Endovascular Treatment for Basilar Artery Occlusion: A Network Meta-analysis Comparing Time-to-treatment Windows and Medical Management
Nicole Baptista de Oliveira1, Mariana Letícia Bastos Maximiano3, Lucca Tamara Alves Carretta1, Ocílio Ribeiro Gonçalves4, Luciano Falcão5, Lucas Pari Mitre6, Rudolfh Batista Arend7, João Vitor Andrade Fernandes8, Pedro Rodrigues Teixeira1, Fernando Rocha Oliveira2, Tassiane Cristina Morais2, Leandro de Assis Barbosa9, AHMET GÜNKAN10
1Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 2Postgraduate department, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 3Federal Fluminense University, 4Federal University of Piauí, 5Bahiana School of Medicine and Public Health, 6Santa Casa de São Paulo School of Medical Sciences, 7Federal University of Fronteira Sul, 8Federal University of Paraíba, 9Department of Neurosurgery, Hospital Estadual Central, 10University of Arizona
Objective:
To evaluate the impact of treatment timing on outcomes by comparing endovascular therapy (EVT) performed in the early (0–6 h) and late (>6 h) windows versus best medical treatment (BMT) in basilar artery occlusion (BAO) using a Bayesian network meta-analysis.
Background:
BAO is an uncommon but highly morbid posterior-circulation stroke subtype, with high mortality and disability despite BMT. EVT has emerged as a viable option, but optimal patient selection and time-to-treatment window remain uncertain.
Design/Methods:
PubMed, Cochrane Library, and Embase were searched for studies assessing EVT timing in BAO reporting ≥1 prespecified outcome. Primary efficacy endpoint was functional independence (mRS 0–2) at 90 days; safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). Direct pairwise meta-analyses were performed when available, followed by a Bayesian random-effects network meta-analysis comparing EVT 0–6 h, EVT >6 h, and BMT. Results are reported as odds ratios (ORs) with 95% confidence intervals (CIs).
Results:
Seven studies encompassing 3,951 BAO patients were included. EVT >6 h showed higher odds of functional independence versus BMT (OR: 2.21; 95% CrI: 1.05–4.73), whereas EVT 0–6 h was not significantly different from BMT (OR: 1.17; 95% CrI: 0.56–2.38). Treatment rankings favored EVT >6 h for functional independence. Mortality did not differ significantly for EVT 0–6 h (OR: 0.68; 95% CrI: 0.22–2.52) or EVT >6 h (OR: 0.78; 95% CrI: 0.20–2.32) versus BMT. sICH rates were also not significantly different for EVT 0–6 h (OR: 2.33; 95% CrI: 0.64–11.0) or EVT >6 h (OR: 3.25; 95% CrI: 0.73–12.7).
Conclusions:
In BAO, EVT >6 h was associated with improved functional independence versus BMT, without significant differences in mortality or sICH. This likely reflects patient selection and device-era effects rather than a benefit of delaying reperfusion. Findings should not justify postponing treatment. Prospective studies directly comparing time windows with standardized selection criteria are needed.
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