Contact Aspiration Versus Combined Thrombectomy in Basilar Artery Occlusion: Clinical Severity and First-pass Recanalization Are Associated with Outcome

Introduction. Acute basilar artery occlusion (BAO) carries high morbidity and mortality rates despite endovascular therapy, and the optimal technique and outcome predictors remain unclear. We compared contact aspiration (CA) alone with CA combined with stent retriever (CA + SR) and identified predictors of first-pass reperfusion and 3-month functional outcome. Methods. We analyzed the prospective multicenter SARA-3 registry, comparing first-pass recanalization (modified Treatment in Cerebral Infarction [mTICI] 2b–3), procedural time, safety, and 3-month functional outcome for CA and CA + SR. Predictors of unfavorable outcome (modified Rankin Scale [mRS] 3–6) were assessed using multivariable logistic regression for risk stratification. Results. Among 68 patients (median age 73 years; median admission National Institutes of Health Stroke Scale [NIHSS] score 11), 50 (73.5%) received CA and 18 (26.5%) CA + SR. Both techniques had similar efficacy, safety, and 3-month unfavorable outcome (48% vs. 53%), but CA was faster (21 vs. 38 min; P = 0.007). Admission NIHSS (odds ratio (OR) 1.08 per point; P < 0.001) and first-pass mTICI 2b–3 (OR 0.06; P < 0.001) independently predicted outcome, and their combination discriminated well (area under the curve 0.83). Patients with NIHSS ≤ 10 and first-pass mTICI 2b–3 fared best, whereas those with NIHSS ≥ 11 and first-pass mTICI 0–2a fared worst, with two-thirds dying. No clinical or imaging characteristics independently predicted first-pass reperfusion. Conclusions. CA and CA + SR achieved similar 3-month outcomes in acute BAO, but CA was faster. Admission NIHSS and first-pass recanalization, rather than first-line technique, best predicted functional outcome and together defined prognostic groups that may guide management if validated.