Comparing Efficacy and Safety of Mechanical Thrombectomy in Vertebrobasilar Tandem Occlusion Versus Isolated Basilar Artery Occlusion Stroke: A Systematic Review and Meta-Analysis
Authors
MuhammadHassanWaseem1Email
ZainulAbideen2Email
MahroshKasbati3Email
MuneebaAhsan3Email
RimshaAdnan3Email
ZoyaAamir3Email
ArushaHasan3Email
MuhammadWajihAnsari4Email
RowaidAhmad4Email
ZaraFahim2Email
PawanKumarThada5✉Email
AdamA.Dmytriw6,7Email
1Allama Iqbal Medical CollegeLahorePakistan
2King Edward Medical UniversityLahorePakistan
3Dow University of Health SciencesKarachiPakistan
4University of Texas Medical BranchGalvestonTexasUnited States
5Sotang Primary HospitalSolukhumbuNepal
6
A
A
Neuroendovascular ProgramMassachusetts General Hospital & Brigham
7
A
Women’s HospitalHarvard Medical SchoolBostonMA
8Neurointerventional & Neuroanalytics Collaboration (NAN-C), School 9. of MedicineToronto Metropolitan UniversityTorontoON
Muhammad Hassan Waseem1, Zain ul Abideen2, Mahrosh Kasbati3, Muneeba Ahsan3, Rimsha Adnan3, Zoya Aamir3, Arusha Hasan3, Muhammad Wajih Ansari4, Rowaid Ahmad4, Zara Fahim2, Pawan Kumar Thada5, Adam A. Dmytriw6,7
Affiliations
1. Allama Iqbal Medical College, Lahore, Pakistan
2. King Edward Medical University, Lahore, Pakistan
3. Dow University of Health Sciences, Karachi, Pakistan
4. University of Texas Medical Branch, Galveston, Texas, United States
5. Sotang Primary Hospital, Solukhumbu, Nepal
6. Neuroendovascular Program, Massachusetts General Hospital & Brigham
7. and Women's Hospital, Harvard Medical School, Boston, MA
8. Neurointerventional & Neuroanalytics Collaboration (NAN-C), School
9. of Medicine, Toronto Metropolitan University, Toronto, ON
Email
1. waseemhassan246@gmail.com
2. mzainulabideen@kemu.edu.pk
3. mahroshkasbati@outlook.com
4. muneeba2003ahsan@gmail.com
5. rimshaadnan42@gmail.com
6. zoyaaamirsid@gmail.com
7. Arushahasan@gmail.com
8. mwansari@utmb.edu
9. roahmad@utmb.edu
10. Zarafahim999@kemu.edu.pk
11. magarpawan87@gmail.com
12. adam.dmytriw@gmail.com
Corresponding Author
Pawan Kumar Thada
magarpawan87@gmail.com
Sotang Primary Hospital, Solukhumbu, Nepal
Abstract
Background
Basilar artery occlusion (BAO) is a rare stroke type, with subtypes like vertebrobasilar tandem occlusion (VBTO), complicating treatment. Mechanical thrombectomy (MT) is increasingly used, but evidence on its safety and effectiveness in VBTO compared to non-VBTO or isolated BAO (iBAO) remains limited.
Methods
PubMed, Cochrane Central and ScienceDirect were searched till May 2025. The risk ratios (RR) were pooled along with 95% Confidence intervals (CI) under the random effects model using Review Manager. The Newcastle Ottawa Scale and GRADE assessment were used to assess the quality of studies and certainty of evidence. Publication bias was assessed using funnel plots and Egger’s regression test.
Results
Nine studies, pooling a total of 737 patients, were included in this analysis. MT showed no significant difference in functional independence in the VBTO group compared to the iBAO group (RR = 1.25; 95%CI:[0.73, 2.12]; p = 0.42). The successful recanalization was also comparable between the VBTO and iBAO arms when MT was performed (RR = 0.96; 95%CI:[0.81, 1.13]; p = 0.60). The risk of symptomatic intracerebral hemorrhage (sICH) was significantly increased when MT was performed in the VBTO arm compared to the iBAO group (RR = 2.20; 95%CI:[1.09, 4.46]; p = 0.03). The mortality rates were also comparable between the two groups (RR = 1.28; 95%CI:[0.78, 2.10]; p = 0.33). Also, in the VBTO patients, the successful recanalization rate showed no significant difference between the clean and dirty road techniques (RR = 1.04; 95%CI:[0.90, 1.20]; p = 0.63).
Conclusion
When MT was performed on VBTO and iBAO patients, the efficacy endpoints—such as functional independence and successful recanalization—and the safety endpoint of mortality were comparable. However, the risk of sICH was higher in the VBTO group.
Keywords:
Stroke
Vertebrobasilar
Tandem occlusion
Thrombectomy
Endovascular therapy
Systematic Review
Meta-Analysis
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Introduction
Acute basilar artery occlusion (BAO) is a severe type of posterior circulation stroke, representing about 1% of all acute ischemic strokes and carrying a high risk of morbidity and mortality up to 85% if not treated [1, 2]. About 25% of BAO patients have uni- or bilateral vertebral artery (VA) stenosis > 70%, usually in the V1 or V2 segments, known as vertebrobasilar tandem occlusion (VBTO) [3]. Tandem occlusions are common in anterior strokes, but in the posterior circulation, especially with BAO, they pose distinct diagnostic and treatment challenges, highlighting their importance in endovascular care [4].
VBTO involves both BAO and significant narrowing of the extracranial vertebral artery, usually at the ostium [5]. Its complex anatomy makes treatment difficult, as both extracranial and intracranial lesions must be addressed [6]. Management depends on VA dominance and whether to access the basilar artery through the blocked or open VA [5].
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Mechanical thrombectomy (MT) is now established as the standard of care for treating acute ischemic strokes caused by large vessel occlusions (LVO) in the anterior circulation [7]. Its role in managing posterior circulation strokes, especially BAO, is gaining recognition. Emerging evidence from randomized controlled trials (RCTs) indicates that MT offers substantial benefits in improving functional recovery and lowering mortality in BAO patients, although it may carry a higher risk of symptomatic intracerebral hemorrhage (sICH) compared to medical therapy alone [8].
Although research on MT for VBTO is expanding, current evidence is primarily based on small, retrospective observational studies. Therefore, our study aims to compare the outcomes of MT in patients with VBTO versus those with non-VBTO or isolated basilar artery occlusion (iBAO). By filling previous gaps and incorporating recent data, we seek to enhance clinical decision-making.
Methods
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The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines [9] and is in accordance with the Cochrane Handbook for Systematic Reviews of Interventions [10]. The protocol of this study was registered on PROSPERO under the ID: CRD420251108065.
Literature Search
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We used the PICO (Patient Population, Intervention, Control, Outcome) criteria to formulate the main study question: "Does MT in adult acute ischemic stroke (AIS) patients with VBTO result in comparable safety and efficacy compared to MT in non-VBTO patients?". Electronic databases including PubMed, Cochrane Central and Science Direct were searched till May 2025 using a combination of keywords and MeSH terms: "thrombectomy", "mechanical thrombectomy", "basilar artery occlusion", "vertebrobasilar tandem occlusion", "tandem occlusion stroke", and "isolated basilar artery occlusion". The detailed search strategies used in each database are provided in Supplementary Table 1.
Eligibility Criteria and Study Selection
Adult patients (≥ 18 years) with AIS due to VBTO treated with MT, where VBTO is defined as basilar artery occlusion with concurrent VA occlusion/stenosis ≥ 50%. The studies need to report at least one of the outcomes analyzed to be eligible for inclusion. The eligible study designs include RCTs and observational studies. Editorials, letters, reviews, and studies reporting only BA-BA tandem occlusions without VA involvement are excluded.
All the articles retrieved through the initial search were imported into EndNote software for screening.
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Two reviewers (M.A. and M.K.) independently screened titles and abstracts of these articles. Full texts of potential studies were reviewed against a pre-defined eligibility criterion for inclusion. A third author resolved any discrepancies in the screening process (M.H.W.). The process is shown in the PRISMA flow diagram (Fig. 1).
Fig. 1
PRISMA flowchart of the study selection process
Click here to Correct
Data Collection and Endpoint Definitions
For each study, we extracted patient characteristics, including sample size, sex distribution, and age. Baseline clinical factors such as the National Institutes of Health Stroke Scale (NIHSS) score were recorded to assess initial stroke severity. Procedural details were gathered, including the use of intravenous thrombolysis (IVT) before MT. The study location, follow-up time, and data on comorbidities, including arterial hypertension, dyslipidemia, and diabetes mellitus, were extracted.
The outcomes extracted were successful recanalization, functional independence at 90 days, 90-day mortality rates and the incidence of sICH. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction (TICI) score of ≥ 2b. The modified Rankin Scale (mRS) is a scale used to assess the severity of stroke, with functional independence defined as an mRS score of 0–2.
Quality Assessment
Observational studies were assessed by two independent reviewers (R.A. and A.H.) via the Newcastle-Ottawa Scale (NOS) [11], with scores ≥ 7 indicating high quality. The NOS assesses the quality based on the domains of selection, comparability, and outcome.
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Discrepancies were resolved through consensus or third reviewer (M.H.W.) adjudication.
Statistical Analysis
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Statistical analysis for this meta-analysis was conducted using Review Manager software version 54.1. For comparisons between patients with VBTO and those with iBAO or non-VBTO, pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was assessed using the Chi-square test and the Higgins I² statistics [12], where I² values of 50% or higher were considered indicative of significant heterogeneity. A random effect model (Mantel-Haenszel) was used for this analysis. Publication bias was evaluated visually through funnel plots and statistically by Egger's regression test performed using the Comprehensive Meta Analysis software version 3.0. This analytic approach ensured that the synthesis of results accounted for both variability across studies and potential sources of bias, providing a comprehensive assessment of the comparative effectiveness and safety of MT in these patient populations. For assessing the certainty of evidence generated, a GRADE assessment was performed using GRADEproGDT [13].
Results
Study selection and baseline characteristics
An initial search of the electronic databases yielded 1,318 articles. After removing 329 duplicates, 989 unique records were screened by title and abstract. This screening resulted in excluding 841 studies. The remaining 148 articles underwent full-text review, and 139 of these were excluded. Ultimately, nine studies [1, 6, 14–20] satisfied the eligibility criteria and were included in the final meta-analysis. The study selection process is illustrated in the PRISMA flow diagram (Fig. 1).
Our meta-analysis comprised a total of 9 studies [1, 6, 14–20]. All the studies were published between 2016 and 2024. Two studies were from China, two from Korea, two from Switzerland and the remaining were from Israel, France and Turkey. The follow-up is nearly 3 months in all the included studies. The baseline characteristics of all the studies included in this systematic review and meta-analysis are shown in Table 1.
Table 1
Baseline Characteristics of the Included Studies
Study
Sample Size
Male %
Age
Arterial hypertension
Dyslipidemia
Diabetes mellitus
Admission NIHSS
IV rtPA
Definition of VA lesion
Country
Follow-up
time
Sun et al. 2020
182
84
62.2 ± 9.1
16/23 vs 25/43
6/23 vs 14/43
0/23 vs 3/43
29.0 (8.5–35.0)
6/23 vs 35/159
Occlusion or > 70% stenosis of VA
China
3 months
Cohen et al. 2016
7
85.7
57 (51–63)
-
-
-
22 (18–24)
1/7
Total occlusion of VA ostium
Israel
3 months
Baik et al. 2020
55
67.3
69.1 (36–88)
-
-
-
16 (8–24) vs 21 (12–26)
-
Occluded or > 70% stenosis of extra-cranial VA
Korea
3 months
Elhorany et al. 2020
89
60.7
64.4 ± 17
8/15 vs 40/74
6/15 vs 31/74
2/15 vs18/74
22 (9–40) vs 21 (9–37)
7/15 vs 28/74
Total occlusion of the dominant extracranial VA
France
3 months
Xing et al. 2020
21
90.5
61(54–66.5)
-
-
-
28 (13.5–31)
4/18
≥ 90% stenosis of VA
China
3 months
Piechowiak et al. 2020
52
80
62.69 (37.1–90)
-
-
-
23.07 (1–36) vs 22.54 (3–36)
7/15 vs 17/37
unilateral or bilateral VA stenosis or occlusion
Switzerland
3 months
Baik et al. 2019
82
56
72.5 (20–90)
20/28 vs 24/34
-
6/28 vs 14/34
13 (7–24)
7/28 vs 15/54
Occluded or > 70% stenosis of extracranial VA
Korea
3 months
Klail et al. 2024
190
54.7
73 (63–83)
39/55 vs 102/133
23/55 vs 57/132
12/55 vs 27/133
15 (7–25)
-
presence of simultaneous VA
stenosis higher than 70%
Switzerland and
Germany
3 months
Dogan et al. 2024
59
62.7
58.14 ± 12.63
12/20 vs 22/39
-
4/20 vs 8/39
22 (17–25)
4/20 vs 14/39
occlusion or severe stenosis (≥ 70%) of the VA
Turkey
3 months
Note: Data is presented as Vertebrobasilar tandem occlusion (VBTO) vs isolated Basilar artery occlusion (iBAO); continuous variables are presented as mean ± standard deviation and median (range); NIHSS: National Institute of Health Stroke Scale; IV rtPA: Intravenous tissue plasminogen activator; VA: Vertebral artery
Quality Assessment
We performed a quality assessment for observational studies using the NOS, with scores ranging from 5 to 9. Klial et al. (2024) [1] and Dogan et al.(2024) [17] achieved full scores (9/9), indicating high quality. In contrast, the remaining studies have a score ranging between 7 and 8, indicating moderate quality of these studies. The detailed quality assessment by NOS is given in Supplementary Table 2.
Outcomes
The summary of the meta-analysis is provided in Table 2, while the GRADE assessment for each endpoint is listed in Table 3.
Table 2
Summary of Meta-analysis
Endpoint
Studies
Sample Size
Effect Size (RR)
95% CI
P value
Heterogeneity
Egger’s Regression test
  
Overall
VBTO
iBAO
 
Lower Limit
Upper Limit
 
Tau2
Chi2
df
P value
I2 (%)
Intercept
P value (2-tailed)
Functional Independence
6
617
151
466
1.25
0.73
2.12
0.42
0.29
16.27
5
0.006
69
0.827
0.787
Successful Recanalization
5
555
138
417
0.96
0.81
1.13
0.60
0.02
16.37
4
0.003
76
-2.09
0.206
Symptomatic Intracranial Hemorrhage
6
647
153
494
2.20
1.09
4.46
0.03
0
5
5
0.42
0
-0.679
0.697
Mortality
6
617
151
466
1.28
0.78
2.10
0.33
0.26
18.06
5
0.003
72
-0.805
0.816
Note: VBTO: Vertebrobasilar tandem occlusion; iBAO: Isolated basilar artery occlusion; RR: Risk ratio; CI: Confidence Interval; df: degree of freedom
Table 3
GRADE Summary of Findings Table
MT in VBTO vs iBAO
Outcomes
Anticipated absolute effects* (95% CI)
Relative effect
(95% CI)
№ of participants
(studies)
Certainty of the evidence
(GRADE)
Risk with IBAO
Risk with VTBO
90-day Functional Independence (mRS 0–2)
245 per 1,000
306 per 1,000
(179 to 519)
RR 1.25
(0.73 to 2.12)
617
(6 non-randomized studies)
⨁◯◯◯
Very lowa,b
Successful Recanalization (TICI 2b-3)
880 per 1,000
845 per 1,000
(713 to 995)
RR 0.96
(0.81 to 1.13)
555
(5 non-randomized studies)
⨁◯◯◯
Very lowa,b
Symptomatic Intracerebral Hemorrhage
40 per 1,000
89 per 1,000
(44 to 181)
RR 2.20
(1.09 to 4.46)
647
(6 non-randomized studies)
⨁⨁◯◯
Low
90-day Mortality
290 per 1,000
371 per 1,000
(226 to 608)
RR 1.28
(0.78 to 2.10)
617
(6 non-randomized studies)
⨁◯◯◯
Very lowa,b
Note: CI: confidence interval; RR: risk ratio; a. Heterogeneity is greater than 60%, b. The 95% Confidence interval crosses 1
Functional Independence
Data on 90-day functional independence were reported in six studies. A total of 617 patients (VBTO: 151; iBAO: 466) were included. No significant difference was observed in 90-day functional independence between the two groups (RR:1.25; 95% CI:0.73, 2.12; p = 0.42). Moderate heterogeneity (I2 = 69%) was observed among the studies (Fig. 2).
Fig. 2
Functional Independence forest plot
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Successful Recanalization
Five studies, including 555 patients (VBTO: 138; iBAO:417), evaluated this outcome. No significant difference was observed in the successful recanalization rate between the two groups (RR:0.96; 95% CI:0.81, 1.13; p = 0.60). High heterogeneity (I2 = 76%) was observed among the studies (Fig. 3).
Fig. 3
Successful recanalization forest plot
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Symptomatic Intracerebral Hemorrhage
Data on sICH were reported in six studies, including 647 patients (VBTO: 153; iBAO:494). Our pooled analysis revealed that MT is associated with a significant increase in the risk of sICH in the VBTO arm as compared to iBAO (RR:2.20; 95% CI:1.09, 4.46; p = 0.03). No heterogeneity (I2 = 0%) was noted among the studies (Fig. 4).
Fig. 4
Symptomatic Intracerebral Hemorrhage Forest Plot
Click here to Correct
All-cause Mortality
Six studies, including a total of 617 participants (VBTO: 151; iBAO:466), evaluated 90-day mortality as an outcome. Our analysis revealed that there was no significant difference in 90-day mortality between the two groups (RR:1.28; 95% CI:0.78, 2.10; p = 0.33). High heterogeneity (I2 = 72%) was noted among the studies (Fig. 5).
Fig. 5
All-cause mortality forest plot
Click here to Correct
Subgroup Analysis
The subgroup analysis was performed based on the MT technique (either clean road or dirty road) for the outcome of successful recanalization, specifically in patients with VBTO. Successful recanalization was achieved in 33 of 36 cases using the clean road procedure, compared to 69 of 82 cases with the dirty road technique. The overall pooled analysis indicated comparable successful recanalization rates between clean and dirty road MT in patients with VBTO. (RR = 1.04; 95%CI:[0.90, 1.20]; p = 0.63; I2 = 5%) (Fig. 6).
Fig. 6
Subgroup analysis of successful recanalization in Vertebrobasilar tandem occlusion (VBTO) patients based on Mechanical thrombectomy techniques (clean or dirty road)
Click here to Correct
Sensitivity Analysis
For outcomes having heterogeneity greater than 50% a leave-one-out sensitivity analysis was performed to investigate the source of heterogeneity. On removing the study by Sun et al. 2020[19] the heterogeneity falls from 69–47% regarding the functional independence endpoint (Supplementary Fig. 1). Similarly, removing the study by Sun et al. 2020[19] from successful recanalization outcome analysis reduced the heterogeneity to 49% (Supplementary Fig. 2). Removing studies by Klail et al. 2024[1] and Sun et al. 2020[19] reduced the heterogeneity from 72–57% and 51% respectively (Supplementary Figs. 3–4).
Publication Bias
Publication bias was assessed visually through funnel plots and statistically via Egger's regression test. No visual asymmetry was observed in the funnel plots, indicating no publication bias. This was further confirmed by Egger's regression test (Supplementary Figs. 5–12).
Discussion
In this updated meta-analysis, 9 cohort studies were included. The pooled results reaffirm that MT yields comparable 90-day functional outcomes and mortality rates in patients with VBTO and those with iBAO or non-VBTO. No significant difference was found in the rates of successful recanalization between the two groups. However, in contrast to prior findings, our analysis found a statistically significant increase in the rate of sICH in VBTO patients [3].
In 2015, the HERMES meta-analysis pooled data from 5 trials that included 1,287 participants and established the efficacy of MT in anterior circulation occlusions [21]. However, there is scarce literature on the efficacy of MT in vertebrobasilar artery occlusions. Two RCTs were conducted for this purpose: BASICS and, which compared medical management to MT. BASICS, failed to meet the primary endpoint, while BEST was terminated due to a high crossover rate and a decrease in recruitment [22, 23]. Most of the studies included in our meta-analysis were retrospective cohorts in design, which introduces inherent limitations such as selection bias, variability in treatment protocols, and lack of standardized outcome assessment.
Choosing between the clean road (via contralateral patent VA) and the dirty road (through the occluded ipsilateral VA) approaches is essential. The clean road approach is faster, negates the need for angioplasty, and overall poses fewer risks. However, contralateral VA must be adequate for the clean road approach to be chosen. In patients where this is not feasible, the dirty-road approach is used. In this approach, angioplasty and stenting must be performed, which adds complexity and risks to the procedure [24].
There are two variants of the dirty-road approach, both bringing various complications. The anterograde, or proximal-to-distal technique, secures the occlusion early but delays reperfusion time. In contrast, the retrograde, or distal-to-proximal technique, provides rapid reperfusion but increases the risk of embolization. However, this risk can easily be mitigated via the use of a balloon guide catheter or suction aspiration [15]. Xing et al.’s study showed that the retrograde strategy is safer as it helps decrease the risk of adverse events such as hemorrhagic transformation during BA mechanical thrombectomy [20]. Ultimately, the optimal sequence should be tailored to each patient's vascular anatomy, plaque morphology, and collateral supply, with procedural strategies adapted to balance speed and safety in complex posterior circulation occlusions.
Pre-procedural imaging that includes only intracranial vessels can miss critical details of the vertebral arteries, which may hinder pathway planning in VBTO cases. CT angiography (CTA) or contrast-enhanced MR angiography (CEMRA) are considered the gold standard for VA assessment, demonstrating sensitivities of approximately 94–95% for detecting extracranial stenosis and occlusion. By fully visualizing the anatomy of the posterior circulation before the procedure, an interventional neurologist can more effectively choose which approach to use [25].
In our updated meta-analysis, VBTO is associated with a statistically significant increase in sICH compared to non-VBTO patients. This finding is clinically significant, as sICH is one of the most feared complications following MT, and is often linked to poorer functional outcomes and higher mortality. A recent systematic review and meta-analysis examining posterior circulation strokes reported that the risk of sICH in this setting was markedly higher than in anterior circulation interventions [26]. While that analysis did not focus exclusively on VBTO, it highlights the increased hemorrhagic risk inherent to posterior circulation MT. This risk may be due to several reasons. The requirement for manipulation or angioplasty of the occluded VA, often involving stenting, may compromise vessel integrity and increase hemorrhage potential [27]. As mentioned earlier, VBTO cases frequently involve longer procedures and multiple device passes, which further elevate the risk of vessel endothelial injury and reperfusion-associated bleeding.
Multiple procedural strategies have been shown to mitigate the risk of sICH in MT. The use of balloon guide catheters (BGCs) can improve hemorrhage prevention by enabling proximal flow arrest or reversal during clot retrieval, which minimizes the risk of distal embolization and reduces the number of required device passes [28]. It is crucial to reduce the number of thrombectomy passes; Lee et al. have shown that exceeding three passes significantly increases the likelihood of vessel injury and sICH [29]. Beyond procedural techniques, patient-level factors such as glucose control also play a role. Hyperglycemia has been identified as an independent risk factor for sICH as it can cause blood-brain barrier disruption and worsen the thrombo-inflammatory response [29].
Future research on VBTO should prioritize standardized reporting of clinical outcomes, procedural techniques, and patient characteristics to enhance comparability across studies. There is a pressing need for larger, multicenter, prospective trials focused specifically on VBTO, as current evidence is limited to small retrospective cohorts. To better understand which subgroups may derive greater benefit from the clean-road or dirty-road strategies, comparative studies are needed. Trials assessing the role of VA stenting, particularly regarding the optimal timing and its impact on recanalization success, complications, and long-term outcomes, would also help refine thrombectomy protocols and improve outcomes.
This meta-analysis has several significant limitations that should be acknowledged. The number of studies included remains relatively small, limiting the statistical power to detect subtle differences between VBTO and non-VBTO or iBAO groups. Moreover, all studies were non-randomized and retrospective, introducing potential biases such as patient selection and unmeasured confounding. The included studies also exhibited considerable heterogeneity in thrombectomy techniques, with variation in devices used, procedural strategies, and perioperative care, making it difficult to isolate the effects of specific interventions. Additionally, most studies lacked data on critical clinical variables such as collateral circulation status, type of anaesthesia, time metrics, or the use of adjunctive techniques like BGCs or aspiration. These missing details hinder deeper subgroup analyses that could help identify predictors of better outcomes.
Conclusion
In conclusion, MT appears to be a safe and reasonable treatment option for patients with VBTO, offering comparable functional outcomes and mortality rates to those seen in isolated BAO. However, our updated meta-analysis highlights a significantly increased risk of sICH in VBTO patients. Although no significant difference was found between the clean-road and dirty-road approaches of MT in VBTO patients, numerical trends and procedural considerations support the use of the clean-road pathway when anatomically feasible. Until more robust prospective data are available, it is reasonable to manage VBTO using the same eligibility criteria currently applied to iBAO or non-VBTO, while tailoring the procedural strategy to individual anatomical and technical factors.
Declarations
A
Funding:
No funding is received
Conflict of Interests:
The authors state that they have no conflicts of interest.
Ethical Approval:
Not applicable
Patient Consent
Not applicable
Clinical trial Number
not applicable
Data Availability:
A
Data can be obtained by reasonable request directed to the authors.
Status
This manuscript has not been published previously and is not under consideration for publication elsewhere
A
Author Contribution
Study concept and design: MHW and ZUA; acquisition of data: MA, MK and RA; analysis and interpretation of data: ZUA, AH, and ZA; drafting of the manuscript: MWA, RA, ZF and PKT; critical revision of the manuscript: MHW and AAD
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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Yes
Total words in MS: 3477
Total words in Title: 22
Total words in Abstract: 261
Total Keyword count: 7
Total Images in MS: 6
Total Tables in MS: 3
Total Reference count: 29