Study likely to change standard of care for deadly strokes

Endovascular therapy, or EVT, – a minimally invasive surgery performed inside the blood vessels – is 2 ½ times more likely than standard medical management to achieve a positive outcome after vertebrobasilar stroke that affects the back of the brain, including the brain stem. A meta-analysis of four randomized clinical trials, published today in The Lancet, was led by UPMC Stroke Institute director Raul Nogueira, M.D.

Investigators from the U.S., Netherlands and China formed a multi-center collaboration of all four randomized trials of EVT in vertebrobasilar occlusion with data that provides the strongest evidence to date of the benefits of EVT over alternative approaches for complicated vessel obstructions in life-sustaining areas of the brain.

Although vertebrobasilar artery occlusions interrupting blood flow in the back of the brain account for only a small fraction of all ischemic strokes, they are especially deadly. Without an appropriate intervention, vertebrobasilar strokes lead to high rates of severe disability and mortality that may exceed 70%.

“While the overwhelming benefit of EVT for acute ischemic strokes due to occlusions of large vessels that supply the anterior brain has been well established, the benefit of this therapy for vertebrobasilar artery occlusion, one of the most devastating forms of stroke, has been more controversial,” said Nogueira, endowed professor of neurology and neurosurgery at the University of Pittsburgh.

To address this uncertainty, the consortium of investigators, called VERITAS, focused on providing more precise, comprehensive and statistically powered estimates of the benefits of EVT with a particular focus on specific patient subgroups of clinical interest.

As the primary coordinating center for the study, the Pitt team established common variables, definitions and trial specifications that laid the groundwork for a core pooled dataset from the four randomized controlled clinical trials ATTENTION, BAOCHE, BASICS and BEST of EVT for stroke due to vertebrobasilar artery occlusion.

Meta-analysis showed that at three months after the surgery, despite higher rates of brain bleeds with the procedure, EVT significantly reduced patient mortality and overall post-stroke disability, increasing patients’ functional independence. Notably, patients who underwent EVT were nearly 2 ½ times more likely to regain their ability to walk independently compared to patients who received the current medical standard of care, including intravenous thrombolytics.

“The results of the VERITAS collaboration are expected to influence treatment guidelines and impact stroke care globally,” Nogueira said. “We hope that this analysis sets the foundation for improved recovery after vertebrobasilar strokes and helps more people regain their independence after this catastrophic medical event.”

Other authors of the study include Tudor Jovin, M.D., of Cooper University; Xinfeng Liu, M.D., Wei Hu, M.D., and Chunrong Tao, M.D., all of the University of Science and Technology of China; Chuanhui Li, M.D., and Xunming Ji, M.D., both of Xuanwu Hospital of Capital Medical University, China; and Wouter Schonewille, M.D., of St. Antonius Hospital, Netherlands, among others. The VERITAS collaboration is self-funded.