What is the management approach for a patient with suspected basilar artery occlusion?

Management of Basilar Artery Occlusion

For patients with basilar artery occlusion and moderate-to-severe symptoms (NIHSS ≥10), endovascular thrombectomy plus best medical treatment (including IV thrombolysis if not contraindicated) should be performed within 12 hours of last known well, and is reasonable up to 24 hours. 1, 2

Immediate Assessment and Triage

Upon suspicion of basilar artery occlusion, rapidly obtain:

• CT angiography to confirm basilar artery occlusion 1
• Posterior circulation ASPECTS (pc-ASPECTS) on imaging - assess for extent of ischemic changes 1
• NIHSS score - critical for treatment stratification 1
• Time of symptom onset or last known well 1

Treatment Algorithm Based on Stroke Severity

For NIHSS ≥10 (Moderate-to-Severe Symptoms)

Within 12 hours of last known well:

• Administer IV thrombolysis immediately if not contraindicated, followed by endovascular thrombectomy 1, 2
• This combined approach (IVT + EVT) is superior to direct EVT alone 2
• The ATTENTION trial demonstrated 46% good outcomes (mRS 0-3) with EVT+BMT versus 23% with BMT alone (adjusted rate ratio 2.06,95% CI 1.46-2.91) 1

Between 12-24 hours of last known well:

• EVT + BMT is reasonable (Class IIa recommendation) 1
• The BAOCHE trial supports treatment in this extended window 1, 3

Beyond 24 hours:

• Consider EVT on a case-by-case basis (Class IIb recommendation) 1
• Successful recanalization has been reported in isolated cases, though outcomes are uncertain 1

For NIHSS <10 (Mild Symptoms)

Best medical treatment alone is preferred over EVT + BMT 2

• Data from the BASICS registry showed universally poor outcomes when recanalization was achieved in patients with NIHSS ≤6 1
• BMT was found to be safer than EVT without clear evidence of superior efficacy in this population 2

Imaging Selection Criteria

pc-ASPECTS 7-10 (minimal ischemic changes):

• Proceed with reperfusion therapy as outlined above 2
• For patients <80 years, pc-ASPECTS ≥6 is required; for those >80 years, pc-ASPECTS ≥8 is required 1

pc-ASPECTS 0-6 (extensive ischemic changes):

• Consider pre-stroke disability, age, and frailty before offering reperfusion therapy 2
• Treatment may still be reasonable in highly selected cases 2

Endovascular Technique

Direct aspiration is preferred over stent retriever as first-line strategy 1, 2

• This recommendation is based on very low quality evidence but represents current expert consensus 1, 2

For suspected intracranial atherosclerotic disease (ICAD) with severe basilar stenosis:

• If initial EVT fails, perform rescue angioplasty and/or stenting 1, 2
• Add-on antithrombotic treatment (GP IIb/IIIa inhibitors like tirofiban) should be considered during or within 24 hours after EVT in patients without concomitant IVT when the procedure is complicated (failed recanalization, imminent re-occlusion, or need for stenting) 1, 2
• This should be used as a rescue strategy after assessing bleeding risk 1, 2

Intravenous Thrombolysis Considerations

IV thrombolysis should be administered up to 24 hours from last known well unless contraindicated 1

• This extends beyond the traditional 4.5-hour window for anterior circulation strokes 1, 4
• Historical data shows IVT alone achieved 50% survival and 22% good outcomes in basilar artery occlusion 5
• Recent single-center data demonstrated 46.5% favorable outcomes with IVT alone, comparable to EVT outcomes 4
• Always combine IVT with EVT rather than performing direct EVT when IVT is not contraindicated 1, 2

Critical Pitfalls to Avoid

Do not assume all basilar artery occlusions require EVT:

• Patients with NIHSS <10 have better outcomes with medical management alone 2
• EVT in mild strokes may cause more harm than benefit 1, 2

Do not delay IV thrombolysis while arranging EVT:

• IVT should be started immediately in eligible patients 1, 2
• The availability of EVT should not preclude administration of IV thrombolysis 1

Do not overlook the extended time window for basilar artery occlusion:

• Unlike anterior circulation strokes, basilar artery occlusion can be treated beyond traditional time windows 1
• Many patients have delayed diagnosis due to non-specific symptoms 1

Do not ignore the role of intracranial atherosclerosis:

• High rates of ICAD in posterior circulation require readiness for angioplasty/stenting 1
• Have rescue antithrombotic therapy available for complicated procedures 1, 2

Do not forget that recanalization is essential:

• Without recanalization, the likelihood of good outcome is close to nil (2%) 5
• Successful recanalization occurs in 53-65% of cases with thrombolysis 5