Basilar artery occlusion management: Specialist perspectives from an international survey

Christopher Edwards; Brian Drumm; James E Siegler; Wouter J Schonewille; Piers Klein; Xiaochuan Huo; Yimin Chen; Mohamad Abdalkader; Muhammad M Qureshi; Daniel Strbian; Xinfeng Liu; Wei Hu; Xunming Ji; Chuanhui Li; Urs Fischer; Simon Nagel; Volker Puetz; Patrik Michel; Fana Alemseged; Simona Sacco; Hiroshi Yamagami; Shadi Yaghi; Davide Strambo; Espen Saxhaug Kristoffersen; Else C Sandset; Robert Mikulik; Georgios Tsivgoulis; Hesham E Masoud; Diana Aguiar de Sousa; João Pedro Marto; Kyriakos Lobotesis; Dylan Roi; Anne Berberich; Jelle Demeestere; Thomas R Meinel; Rodrigo Rivera; Sven Poli; Mai Duy Ton; Yuyou Zhu; Fengli Li; Hongfei Sang; Götz Thomalla; Mark Parsons; Bruce C V Campbell; Osama O Zaidat; Hui-Sheng Chen; Thalia S Field; Jean Raymond; Johannes Kaesmacher; Raul G Nogueira; Tudor G Jovin; Dapeng Sun; Raynald Liu; Adnan I Qureshi; Zhongming Qiu; Zhongrong Miao; Soma Banerjee; Thanh N Nguyen

doi:10.1111/jon.13084

Basilar artery occlusion management: Specialist perspectives from an international survey

J Neuroimaging. 2023 May-Jun;33(3):422-433. doi: 10.1111/jon.13084. Epub 2023 Feb 13.

Authors

Christopher Edwards¹, Brian Drumm², James E Siegler¹, Wouter J Schonewille³, Piers Klein⁴, Xiaochuan Huo⁵, Yimin Chen⁶, Mohamad Abdalkader⁴, Muhammad M Qureshi^{4

7}, Daniel Strbian⁸, Xinfeng Liu^{9

10}, Wei Hu¹⁰, Xunming Ji¹¹, Chuanhui Li¹², Urs Fischer^{13

14}, Simon Nagel^{15

16}, Volker Puetz^{17

18}, Patrik Michel¹⁹, Fana Alemseged²⁰, Simona Sacco²¹, Hiroshi Yamagami²², Shadi Yaghi²³, Davide Strambo¹⁹, Espen Saxhaug Kristoffersen^{24

25}, Else C Sandset²⁶, Robert Mikulik²⁷, Georgios Tsivgoulis²⁸, Hesham E Masoud²⁹, Diana Aguiar de Sousa³⁰, João Pedro Marto³¹, Kyriakos Lobotesis³², Dylan Roi³², Anne Berberich¹⁵, Jelle Demeestere³³, Thomas R Meinel¹³, Rodrigo Rivera³⁴, Sven Poli^{35

36}, Mai Duy Ton^{37

38

39}, Yuyou Zhu¹⁰, Fengli Li⁴⁰, Hongfei Sang⁴¹, Götz Thomalla⁴², Mark Parsons⁴³, Bruce C V Campbell²⁰, Osama O Zaidat⁴⁴, Hui-Sheng Chen⁴⁵, Thalia S Field⁴⁶, Jean Raymond⁴⁷, Johannes Kaesmacher⁴⁸, Raul G Nogueira⁴⁹, Tudor G Jovin¹, Dapeng Sun⁵, Raynald Liu⁵, Adnan I Qureshi⁵⁰, Zhongming Qiu^{38

51}, Zhongrong Miao⁵, Soma Banerjee², Thanh N Nguyen^{4

52}

Affiliations

¹ Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA.
² Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK.
³ Department of Neurology, St. Antonius Hospital, Nieuwegein, The Netherlands.
⁴ Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA.
⁵ Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
⁶ Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China.
⁷ Radiation Oncology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA.
⁸ Department of Neurology, Helsinki University Hospital, Helsinki, Finland.
⁹ Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
¹⁰ Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
¹¹ Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
¹² Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
¹³ Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland.
¹⁴ Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.
¹⁵ Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany.
¹⁶ Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
¹⁷ Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁸ Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
¹⁹ Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
²⁰ Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.
²¹ Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
²² Department of Stroke Neurology, National Hospital Organization, Osaka National Hospital, Osaka, Japan.
²³ Department of Neurology, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA.
²⁴ Department of Neurology, Akershus University Hospital, Lørenskog, Norway.
²⁵ Department of General Practice, University of Oslo, Oslo, Norway.
²⁶ Department of Neurology, The Norwegian Air Ambulance Foundation, Oslo, Norway.
²⁷ Department of Neurology, International Clinical Research Center, St Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
²⁸ Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
²⁹ Department of Neurology, State University of New York, Upstate Medical University, Syracuse, New York, USA.
³⁰ Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.
³¹ Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
³² Department of Radiology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK.
³³ Neurology Department, Leuven University Hospital, Leuven, Belgium.
³⁴ Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo, Santiago, Chile.
³⁵ Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany.
³⁶ Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany.
³⁷ Stroke Center, Bach Mai Hospital, Hanoi, Vietnam.
³⁸ Hanoi Medical University, Hanoi, Vietnam.
³⁹ Vietnam National University of Medicine and Pharmacy, Hanoi, Vietnam.
⁴⁰ Department of Neurology, Xinqiao Hospital of the Army Medical University, Chongqing, China.
⁴¹ Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
⁴² Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
⁴³ Sydney Brain Center, University of New South Wales, Sydney, New South Wales, Australia.
⁴⁴ Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio, USA.
⁴⁵ Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China.
⁴⁶ Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada.
⁴⁷ Neuroradiologie Interventionelle, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada.
⁴⁸ Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland.
⁴⁹ Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁵⁰ Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China.
⁵¹ Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA.
⁵² Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA.

PMID: 36781295
DOI: 10.1111/jon.13084

Abstract

Background and purpose: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties.

Methods: We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics.

Results: Among the 1245 respondents (nINTs = 702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p < .01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific clinical circumstances (p = .45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p > .05), although nINTs more commonly preferred perfusion imaging (24.2% vs. 19.7%, p = .04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9% vs. 6.9%, p < .01).

Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.

Keywords: basilar artery occlusion; endovascular therapy; intravenous thrombolysis; mechanical thrombectomy.

MeSH terms

Arterial Occlusive Diseases*
Basilar Artery / diagnostic imaging
Endovascular Procedures* / methods
Humans
Retrospective Studies
Stroke* / therapy
Thrombectomy / methods
Treatment Outcome