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Penultimate proof for posterior occlusions: a commentary on “Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients”
  1. Rashid A Ahmed1,
  2. Joshua A Hirsch2,
  3. Thabele M Leslie-Mazwi3,
  4. Aman B Patel4,
  5. Robert W Regenhardt1,4
    1. 1Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
    2. 2Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
    3. 3Department of Neurology, University of Washington, Seattle, Washington, USA
    4. 4Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
    1. Correspondence to Dr Rashid A Ahmed, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; RAHMED7{at}mgh.harvard.edu

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    Basilar Artery occlusion (BAO) accounts for 5% of emergent large vessel occlusions (ELVO), with up to 68% of patients dying or remaining disabled despite advances in stroke care.1 Given two recent positive randomized endovascular therapy (EVT) trials—ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) and BAOCHE (Basilar Artery Occlusion Chinese Endovascular Trial)—this ‘Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients’ is well received and much needed.2 ,3 4 These two positive trials come after two other trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs Standard Medical Treatment) and BASICS (Basilar Artery International Cooperation Study) failed to show a clear benefit from EVT over medical therapy alone.5 6

    In summary, the focused guidelines include new updates that recommend EVT in certain patient populations. For patients presenting with an acute ischemic stroke due to basilar or vertebral artery occlusion confirmed on CT angiography, with a posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) ≥6, National Institutes of Health Stroke Scale (NIHSS) score ≥6, and age 18 to 89 years, EVT ‘is indicated’ within 12 hours since last known well (class I, level B-R) and ‘is reasonable’ 12–24 hours from last known well (class IIa, level B–R). Furthermore, EVT ‘may be considered on a case-by-case basis’ for patients presenting beyond 24 hours since last known well (class IIb, level C–EO) or in those younger than 18 or older than 89 years of age (class IIb, level C–EO).

    Despite a now clear benefit …

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    • X @Takanshooka, @rwregen

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; internally peer reviewed.

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