Acute basilar artery occlusion (aBAO) is a rare yet highly devastating form of acute cerebrovascular occlusion, accounting for approximately 1% of all strokes (1–3). Due to its extremely high mortality and disability rates, most patients experience severe post-onset functional impairments. Current treatment modalities for aBAO primarily include intravenous and intra-arterial thrombolysis, mechanical thrombectomy, and bridging therapy, with the latter three collectively referred to as endovascular treatment (EVT) (4, 5). In recent years, several clinical trials have confirmed the safety and efficacy of EVT for the treatment of anterior circulation large-vessel occlusions (6, 7).

However, patients with basilar artery occlusion differ significantly from those with anterior circulation stroke in terms of vascular anatomy, clinical presentation, and severity of neurological deficits (8, 9). Therefore, although EVT has gained widespread acceptance for the treatment of anterior circulation occlusions, its efficacy in patients with posterior circulation aBAO remains a subject of debate (10, 11). Multiple large-scale, multicenter randomized clinical trials (RCTs) on posterior circulation aBAO, such as the BEST, BASICS, and BASILAR studies, have explored EVT efficacy (12, 13). However, the results of these studies have been inconclusive. In the BEST and BASICS trials, no significant differences in favorable outcomes at 90 days post-procedure were observed between the EVT and medical management groups, potentially due to suboptimal patient recruitment (14). Moreover, adjustments to the enrollment criteria in the BASICS trial may have further influenced the outcomes (15).

Nonetheless, recent real-world studies and RCTs, such as the BASILAR study and China’s BAOCHE and ATTENTION trials, have provided robust evidence supporting the potential benefits of EVT for the treatment of aBAO (16–18). These studies demonstrated that compared with best medical management, EVT significantly improves favorable outcomes at 90 days and reduces mortality, particularly in severe cases (19). These findings offer new clinical evidence for the treatment of large-vessel occlusions in the posterior circulation and may prompt updates to the clinical guidelines.

Therefore, this study aimed to compare the clinical efficacy and prognosis of EVT and BMM in patients with acute basilar artery occlusion, to provide a basis for further optimization of treatment strategies for aBAO.

The optimal treatment strategy for aBAO remains an important and evolving issue in stroke management (25). While EVT has become the standard treatment for anterior circulation large-vessel occlusions, its efficacy in posterior circulation stroke has historically been less certain (26). Early randomized controlled trials, including BEST and BASICS, did not demonstrate a clear functional benefit of EVT over medical therapy in patients with aBAO (27).

Recently, accumulating evidence has supported the potential benefit of EVT in patients with aBAO. The BASILAR study, a large prospective registry, reported that EVT was associated with improved functional outcomes and reduced one-year mortality in real-world clinical practice (28). Subsequently, the ATTENTION trial demonstrated that EVT significantly improved functional outcomes compared with BMM in patients treated within an early therapeutic window (29). In addition, the BAOCHE trial further extended the therapeutic window and showed that EVT remained beneficial in patients treated 6–24 h after symptom onset when appropriate imaging selection criteria were applied (10). Together, these studies have strengthened the evidence supporting EVT as an effective treatment strategy for selected patients with aBAO. Consistent with these recent findings, the results of the present study demonstrated that patients treated with EVT achieved significantly better functional outcomes than those receiving BMM, particularly with respect to mRS and EQ-5D scores at 30 and 90 days. These findings suggest that timely endovascular reperfusion may play an important role in improving neurological recovery and overall functional status in patients with aBAO. Therefore, our results provide additional real-world evidence supporting the clinical value of EVT in the management of aBAO.

The results of this study demonstrated that the EVT group exhibited significantly better functional recovery than the BMM group, particularly in terms of mRS and EQ-5D scores at 30 and 90 days. These findings align with those of recent studies, such as ATTENTION and BAOCHE, which reported that the EVT group had a higher rate of favorable functional outcomes at 90 days (30). This improvement may be attributed to the ability of EVT to rapidly restore blood flow in the basilar artery and reduce the duration of ischemia, thereby mitigating neural damage and facilitating long-term recovery. Additionally, Abdalkader et al. (31) showed that the EVT group had a higher likelihood of achieving an mRS of 0–3 at 90 days, but also a higher incidence of symptomatic intracranial hemorrhage, while demonstrating lower mortality. Furthermore, Chen et al. (32) noted that EVT was associated with better functional recovery and lower mortality risk in patients with BAO, although they also showed a higher risk of symptomatic intracranial hemorrhage. These findings are consistent with the results of the present study, further supporting the use of EVT as an effective treatment for aBAO.

Although the EVT group demonstrated significant advantages in functional recovery, there were no statistically significant differences between the EVT and BMM groups in terms of safety indicators such as incidence of symptomatic intracranial hemorrhage, 90-day mortality, and functional deterioration rates. Shuo et al. (33) reported that in patients with atrial fibrillation complicated by basilar artery occlusion, there were no significant differences in symptomatic intracranial hemorrhage or mortality between the EVT and BMM groups at 90 days. Similarly, Chuanhui et al. (34) found that endovascular treatment did not significantly affect 90-day mortality, 24-h symptomatic intracranial hemorrhage rates, or the number of procedure-related complications. These results suggest that, in terms of safety, EVT does not significantly increase the risk of complications.

Regarding neurological function recovery, the EVT group demonstrated superior performance compared to the BMM group, as reflected by the significantly lower NIHSS scores at 24, 30, and 90 days post-treatment. This indicates that EVT is more effective in mitigating neurological deficits, likely because of its ability to rapidly restore blood flow and reduce ischemic damage. Yoshimoto et al. (8) found that in patients with severe neurological deficits due to aBAO, those treated with EVT were more likely to walk independently compared to those receiving BMM, while patients with mild neurological deficits that received either treatment showed similar independence rates. Additionally, the EVT group exhibited significantly higher PC-ASPECTS scores and basilar artery recanalization rates on imaging assessment, further supporting the superiority of EVT in reducing infarct volume and improving vascular patency. Therefore, EVT has significant clinical value as a treatment option for aBAO, with notable advantages in terms of neurological recovery and vascular recanalization.

The findings of this study provide additional evidence supporting the use of EVT in the management of aBAO. Although some safety outcomes did not reach statistical significance, EVT demonstrated advantages in functional recovery, neurological outcomes, and imaging assessments. These results suggest that EVT may be a valuable therapeutic option for patients with aBAO and may provide useful insights for optimizing clinical management strategies.

However, several limitations should be acknowledged. First, the relatively small sample size may have reduced the statistical power of the analysis, particularly in detecting subtle differences between groups and identifying rare adverse events. Second, this was a single-center study, and the patient population was derived from a single institution. Therefore, regional differences in medical resources, treatment strategies, and patient characteristics may limit the generalizability of the findings. In addition, the retrospective study design means that treatment allocation was based on the therapy actually received rather than randomized assignment, which may introduce selection bias and potential confounding. Although baseline characteristics between the two groups were comparable, advanced statistical adjustment methods, such as multivariable regression or propensity score matching, were not applied. Consequently, residual confounding cannot be completely excluded. Furthermore, the follow-up period was limited to 90 days. While this time point is widely used as a standard endpoint in stroke studies for functional outcome assessment, it may not fully capture long-term functional recovery, cognitive outcomes, or sustained improvements in health-related quality of life. Longer-term follow-up is therefore warranted to further evaluate the long-term efficacy and safety of EVT in patients with aBAO. Finally, although no significant differences in safety outcomes were observed between the two groups, the limited sample size and study design may have restricted the statistical power to detect rare adverse events. Larger, multicenter, prospective studies are needed to further validate the efficacy and safety of EVT in the treatment of aBAO. In summary, while the findings of this study are encouraging, further large-scale, multicenter randomized controlled trials are required to confirm these results.