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Original research
Bridging versus direct endovascular therapy in basilar artery occlusion
  1. Sergio Nappini1,
  2. Francesco Arba2,
  3. Giovanni Pracucci3,
  4. Valentina Saia4,
  5. Danilo Caimano3,
  6. Nicola Limbucci1,
  7. Leonardo Renieri1,
  8. Andrea Zini5,
  9. Domenico Inzitari3,
  10. Danilo Toni6,
  11. Salvatore Mangiafico1
  12. On behalf of the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) Study Group
  1. 1 Neurovascular Interventional Unit, University Hospital Careggi, Firenze, Italy
  2. 2 Stroke Unit, University Hospital Careggi, Firenze, Italy
  3. 3 NEUROFARBA Department, Universita degli Studi di Firenze Scuola di Scienze della Salute Umana, Firenze, Italy
  4. 4 Neurology and Stroke Unit, Hospital Santa Corona Pietra Ligure, Pietra Ligure, Italy
  5. 5 Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche, Maggiore Hospital, Bologna, Italy
  6. 6 Neurological Sciences, University of Rome La Sapienza, Roma, Italy
  1. Correspondence to Dr Sergio Nappini, Neurovascular Interventional Unit, University Hospital Careggi, Firenze, Italy; nappini{at}


Background We evaluated safety and efficacy of intravenous recombinant tissue Plasminogen Activator plus endovascular (bridging) therapy compared with direct endovascular therapy in patients with ischaemic stroke due to basilar artery occlusion (BAO).

Methods From a national prospective registry of endovascular therapy in acute ischaemic stroke, we selected patients with BAO. We compared bridging and direct endovascular therapy evaluating vessel recanalisation, haemorrhagic transformation at 24–36 hours; procedural complications; and functional outcome at 3 months according to the modified Rankin Scale. We ran logistic and ordinal regression models adjusting for age, sex, National Institutes of Health Stroke Scale (NIHSS), onset-to-groin-puncture time.

Results We included 464 patients, mean(±SD) age 67.7 (±13.3) years, 279 (63%) males, median (IQR) NIHSS=18 (10–30); 166 (35%) received bridging and 298 (65%) direct endovascular therapy. Recanalisation rates and symptomatic intracerebral haemorrhage were similar in both groups (83% and 3%, respectively), whereas distal embolisation was more frequent in patients treated with direct endovascular therapy (9% vs 3%; p=0.009). In the whole population, there was no difference between bridging and direct endovascular therapy regarding functional outcome at 3 months (OR=0.79; 95% CI=0.55 to 1.13). However, in patients with onset-to-groin-puncture time ≤6 hours, bridging therapy was associated with lower mortality (OR=0.53; 95% CI=0.30 to 0.97) and a shift towards better functional outcome in ordinal analysis (OR=0.65; 95% CI=0.42 to 0.98).

Conclusions In ischaemic stroke due to BAO, when endovascular therapy is initiated within 6 hours from symptoms onset, bridging therapy resulted in lower mortality and better functional outcome compared with direct endovascular therapy.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. All free text entered below will be published.

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Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. All free text entered below will be published.

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  • SN and FA contributed equally.

  • Collaborators Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) Study Group: Antonio Laiso; Carolina Capirossi; Enrico Fainardi; Patrizia Nencini; Fabrizio Sallustio; Daniele Morosetti; Stefano Vallone; Guido Bigliardi; Sergio Vinci; Paolino La Spina; Tommaso Casseri; Rosanna Tassi; Mauro Bergui; Paolo Cerrato; Andrea Saletti; Ilaria Casetta; Roberto Gasparotti; Mauro Magoni; Ciro Princiotta; Maria Ruggiero; Enrico Maria Lotti; Lucio Castellan; Laura Malfatto; Roberto Menozzi; Umberto Scoditti; Mirco Cosottini; Michelangelo Mancuso; Alessio Comai; Enrica Franchini; Iacopo Valente; Fabio Pilato; Edoardo Puglielli; Alfonsina Casalena; Giacomo Cester; Claudio Baracchini; Chiara Comelli; Alessandra Giai Via; Mauro Plebani; Manuel Cappellari; Luigi Chiumarulo; Marco Petruzzellis; Giuseppina Sanfilippo; William Boadu; Nicola Cavasin; Adriana Critelli; Alessandra Briatico Vangosa; Angela Pesare; Alberto Terrana; Elisa Candeloro; Umberto Silvagni; Carmen Gaudiano; Francesco Biraschi; Ettore Nicolini; Valeria Ledda; Maurizio Melis; Valentina Caldiera; Tiziana Tassinari; Nunzio Paolo Nuzzi; Simona Marcheselli; Simona Sacco; Marco Pavia; Paolo Invernizzi; Ivan Gallesio; Delfina Ferrandi; Maria Cristina Fancello; Alessandro Mela; Pietro Amistà; Monia Russo; Claudio Fabio; Antonello Caddeo; Giuseppe Craparo; Marina Mannino.

  • Contributors SN and FA conceived and planned the study, gaining access to the IRETAS database. SN, FA, GP, NL, LR and DC performed data analysis and interpretation. SN, FA and DC drafted the manuscript. SM, DT, DI, NL, GP and VS took care of the critical review of the manuscript, constantly providing ideas that allowed its development. AL, CC, EF, PN, FS, DM, SV, GB, SV, PLS, TC, RT, MB, PC, AS, IC, RG, MM, CP, MR, EML, LC, LM, RM, US, MC, MM, AC, EF, IV, FP, EP, AC, GC, CB, CC, AGV, MP, MC, LC, MP, GS, WB, NC, AC, ABV, AP, AT, EC, US, CG, FB, EN, VL, MM, VC, TT, NPN, SM, SS, MP, PI, IG, DF, MCF, AM, PA, MR, CF, AC, GC and MM collected data.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AZ is the national coordinator for Italy for BASICS trial and received speaker and consulting fees from Boehringer-Ingelheim, Medtronic, Cerenovus and advisory board from Boehringer-Ingelheim and Stryker. Other authors report no conflict of interests relevant to this paper.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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