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Abstract：
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
摘要：
本欧洲卒中组织（ESO）指南的目的是为基底动脉闭塞（BAO）患者的急性治疗提供循证建议。这些指南是根据ESO的标准操作程序并根据GRADE方法编写的。尽管BAO仅占所有笔划的1-2％，自然结果很差。我们确定了10个相关的临床情况，并制定了相应的人口干预比较结果（PICO）问题，在此基础上进行了系统的文献检索和综述。工作组由10名有投票权的成员（5名代表ESO，5名代表欧洲微创神经治疗学会（ESMINT））和3名无投票权的初级成员组成。证据的确定性通常很低。在许多PICO中，可用数据稀缺或缺乏，因此，我们提供了专家共识声明。首先,我们比较了静脉溶栓（IVT）与非IVT，但具体的BAO相关数据不存在。然而，历史上,IVT是BAO患者的标准护理，这些患者也被纳入IVT试验（尽管数量很少）。仅IVT队列的非随机研究显示了高比例的有利结果。专家共识建议使用IVT长达24小时，除非另有禁忌。我们进一步建议IVT加血管内治疗（EVT）而不是直接EVT。在最佳药物治疗（BMT）之上的EVT在最后一次观察良好的6和6-24小时内与单独的BMT进行了比较。在两个时间窗口中，我们观察到不同的治疗效果，这取决于a）患者接受治疗的地区（欧洲与亚洲），B)关于BMT臂中IVT的比例，和c)初始中风严重程度。在BMT组中IVT比例高以及美国国立卫生研究院卒中量表（NIHSS）评分低于10的患者中，未发现EVT加BMT优于单独BMT。基于非常低的证据确定性，我们建议EVT+BMT优于单独BMT(这是基于至少有10个NIHSS点和BMT中IVT比例较低的患者的结果).对于NIHSS评分低于10的患者，我们没有发现推荐EVT优于BMT的证据。事实上,BMT比EVT更好且更安全。此外，我们发现,与远端位置相比,在BAO的近端和中间位置,EVT+BMT比单独BMT具有更强的治疗效果.虽然对于后颅窝没有广泛早期缺血性改变的患者的建议可以，总的来说,跟随其他PICOs，我们制定了一份专家共识声明,建议对有广泛双侧和/或脑干缺血改变的患者进行再灌注治疗.另一个专家共识建议再灌注治疗，无论侧支评分如何。基于有限的证据,我们建议直接抽吸支架取出器作为机械血栓切除术的一线策略.作为专家共识,我们建议在EVT手术失败后进行经皮腔内血管成形术和/或支架置入治疗.最后,基于非常低的证据确定性，我们建议无合并IVT且EVT复杂的患者在EVT期间或EVT后24小时内进行附加抗血栓治疗(定义为失败或即将再次闭塞,或需要额外的支架或血管成形术)。
