Rescue intracranial stenting for failed mechanical thrombectomy of vertebrobasilar occlusions: a pooled analysis from the French and German national stroke registries

Background Whether rescue intracranial stenting (RIS) should be performed in patients with vertebrobasilar occlusions (VBO) refractory to endovascular mechanical thrombectomy (MT) remains an open question. Methods We conducted a pooled analysis using data from two national stroke registries, the Endovascular Treatment in Ischemic Stroke registry in France, and the German Stroke Registry–Endovascular Treatment. Patients with VBO who underwent RIS for failed MT, defined as a modified treatment in cerebral infarction (mTICI) score of 0 to 2a after MT, from January 2015 to December 2023 were included. The primary outcome was a modified Rankin Scale (mRS) score of 0–3 at 90 days. Secondary outcomes included mRS distribution and mortality at 90 days, any intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Propensity score matching and inverse propensity weighting were employed to balance baseline differences. Results Among 2028 patients, 307 (15.1%) patients had MT-refractory VBO. Of these, 127 (41.4%) underwent RIS and 180 (58.6%) patients no RIS. After propensity score matching, two balanced groups were obtained: 106 patients with RIS and 99 without RIS. Patients who underwent RIS had higher odds of achieving an mRS 0–3 (adjusted odds ratio (aOR) 3.45, 95% confidence interval (CI) 1.27 to 9.34. P=0.014), a favorable shift across the mRS distribution (aOR 2.55 per 1-point mRS improvement, 95% CI 1.22 to 5.34; P=0.013) and lower odds of 90-day mortality (aOR 0.26, 95% CI 0.09 to 0.71; P=0.008). There were no significant differences in any ICH and sICH. Conclusion This registry-based study provides level 3 evidence supporting the use of RIS in patients with VBO refractory to MT. Prospective randomized trials are necessary to validate the potential benefits of RIS in this condition.