Endovascular treatment for basilar artery occlusion: A Bayesian network meta-analysis comparing time-to-treatment windows and medical management

Background and objectivesBasilar artery occlusion accounts for a small fraction of ischemic strokes but carries a disproportionally poor natural history, with high rates of death and disability under best medical therapy (BMT). Endovascular treatment is used to treat these patients, though evidence of its safety and efficacy in different time windows compared to BMT remains conflicted. To address this, this Bayesian meta-analysis evaluates the outcomes of endovascular treatment for basilar artery occlusion performed in early (0-6 h) and late (>6 h) windows versus BMT.Materials and methodsFollowing PRISMA guidelines, databases were searched through for studies comparing endovascular versus BMT in patients with basilar artery occlusion. Randomized controlled trials, prospective, and retrospective studies reporting at least one clinical outcome were included. A Bayesian random-effects network meta-analysis was performed to compare endovascular treatment within 0-6 h and beyond 6 h with BMT.ResultsSeven studies comprising 4,125 patients were included. EVT demonstrated superior functional outcomes compared to BMT across both time windows, with the late (>6 h) window showing a higher probability of achieving favorable modified Rankin Scale (mRS) scores (0-2). Mortality reduction was not consistent, and both early and late EVT were associated with higher risks of hemorrhagic and overall complications. Despite these safety concerns, the overall benefit-to-risk balance favored EVT as the preferred therapy for BAO.ConclusionThe findings underscore the importance of imaging-based selection and individualized decision-making, suggesting that EVT beyond traditional time windows remains effective when guided by appropriate clinical and radiological criteria.