medwireNews: Endovascular therapy administered to patients with vertebrobasilar artery occlusion (VBAO) significantly improves functional outcome at 90 days compared with standard medical treatment, say the investigators of the VERITAS study.
“The observed benefit has important implications for clinical practice and health policies, and might result in changes to guidelines,” say Wei Hu (University of Science and Technology of China, Anhui) and colleagues in The Lancet.
The team pooled patient data from four studies – ATTENTION, BAOCHE, BASICS, and BEST – conducted between 2010 and 2023, of which three were conducted in China, and one in Brazil and Europe. Together the four studies randomly assigned a total of 988 VBAO patients (median age 67 years, 69% men) to receive either endovascular therapy (n=556), such as thrombectomy, stent retrievers, thromboaspiration, balloon angioplasty, stent deployment, intra-arterial thrombolysis, or a combination, or standard medical therapy (n=432), including intravenous thrombolytic agents, antiplatelet drugs, or anticoagulation. Ninety-one percent of participants received treatment within 12 hours.
All the patients had VBAO stroke, with or without the involvement of the intracranial vertebral artery, confirmed with imaging a median of 3.81 hours after estimated stroke onset. At baseline, patients scored a median of 22 points on the 42-point National Institutes of Stroke Scale (NIHSS), where 22 indicates severe stroke and higher scores greater severity, and a median of 9 points on the 10-point posterior circulation Acute Stroke Prognosis Early Computed Tomography score (pc-ASPECTS), where higher scores indicate less infarct burden and a potentially higher likelihood of benefit from endovascular therapy.
The investigators report that patients treated with endovascular therapy were a significant 2.41 times more likely to have a favorable functional status at 90 days (defined as a score of 0–3 points on the modified Rankin Scale [mRS], where 0 points indicates no symptoms and 3 points indicates moderate disability), after taking into account factors such as age, the occurrence of atrial fibrillation, occlusion location, and stroke severity.
Specifically, 45% of patients receiving endovascular therapy achieved favorable functional status versus 30% of those receiving standard medical treatment, and Hu and colleagues report that the number needed to treat for one additional patient to have a favorable functional status was six.
Patients in the endovascular treatment group were also significantly more likely to achieve functional independence (mRS score of 0–2 points) at the 90-day follow-up, at a rate of 35% versus 21% in the standard medical treatment arm (adjusted odds ratio [aOR]=2.52), and to improve by at least 1 point on the mRS in this timeframe (adjusted OR=2.09).
The team notes that, while the rate of symptomatic intracranial hemorrhage at 24–72 hours was significantly higher in the endovascular group than the medical therapy group (5 vs <1%; aOR=11.98), endovascular therapy was nevertheless associated with a significantly reduced rate of mortality at the 90-day follow-up (36 vs 45%; aOR=0.60).
The beneficial effect of endovascular therapy was consistent across all prespecified subgroups, including patients with non-intracranial atherosclerotic disease-related VBAO (aOR=2.52), and those with atrial fibrillation (aOR=2.63).
The only exceptions were an uncertain benefit for the 10% of patients with a mild baseline stroke severity (NIHSS score below 10 points), for whom the analysis was underpowered, say the researchers, and an increased benefit in patients with more proximal versus distal occlusions.
In a related comment, Jan Ho and Graeme Hankey, both from the University of Western Australia in Perth, congratulate Hu et al on their study, but also point out other selection biases, namely only 31% of participants were women and the majority (70%) were recruited from China, which “raises uncertainty about the generalisability of the results to other populations and patients with VBAO.”
They conclude that the clinical implications of the study are that “endovascular therapy is effective for select patients when undertaken within 24 [hours] of onset of posterior circulation stroke due to VBAO,” adding that the “magnitude of the treatment effect is similar to that of endovascular therapy for anterior circulation stroke due to large artery occlusion.”
They call for further trials to “help stratify those patients who are most, and least, likely to benefit from endovascular therapy.”
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Lancet 2025; 405: 61–69
Lancet 2025; 405: 5–7
