{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T02:04:34Z","timestamp":1792807474718,"version":"4.5.0"},"reference-count":102,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2025,12,13]],"date-time":"2025-12-13T00:00:00Z","timestamp":1765584000000},"content-version":"vor","delay-in-days":377,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2024,12,1]],"date-time":"2024-12-01T00:00:00Z","timestamp":1733011200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,12,1]]},"abstract":"<jats:p>The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%\u20132% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24\u2009h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6\u201324\u2009h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT\u2009+\u2009BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT\u2009+\u2009BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and\/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and\/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24\u2009h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).<\/jats:p>","DOI":"10.1177\/23969873241257223","type":"journal-article","created":{"date-parts":[[2024,5,16]],"date-time":"2024-05-16T09:00:15Z","timestamp":1715850015000},"page":"835-884","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":47,"title":["European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion"],"prefix":"10.1093","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9095-2344","authenticated-orcid":false,"given":"Daniel","family":"Strbian","sequence":"first","affiliation":[{"name":"Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland 1"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0640-3797","authenticated-orcid":false,"given":"Georgios","family":"Tsivgoulis","sequence":"additional","affiliation":[{"name":"Second Department of Neurology, \u2018Attikon\u2019 University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece 2"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0029-6764","authenticated-orcid":false,"given":"Johanna","family":"Ospel","sequence":"additional","affiliation":[{"name":"Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada 3"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6921-0597","authenticated-orcid":false,"given":"Silja","family":"R\u00e4ty","sequence":"additional","affiliation":[{"name":"Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland 1"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8058-383X","authenticated-orcid":false,"given":"Petra","family":"Cimflova","sequence":"additional","affiliation":[{"name":"Foothills Medical Center, University of Calgary, Calgary, AB, Canada 4"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Georgiopoulos","sequence":"additional","affiliation":[{"name":"Department of Physiology, School of Medicine, University of Patras, Greece 5"},{"name":"School of Biomedical Engineering and Imaging Sciences, King\u2019s College London, London, UK 6"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6717-0915","authenticated-orcid":false,"given":"Teresa","family":"Ullberg","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malm\u00f6, Malm\u00f6, Sweden 7"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7347-1039","authenticated-orcid":false,"given":"Caroline","family":"Arquizan","sequence":"additional","affiliation":[{"name":"Department of Neurology, H\u00f4pital Gui de Chauliac, INSERM U1266, Montpellier, France 8"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1953-9033","authenticated-orcid":false,"given":"Jan","family":"Gralla","sequence":"additional","affiliation":[{"name":"Neuroradiology, Inselspital, University of Bern, Bern, Switzerland 9"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0416-2985","authenticated-orcid":false,"given":"Kamil","family":"Zele\u0148\u00e1k","sequence":"additional","affiliation":[{"name":"Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia 10"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1691-8428","authenticated-orcid":false,"given":"Salman","family":"Hussain","sequence":"additional","affiliation":[{"name":"European Stroke Organisation, Basel, Switzerland 11"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8533-7478","authenticated-orcid":false,"given":"Jens","family":"Fiehler","sequence":"additional","affiliation":[{"name":"UMC Hamburg-Eppendorf, Hamburg, Germany 12"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrik","family":"Michel","sequence":"additional","affiliation":[{"name":"Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, B\u00e2timent Hospitalier Principal, Lausanne, Switzerland 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