Safety outcomes in endovascular treatment versus best medical management for basilar artery occlusion acute ischemic stroke: A systematic review and meta-analysis of randomized trials

Background: Endovascular therapy (EVT) improves functional outcomes and reduces mortality in acute ischemic stroke (AIS) due to basilar artery occlusion (BAO). However, data on hemorrhagic complications and nonneurologic adverse events remain limited. We conducted a systematic review and meta-analysis to assess these outcomes in randomized controlled trials (RCTs) comparing EVT versus best medical management (BMM). Methods: We searched PubMed, Cochrane Library, and Embase in December 2024 for RCTs comparing EVT and BMM (PROSPERO registry CRD42024617681). Outcomes included any parenchymal hematoma (PH), PH type 1 and 2, subarachnoid hemorrhage (SAH), systemic/extracranial hemorrhage, pneumonia, and heart failure. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Results: Four RCTs, 988 patients (556 EVT, 432 BMM), were included. EVT increased the risk of SAH (RR 5.14; 95% CI [1.35–19.56]; I²-=-0.0%) and PH type 2 (RR 5.53; 95% CI [1.47–20.84]; I²-=-0.0%) compared to BMM. No significant differences were observed for any PH (RR 1.91; 95% CI [0.92–3.97]; I²-=-0.0%), PH type 1 (RR 0.71; 95% CI [0.22–2.29]; I²-=-3.4%), systemic/extracranial hemorrhage (RR 1.06; 95% CI [0.71–1.60]; I²-=-12.2%), pneumonia (RR 1.00; 95% CI [0.83–1.21]; I²-=-0.0%), or heart failure (RR 2.00; 95% CI [0.34–11.92]; I²-=-55.4%). Conclusion: In patients with BAO AIS, EVT is associated with an increased risk of SAH and PH type 2 compared with BMM. There was no significant difference in any PH, PH type 1, systemic/extracranial hemorrhage, pneumonia, and heart failure between groups. © The Author(s) 2025