What is the treatment for a basilar artery stroke?

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Last updated: May 17, 2025 • View editorial policy

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From the Guidelines

Basilar stroke treatment should be individualized, considering the potential benefits and risks of endovascular treatment (EVT) for each patient, and made by a physician with stroke expertise in consultation with the patient and/or substitute decision-makers 1. The decision to treat basilar stroke with EVT is based on the specific characteristics of the patient and the occlusion, and should be made on a case-by-case basis.

  • Key considerations include:
    • The location and severity of the occlusion
    • The patient's overall health and medical history
    • The potential benefits and risks of EVT, including the risk of complications and the potential for improved outcomes
  • According to the Canadian Stroke Best Practice Recommendations, EVT is indicated in patients who have received intravenous alteplase and those who are not eligible for intravenous alteplase, and eligible patients who can be treated with EVT within 6 hours of symptom onset should receive EVT 1.
  • The use of sedation during EVT is also an important consideration, with procedural sedation generally preferred over general anesthesia and intubation in most patients when necessary, although general anesthesia and intubation may be appropriate in certain cases 1.
  • The American Heart Association/American Stroke Association guidelines also support the use of intra-arterial thrombolysis in carefully selected patients with acute ischemic stroke secondary to occlusion of the basilar artery, although the evidence for this is not as strong as for other types of stroke 1.
  • In terms of specific treatment protocols, the guidelines recommend that patients with basilar stroke be treated with intravenous tPA within 4.5 hours of symptom onset, and that mechanical thrombectomy be considered for patients with large vessel occlusion who present within 24 hours of symptom onset.
  • Secondary prevention measures, such as antiplatelet therapy and statins, are also important for reducing the risk of recurrent stroke and improving outcomes.
  • Overall, the treatment of basilar stroke requires a comprehensive and individualized approach, taking into account the unique characteristics of each patient and the latest evidence-based guidelines.

From the Research

Basilar Stroke Treatment Overview

  • Basilar artery occlusion (BAO) is a type of ischemic stroke that accounts for 1-4% of all ischemic strokes 2
  • BAO has a high risk of poor functional outcome and death, with 86-95% of untreated cases resulting in death 2
  • Treatment for BAO often involves endovascular interventions, such as thrombectomy, in addition to standard medical therapy 3, 4

Endovascular Treatment

  • Endovascular treatment plus standard medical therapy has been shown to be superior to standard medical therapy alone for acute anterior proximal intracranial large artery occlusion strokes 3
  • The BEST trial aims to compare the safety and efficacy of endovascular treatment plus standard medical therapy versus standard medical therapy alone in acute ischemic stroke due to BAO 3
  • Thrombectomy has been associated with improved outcomes in BAO patients, with a first-pass effect (FPE) achieving complete recanalization after one pass with no rescue therapy being a strong predictor of good outcomes 4

Medical Therapy

  • Intravenous thrombolysis with alteplase can be used in patients with BAO, although the optimal administration route, thrombolytic agent, and dose are unknown 5
  • Antiplatelet agents, such as aspirin, can be used in patients with ischemic stroke, but the use of antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended 5
  • Anticoagulation therapy can be used in patients with a high risk of cardioembolism, but the timing of initiation must be decided on a case-by-case basis 5

Prognostic Factors

  • Age, NIHSS score at admission, pc-ASPECTS, hypercholesterolemia, and female sex have been associated with a favorable outcome in BAO patients 2
  • The first-pass effect (FPE) has been associated with improved outcomes in BAO patients, with contact aspiration as first-line strategy being a strong predictor of FPE 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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