First-Line Stent Retriever versus Direct Aspiration for Acute Basilar Artery Occlusions: A Systematic Review and Meta-analysis

Background: Mechanical thrombectomy (MT) for anterior circulation stroke has been proven to be highly effective. In comparison, MT for basilar artery occlusion (BAO) continues to lack definitive evidence of efficacy. The main MT modalities are stent retriever (SR) and direct aspiration (DA). Several studies have been published comparing the 2 approaches. Objective: We sought to directly compare and synthesize safety and efficacy outcomes with SR versus DA for acute BAO. Methods: A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Overall, 8 studies comprising 693 patients with BAO were included (SR: 457; DA: 236). The SR group was associated with statistically significant lower odds of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.31–0.94) and mTICI3 (OR: 0.47; 95% CI: 0.23–0.95) compared with DA. Favorable outcome rates were similar between the 2 groups (OR: 0.83; 95% CI: 0.60–1.16). The rates of symptomatic intracerebral hemorrhage (OR: 3.57; 95% CI: 0.75–16.95), subarachnoid hemorrhage (SAH) (OR: 4.71; 95% CI: 0.82–26.90), and vessel perforation (OR: 2.64; 95% CI: 0.43–16.33) were higher in the SR group, but statistical significance was not reached. The rates of 90-day mortality were similar between the 2 groups (OR: 1.07; 95% CI: 0.67–1.70). Procedure duration was significantly shorter when DA was used compared with SR (weighted mean difference: 26.10 minutes; 95% CI: 13.28–38.92). Conclusions: SR is associated with statistically significant lower odds of mTICI 2b/3 and mTICI 3 recanalization rates compared with DA. SR appears to be associated with a higher complication rate, but significance was not reached.