Synoptic table of all recommendations and Expert Consensus Statements
| Recommendation | Expert Consensus Statement (10 voting members) |
| PICO 1 For adults with BAO-related acute ischaemic stroke presenting within 24 hours from the time last known well, does intravenous thrombolysis (IVT) alone compared with no IVT improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke presenting within 24 hours from the time last known well, there are insufficient data to make an evidence-based recommendation on the use of IVT. Please see the Expert Consensus Statement below. Quality of evidence: - Strength of recommendation: - |
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| PICO 2 For adults with BAO-related acute ischaemic stroke within 6 hours of symptoms onset, does endovascular treatment (EVT) plus best medical treatment (BMT) compared with BMT alone improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke presenting within 6 hours from the time last seen well, we suggest EVT plus BMT over BMT alone*. However, there are caveats, and this recommendation does not apply to all patients as detailed below. The recommendation considers only patients with NIHSS≥10 (please see also PICO 4). *The effect of treatment depends on use of IVT in BMT group, with greater benefit of EVT seen in those trials with lesser use of IVT. Actually, much of this evidence comes from Asian trials with high prevalence of ICAD, and in which BMT often comprises conventional therapy only (antiaggregatory and anticoagulation). For imaging criteria, please refer to PICO 5). Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? | |
| PICO 3 For adults with BAO-related acute ischaemic stroke 6–24 hours from the time last known well, does EVT plus BMT compared with BMT alone improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke presenting within 6–24 hours from the time last known well, we suggest EVT plus BMT over BMT alone.* However, there are caveats, and this recommendation does not apply to all patients as detailed below. The recommendation considers only patients with NIHSS≥10 (please see also PICO 4). *Much of this evidence comes from Asian trials with high prevalence of ICAD, and in which BMT often comprises conventional therapy only (antiaggregatory and anticoagulation). For imaging criteria, please refer to PICO 5. Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? | |
| PICO 4 For adults with BAO-related acute ischemic stroke, does selection of reperfusion treatment (IVT or EVT) based on specific presentation (eg, high NIHSS cut-off, coma on admission, proximal location of basilar artery occlusion) compared with other presentation features (eg, low NIHSS cut-off, no coma on admission, distal location of basilar artery occlusion) modify the outcome? | |
| For adults with BAO-related acute ischaemic stroke, there is a differential treatment effect (a significant interaction) of reperfusion therapy according to specific presentation. The treatment effect is different for patients with high compared with low NIHSS scores and for proximal or middle locations of basilar artery occlusions compared with distal locations. (See also PICO 2 and 3 for caveats in general recommendations). For patients presenting with severe symptoms (NIHSS≥10), we suggest BMT+EVT over BMT only*. *The effect is stronger for proximal and middle location of the occlusion. Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? For patients presenting with mild-to-moderate symptoms (NIHSS<10), we could not find evidence to recommend EVT over BMT for efficacy, but BMT appeared safer than EVT. We suggest BMT only over EVT+BMT in this group*. *These data come from a randomised trial with low prevalence of ICAD, and in which BMT very often comprised intravenous thrombolysis. These findings are also supported by non-randomised data. Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? | |
| PICO 5 For adults with BAO-related acute ischaemic stroke, does selection of reperfusion therapy (IVT and/or EVT) candidates based on a particular pc-ASPECTS compared with no specific threshold improve identification of patients with a therapy effect on outcomes? | |
| For adults with BAO-related acute ischaemic stroke without extensive ischaemic changes at baseline (pc-ASPECTS 7–10), we suggest reperfusion therapy over no reperfusion therapy according to the certainty of evidence and strength of recommendation in PICOs 1, 2, 3, 4, and 7. For adults with BAO-related acute ischaemic stroke with pc-ASPECTS 0–6, there are insufficient data to make an evidence-based recommendation on the use of reperfusion therapy. (See the Expert Consensus Statement below). Quality of evidence: - Strength of recommendation: - | For adults with BAO-related acute ischaemic stroke with ischaemic changes at baseline being more extensive than those included in randomised controlled clinical trials (ie, pc-ASPECTS 0–6), 10/10 MWG members suggest considering other prognostic variables (such as pre-stroke handicap, age, frailty) before offering reperfusion therapy. However, for patients with very extensive bilateral and/or brainstem ischemic lesions, 7/10 MWG members suggest no reperfusion therapy. |
| PICO 6 For adults with BAO-related acute ischaemic stroke, does selection of reperfusion therapy (EVT or IVT) candidates based on advanced imaging criteria (perfusion, core, or collateral imaging) compared with no advanced imaging improve identification of patients with a therapy effect on outcomes? | |
| For adults with BAO-related acute ischaemic stroke, there are insufficient data to make an evidence-based recommendation on the selection of reperfusion therapy based on evaluation of advanced imaging (perfusion, core, or collateral imaging). Please see the Expert Consensus Statement below. Quality of evidence: - Strength of recommendation: - | For adults with BAO-related acute ischaemic stroke (and in the absence of extensive ischaemic changes in the posterior circulation*), 10/10 MWG members suggest reperfusion therapy (EVT or IVT) rather than no reperfusion therapy, irrespective of any collateral score points. *extensive bilateral and/or brainstem ischemic changes |
| PICO 7 For adults with BAO-related acute ischaemic stroke without contraindication for IVT, does direct EVT compared with EVT plus IVT improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke, we suggest combined IVT and EVT treatment over direct EVT in case IVT is not contraindicated. Quality of evidence: Low ⊕⊕ Strength of recommendation: Weak for intervention ↑? | |
| PICO 8 For adults with BAO-related acute ischaemic stroke, does mechanical thrombectomy using direct aspiration as the first-line strategy compared with a stent retriever as the first-line strategy improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke, we suggest EVT using direct aspiration over stent retriever as the first-line strategy. Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? | |
| PICO 9 For adults with BAO-related acute ischaemic stroke and with suspected intracranial atherosclerotic disease (ICAD) and BA stenosis, does PTA and/or stenting of the basilar artery plus EVT compared with EVT alone improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke and with a suspected ICAD and BA stenosis, there is insufficient evidence to make an evidence-based recommendation on the use of PTA and/or stenting in addition to EVT. Please see the Expert Consensus Statement below. Quality of evidence: - Strength of recommendation: - | For adults with BAO-related acute ischaemic stroke and with suspected ICAD and severe underlying BA stenosis, 10/10 MWG members suggest rescue PTA and/or stenting after failed endovascular procedure (please also see PICO 10). |
| PICO 10 For adults with BAO-related acute ischaemic stroke subjected to reperfusion therapy (EVT or IVT), does add-on antithrombotic treatment during EVT or within 24 hours after IVT or EVT compared with no add-on antithrombotic treatment improve outcomes? | |
| For adults with BAO-related acute ischaemic stroke treated with EVT and no concomitant IVT, and where EVT procedure is complicated (defined as failed, or imminent re-occlusion, or need for additional stenting or angioplasty), we suggest add-on antithrombotic* treatment during EVT procedure or within 24 hours after EVT over no add-on antithrombotic treatment. *However, this should be used as a rescue strategy after assessing the bleeding risk of patients in case of failed EVT, in line with the ESO guidelines on the management of ICAD95. Quality of evidence: Very low ⊕ Strength of recommendation: Weak for intervention ↑? | |
BAO, basilar artery occlusion; MWG, Guideline Module Working Group.