Background and Aims:

Mechanical thrombectomy (MT) is an effective treatment basilar artery occlusion (BAO) acute ischaemic stroke (AIS) patients. It remains unclear whether bridging intravenous thrombolysis (IVT) prior to MT confers benefit. This study compared the outcomes of patients with BAO AIS who were treated with direct MT versus combined IVT plus MT.

Methods:

Patients who were treated for BAO from seven comprehensive stroke centres in Europe and Asia between 2015 and 2020 were studied. All patients received direct MT or bridging IVT (alteplase at a 0.9-mg/kg dose) plus MT. Primary outcome was a favourable functional outcome [modified Rankin Scale (mRS) of 0-3 at 90 days]. Secondary outcomes included mortality and bleeding complications. Univariable and multivariable logistic regression was employed.

Results:

Among 322 patients, 127 (39.4%) underwent bridging IVT and 195 (60.6%) underwent direct MT. The mean age was 67.5 yrs (SD = 14.1), and median NIHSS was 17 (IQR = 17). At 90-days, the rate of favourable functional outcome was similar between the two groups (39.4% vs 34.4%; OR=1.28; 95%CI = 0.79–2.07; p=0.313).

In subgroup analyses, a significant treatment effect of bridging IVT was observed in BAO patients who had underlying large artery atherosclerosis (LAA) (37.2% vs 15.5%; OR=3.12; p=0.022). On ordinal analyses, bridging IVT was associated with a favourable shift in the mRS outcomes in BAO patients with LAA.

Conclusions:

Functional outcomes were similar in BAO patients treated with bridging IVT versus direct MT. In the subgroup of patients with underlying LAA stroke mechanism, bridging IVT may potentially confer benefit and this warrants further investigation.