Acute basilar artery occlusion (BAO) results in strokes characterized by poor outcome. Intravenous and intraarterial thrombolysis with rt-PA (IV rt-PA and IA rt-PA, respectively) and mechanical thrombectomy (MT) are the most commonly used techniques to treat BAO, but their efficacy remains unclear. Unlike in previous papers, we compared all three methods of the treatment in a single work, including an update of meta-analysis regarding each of the three therapeutic approaches with recent trials.

We systematically reviewed all original studies testing the efficacy of any of the three basic methods of BAO treatment dated up to the end of Jan 2017.

The final analysis included 31 studies that summarized 1358 patients. These subjects were organized into three therapeutic groups: IV rt-PA, IA rt-PA±IV rt-PA, MT±IV rt-PA±IA rt-PA. The weighted pooled estimates of a favorable outcome (mRS 0–2) were 32.57% (95% CI 16.44–51.03%/I2=67.5%, p=0.0795) in the first group, 22.56% (95% CI 16.85–28.79%/I2=52.1%, p=0.027) in the second group, and 37.04% (95% CI 32.27–41.92%/I2=32%, p=0.0895) in the third group. The Q-test subgroup analysis revealed the statistical superiority of MT±IV rt-PA±IA rt-PA over IA rt-PA±IV rt-PA (mRS 0–2: p=0.0003, mRS 6: p=0.0010) and over any rt-PA administration (either IV rt-PA or IA rt-PA±IV rt-PA) (mRS 0–2: p=0.0006, mRS 6: p=0.0056).

Current data on the effects of the three basic approaches of the treatment of BAO are insufficient to generate high-class EBM guidelines. MT seems to be the most effective method of the treatment of acute BAO. The efficacy of IV or IA thrombolytic therapy in this indication remains unclear.