Direct Mothership Presentation Boosts Clinical Outcomes for Octogenarians with VBA Occlusion

Background Endovascular thrombectomy (EVT) is the established therapy for acute vertebrobasilar occlusions (VBAOs). However, the influence of advanced age and interhospital transfer on outcomes remains uncertain. Octogenarians may be particularly vulnerable to transfer‐related factors, yet multicenter data are limited. We sought to evaluate the impact of age (<80 vs. ≥80 years) and presenting site (transfer vs. mothership) on clinical outcomes after EVT for VBAOs in a 10‐year multicenter cohort. Methods We retrospectively included patients with VBAOs treated with EVT from a prospectively maintained registry across three thrombectomy‐capable centers between 2014 and 2024. Patients were stratified by age (<80 vs. ≥80 years) and by presenting site (transfer vs. mothership). Baseline demographics, imaging, and procedural variables were compared. The primary outcomes were modified Rankin Score at 90 days (mRS 0‐3) and 90‐day mortality. Logistic regression was used to assess the interaction between age and transfer status, with adjusted odds ratios (aOR) and 95% confidence intervals (CI) reported. Results A total of 294 patients were included, with a median age of 69 years [IQR 58‐77]; 62 patients (21.1%) were ≥80 years. Octogenarians had higher rates of atrial fibrillation (43.5% vs. 12.9%, p<0.001) and cardioembolic stroke etiology (59.0% vs. 26.1%, p<0.001), while rates of successful reperfusion (mTICI ≥2b) were similar across age groups (>90%). In patients <80 years, outcomes were comparable between transfer and mothership presentations (mortality 41.1% vs. 49.3%, p=0.3; mRS 0‐3: 46.6% vs. 37.7%, p=0.2). By contrast, octogenarians presenting via transfer experienced worse outcomes (mortality 70.5% vs. 55.6%; mRS 0‐3: 18.2% vs. 38.9%), with significant interaction effects. After adjustment for baseline imbalances, the interaction effect demonstrated that mothership presentation in octogenarians was associated with markedly higher odds of functional independence (aOR 10.1, 95% CI 1.6‐64.2, interaction p=0.01) and reduced mortality (aOR 0.14, 95% CI 0.02‐0.88, interaction p=0.03). Conclusion This 10‐year multicenter experience demonstrates that octogenarians with VBO are disproportionately affected by interhospital transfer, with significantly lower functional independence and higher mortality compared to direct mothership presentation. Despite similar reperfusion rates, older patients showed reduced tolerance to transfer‐related factors. These findings highlight the need for age‐sensitive triage protocols that prioritize direct transport of elderly patients to thrombectomy‐capable centers. Optimizing EVT access for this high‐risk population may improve survival and functional recovery in VBO.