理中的结果。
通过制定一个严格评价的主题来实现该目标，该主题包括临床病例、结构化问题、文献检索策略、严格评价、结果评估、证据总结、评论和底线结论。参与者包括顾问和住院神经科医生，以及血管和医院神经科领域的内容专家。
选择了最近的一项荟萃分析进行严格评价，以评估急性BAO中的再通假说。作者通过2013年8月进行了系统的文献检索，并汇总分析了45项研究和2056例患者。在这项荟萃分析中，总体再通率为75%。作者得出结论，再通与死亡或依赖风险降低1.5倍以及死亡风险降低2倍相关。比较不同干预模式的亚组分析显示，数据支持血管内干预优于静脉溶栓（IVT）。然而，由于他们的荟萃分析包括观察性研究，作者无法获得这两种疗法的统计学有效直接比较。治疗窗的亚组分析显示，与发病至治疗时间>12小时相比，发病至治疗时间<12小时与更高的再通率（81%）和更低的颅内出血率（10%）相关。
对于症状发作4.5小时内就诊的BAO患者，IVT是标准治疗方法，而无论再通如何实现，再通都与更好的结果相关。需要进行随机对照试验，比较IVT联合血管内治疗与IVT治疗急性BAO，以提供基于证据的管理指导。
