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ESOC 2022 | ATTENTION results: endovascular therapy vs. best medical management for basilar artery occlusion

Raul Nogueira, MD, University of Pittsburgh, Pittsburgh, PA, shares the anticipated findings of the randomized, controlled ATTENTION trial (NCT04751708), assessing the safety and efficacy of endovascular treatment for acute basilar artery occlusion (BAO), compared to best medical management (BMM). In total, 340 patients with acute ischemic stroke with basilar artery occlusion were recruited and followed up for 90 days. The primary outcome of the trial was a favorable outcome, defined as a modified Rankin scale score of 0-3. There was a significant difference in favorable outcomes in the thrombectomy group compared to BMM (46% vs. 24%), as well as a lower degree of overall disability, lower mortality rate, and more patients achieving independence. A significant increase in the rate of symptomatic intercranial hemorrhage with endovascular treatment was reported, compared to BMM. This interview took place at European Stroke Organisation Conference 2022 in Lyon, France.

Transcript (edited for clarity)

Within the ATTENTION Network, we actually expand the number of hospitals in the registry and this is starting 2017. We start prospectively collecting data from basilar artery occlusion patients within the first 24 hours that were treated according to local standards of care, with either endovascular treatment or best medical management. Over the course of a few years, we collect a total of actually over 2100 patients, most of which, like just over 1600 patients, were treated with endovascular therapy and about 460 were treated with best medical management alone...

Within the ATTENTION Network, we actually expand the number of hospitals in the registry and this is starting 2017. We start prospectively collecting data from basilar artery occlusion patients within the first 24 hours that were treated according to local standards of care, with either endovascular treatment or best medical management. Over the course of a few years, we collect a total of actually over 2100 patients, most of which, like just over 1600 patients, were treated with endovascular therapy and about 460 were treated with best medical management alone. So with that, you could do an adjusted analysis comparing both therapies.

What you found was that patients were treated with endovascular treatment had more favorable outcomes, defined as a modified Rankin scale of 0-3 at 90 days, meaning you can walk on your own. Even if you aren’t fully independent, you are able to walk on your own. But also there was a higher rate of functional independence at 90 days. There was an overall reduction in the degree of disability and even lower mortality, despite an increase in the rates of symptomatic intracranial hemorrhage. So, that was our registry, right? Which is great data, a lot of patients, that’s the strength of it. But whenever you do registries and you compare groups, you can have bias. So, it’s really important we do what we end up also doing kind of in parallel with the registry in January last year, we start randomizing patients. Two to one; two patients would get randomized to thrombectomy for every patient getting randomized for best medical management. We conclude the recruitment of the patients, 340 patients were recruited in February and then you follow them up for 90 days. And the results we present is from this cohort of 340 patients that were randomizing this trial.

What the trial essentially demonstrate is that the primary end point of more favorable outcomes, again, modified Rankin scale 0-3 was higher with endovascular treatment. We had 46% of the patients achieving that primary end point with endovascular treatment versus only 22.8% of the patients in the best medical management arm. That gives us an adjusted risk ratio of 2.1, which was highly significant with a P value less than 0.001, and a number needed to treat of just four. For every four patients you treat, one patient you benefit, which is an extremely low number. Moreover, there was a lower degree of overall disability. When you look at the modified Rankin scale and we do what’s called the ordinal shift analysis, which means for every patient that is treated, you are actually decreasing at least one point in terms of the disability scale. The common odds ratio was 2.8, which is actually just as good, numerically better than what you’ve seen in anterior circulation, which is 2.5.

That was another great finding. And finally were also able to demonstrate a significant difference in terms of more people being fully independent at 90 days with an adjusted risk ratio of 3.2, as well as lower mortality at 90 days with an adjusted risk ratio of 0.7. That all happened despite a slightly higher but significant increase in symptomatic intracranial hemorrhage with endovascular therapy, which was 5.3% versus 0% in the best medical management group.

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