What are the treatment options for a basilar artery stroke?

From the Guidelines

Treatment for basilar artery stroke should prioritize immediate medical attention, with a focus on restoring blood flow through mechanical thrombectomy if within 24 hours and there is a large vessel occlusion, as recommended by the most recent guidelines 1.

Key Considerations

• The decision to treat with endovascular therapy (EVT) for basilar artery occlusion should be based on the potential benefits and risks of the treatment for the individual patient, and made by a physician with stroke expertise in consultation with the patient and/or substitute decision-makers 1.
• Initial treatment may also involve intravenous thrombolysis with tissue plasminogen activator (tPA) if within 4.5 hours of symptom onset, although the evidence for this is not as strong for basilar artery strokes as for other types of strokes 1.
• After the acute phase, patients are usually placed on antiplatelet therapy, such as aspirin (81-325 mg daily) or clopidogrel (75 mg daily), and may require anticoagulation with medications like warfarin or direct oral anticoagulants if the stroke was caused by atrial fibrillation or other cardiac sources.

Additional Interventions

• Blood pressure management is crucial, typically aiming for levels below 140/90 mmHg using medications such as ACE inhibitors, ARBs, or calcium channel blockers.
• Cholesterol-lowering statins like atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) are also prescribed.
• Rehabilitation including physical, occupational, and speech therapy should begin as soon as the patient is medically stable.

Importance of Rapid Treatment

• Basilar artery strokes are particularly dangerous because this artery supplies critical brainstem structures that control consciousness, breathing, and other vital functions, making rapid treatment essential for preventing severe disability or death.
• The most recent guidelines emphasize the importance of prompt treatment, with EVT indicated in patients who have received intravenous alteplase and those who are not eligible for intravenous alteplase 1.

From the Research

Basilar Artery Stroke Treatment Options

• Intravenous thrombolysis (IV rt-PA) is a commonly used treatment for basilar artery occlusion (BAO), but its efficacy remains unclear 2
• Intraarterial thrombolysis (IA rt-PA) is another treatment option, which may be used alone or in combination with IV rt-PA 2, 3
• Mechanical thrombectomy (MT) is a minimally invasive procedure that has shown promising results in treating BAO, with some studies suggesting it may be the most effective treatment option 2, 4
• Bridging therapy, which combines intravenous abciximab and intraarterial rt-PA, has also been shown to be effective in treating BAO, with higher recanalization and improved survival rates compared to intraarterial thrombolysis alone 3
• Endovascular treatment, including MT and intraarterial thrombolysis, has emerged as a promising treatment option for BAO, with several randomized controlled trials demonstrating clinical benefits 4, 5

Efficacy and Safety of Treatment Options

• A systematic review and meta-analysis found that MT ± IV rt-PA ± IA rt-PA was associated with a higher rate of favorable outcomes (mRS 0-2) compared to IA rt-PA ± IV rt-PA and IV rt-PA alone 2
• A randomized controlled trial found that endovascular thrombectomy within 12 hours after stroke onset led to better functional outcomes at 90 days compared to best medical care, but was associated with procedural complications and intracerebral hemorrhage 4
• A study found that bridging therapy with intravenous abciximab and intraarterial rt-PA was associated with higher recanalization and improved survival rates, as well as an overall improved chance for a better outcome, compared to intraarterial thrombolysis alone 3

Novel Treatment Approaches

• A novel route of revascularization in basilar artery occlusion using thyrocervical collaterals for anterograde mechanical aspiration has been reported, with successful resolution of the patient's clinical stroke syndrome 6
• Future research directions may address therapeutic treatment thresholds, combination strategies, and long-term outcomes for endovascular treatment of BAO 5