Endovascular therapy versus standard medical treatment for vertebrobasilar artery occlusion: a systematic review and meta-analysis

BACKGROUND: Acute vertebrobasilar artery occlusion (VBAO) is a devastating condition with high mortality and severe disability. Recent randomized controlled trials (RCTs) have significantly demonstrated that endovascular therapy is highly effective for VBAO, but its effectiveness for broader and real-world patient populations remains uncertain. This review aims to systematically evaluate the efficacy and safety of endovascular therapy for VBAO, integrating evidence from both RCTs and real-world data. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library from January 2000 to July 2025 for RCTs and observational cohort studies comparing endovascular therapy with standard medical treatment in patients with VBAO. Our primary outcome was 90-day favourable functional status, defined as a modified Rankin Scale score of 0 to 3. Secondary outcomes included functional independence (90-day modified Rankin Scale score of 0-2). Safety outcomes were symptomatic intracranial haemorrhage and 90-day mortality. RESULTS: A total of 15 studies were included in the analysis, consisting of 4 RCTs (n = 988) and 11 observational cohort studies (n = 7,521). Compared with SMT, EVT was associated with a significantly higher likelihood of a favorable functional outcome (mRS score 0-3: OR = 1.92; 95%CI 1.51-2.43) and functional independence (mRS score 0-2: OR = 1.76; 95%CI 1.39-2.23), and a significantly lower risk of 90-day all-cause mortality (OR = 0.58; 95%CI 0.49-0.68). However, endovascular therapy increased the risk of symptomatic intracranial hemorrhage (OR = 2.57, 95%CI 1.31-5.06). Subgroup analyses showed that EVT was beneficial in patients with NIHSS ≥10, PC-ASPECTS <8, and onset-to-admission time >6 h (all p < 0.05). However, the treatment benefit was not significant in several subgroups, including elderly patients (≥75 years), those with mild deficits (NIHSS<10), distal basilar occlusion, and patients who received intravenous thrombolysis. CONCLUSION: This integrated analysis confirms endovascular therapy as a cornerstone treatment for acute vertebrobasilar artery occlusion, demonstrating significant improvements in functional outcomes and mortality despite increased symptomatic intracranial hemorrhage risk. SYSTEMATIC REVIEW REGISTRATION: https://inplasy.com/projects/, identifier INPLASY202590088.