Endovascular therapy compared to best medical treatment in Non-ATTENTION patients: a multicenter registry study

We aimed to investigate the efficacy and safety of endovascular therapy (EVT) in adult stroke patients with vertebrobasilar artery occlusion (VBAO) not fulfilling the ATTENTION (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion) inclusion criteria. We retrospectively enrolled VBAO patients from 65 Chinese stroke centers (December 2015–June 2022), excluding those meeting ATTENTION criteria. We compared EVT recipients with those receiving best medical treatment (BMT) alone. The primary efficacy outcome was favorable functional outcome (modified Rankin Scale [mRS] 0–3 at 90 days). Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Of 4124 VBAO patients, 1345 (35.6%) did not meet ATTENTION criteria; 472 (35.1%) received EVT. After adjusting for confounders, EVT patients had higher odds of favorable functional outcome (OR 1.44, 95% CI 1.11–1.87), increased sICH risk (OR 1.94, 95% CI 1.06–3.55), and lower mortality (OR 0.54, 95% CI 0.40–0.75) compared to BMT. However, when the NIHSS score in ATTENTION criteria was lowered to ≥ 6, EVT’s advantage over BMT was not statistically significant (OR 1.32, 95% CI 0.93–1.86). In VBAO patients not meeting ATTENTION criteria, EVT was still associated with better functional outcomes. Extending the NIHSS score to ≥ 6 may be a more suitable criterion, supporting broader EVT eligibility to benefit more patients.