# Aspiration, stent retriever, or combined approach for basilar artery occlusion: a three-way comparative analysis

## TL;DR

A study compared three clot-removal techniques for a life-threatening brainstem stroke, finding similar overall recovery but differences in success rates and bleeding risks.

## Contribution

The study provides a three-way comparison of mechanical thrombectomy techniques for basilar artery occlusion, identifying subgroup-specific outcomes.

## Key findings

- Stent retrievers achieved higher recanalization rates compared to aspiration.
- The combined approach was associated with less haemorrhagic transformation.
- Stent retrievers led to better outcomes in patients aged 80 or older compared to aspiration.

## Abstract

Basilar artery occlusion (BAO) is a rare but devastating form of ischaemic stroke, with high rates of disability and mortality. While randomized trials have demonstrated the benefit of mechanical thrombectomy (MT) in BAO, the optimal first-line technique – aspiration, stent retriever, or a combined approach – remains undefined.

This multicentre study aimed to provide a three-way comparison of MT techniques in terms of efficacy, safety and subgroup-specific outcomes.

A retrospective observational study.

We prospectively included 517 consecutive patients with acute isolated BAO treated with MT across seven comprehensive stroke centres between January 2019 and December 2023. Patients were grouped by first-line technique: aspiration (n = 200), stent retriever (n = 260), or combined approach (n = 57). The primary outcome was favourable functional outcome at 90 days (mRS 0–3). Inverse probability weighting (IPW) adjusted for baseline imbalances. Secondary outcomes included successful recanalization, excellent outcome (mRS 0–1), functional independence (mRS 0–2), mortality, symptomatic intracranial haemorrhage (sICH) and haemorrhagic transformation (HT). Predefined subgroup analyses were performed.

After adjustment, 90-day outcomes were similar across groups. Stent retrievers achieved higher recanalization rates (RR 1.86 vs aspiration, p < 0.001), while the combined technique was associated with less HT (RR 0.39 vs aspiration, p = 0.008). In patients ⩾80 years, stent-retriever use led to better outcomes than aspiration (39.2% vs 18%; p = 0.021). No other significant subgroup interactions were found.

While overall functional outcomes were comparable, stent retrievers yielded superior recanalization and the combined technique reduced haemorrhagic complications. Technique selection may benefit from individualized, anatomy-driven decision-making. Randomized studies are warranted.

Comparing three techniques to remove blood clots in the basilar artery: a multicenter study of aspiration, stent retriever, and combined approaches

A stroke caused by a blockage in the basilar artery, a major blood vessel that supplies the brainstem, can be life-threatening and often leads to severe disability. Different techniques can be used to remove the clot and restore blood flow, but it is not yet clear which method works best. In this study, we analysed data from 517 patients treated for basilar artery blockage between 2019 and 2023 at seven stroke centres. Patients were treated using one of three approaches: aspiration, where suction is used to remove the clot; stent retriever, where a small device is used to pull the clot out; or a combined approach using both techniques. We assessed recovery 90 days after treatment, focusing on whether patients regained independence in their daily activities. Overall, the three techniques led to similar recovery rates, but there were some important differences. The stent retriever method achieved the highest success in reopening the blocked artery, while the combined approach had the lowest risk of bleeding in the brain. Among patients aged 80 years or older, treatment with a stent retriever resulted in better recovery compared to aspiration. These findings suggest that all three techniques are generally safe and effective, but the stent retriever may be preferred for older patients, and the combined approach may be considered when there is a higher risk of bleeding. Further studies, including randomized clinical trials, are needed to confirm these results and guide doctors in choosing the most appropriate treatment for each patient.