Assessing IV Thrombolysis Before EVT in Basilar Artery Occlusions: A Comprehensive Pooled Analysis

A pooled patient-level analysis of four randomized trials finds no significant difference in 90‑day functional outcomes when IV thrombolysis is given before endovascular thrombectomy (EVT) for basilar artery occlusion—findings that may prompt reappraisal of pre‑EVT workflows.

The analysis pooled patient-level data from four randomized controlled trials (BEST, BASICS, ATTENTION, BAOCHE) and examined 556 EVT-treated patients (223 received IVT+EVT and 333 received EVT alone). The prespecified primary endpoint was favorable outcome, defined as modified Rankin Scale (mRS) 0–3 at 90 days; rates were 47% with IVT+EVT versus 44% with EVT alone (adjusted OR 0.88, 95% CI 0.57–1.36).

Symptomatic intracranial hemorrhage and mortality did not increase with bridging therapy in the pooled dataset: sICH occurred in 6.3% versus 4.9% (adjusted OR 1.87, 95% CI 0.77–4.57), and mortality was 33% versus 38% (adjusted OR 0.93, 95% CI 0.59–1.44).

The pooled analysis did not provide prespecified subgroup estimates for patients on therapeutic anticoagulation and was not powered to evaluate anticoagulation–IVT interactions. Effect estimates for anticoagulated patients require cautious interpretation and targeted registry or observational follow-up.