World Stroke Organization The Paper of The Month – January
21 Jan 2025Advancing the Treatment of Vetebrobasilar Occlusion with VERITAS
Advancing the Treatment of Vetebrobasilar Occlusion with VERITAS
By Prof. Octavio Marques Pontes-Neto, MD, PHD – WSA Editor-in-Chief
This article is a commentary on the following: Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis. Lancet. 2025 Jan 4;405(10472):61-69. doi: 10.1016/S0140-6736(24)01820-8. Epub 2024 Dec 12. PMID: 39674187.
Commentary:
The study “Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): A systematic review and individual patient data meta-analysis,” published in The Lancet, summarises the recent milestones in our understanding of vertebrobasilar artery occlusion (VBAO), a stroke subtype characterized by its devastating prognosis and high mortality rates. Synthesizing data from nearly 1,000 patients across four major randomized controlled trials (RCTs)—BEST, BASICS, ATTENTION, and BAOCHE—VERITAS provides compelling evidence supporting the efficacy of endovascular therapy (EVT) in this challenging clinical scenario.
The findings of VERITAS leave little doubt about the transformative potential of EVT in VBAO management. Patients treated with EVT exhibited a 2.5-fold increase in the likelihood of achieving favorable functional outcomes (modified Rankin Scale [mRS] 0–3) and functional independence (mRS 0–2) at 90 days, compared to those receiving standard medical therapy. Notably, EVT also reduced mortality rates by 40% despite an elevated risk of symptomatic intracranial hemorrhage. These results resonate with the broader stroke literature, reinforcing EVT as the cornerstone of care for large vessel occlusions.
While VERITAS offers robust data, it also sheds light on unresolved questions. The analysis underscores the need for cautious interpretation in patients with milder strokes (NIHSS <10) or extensive infarcts on neuroimaging, as the benefits of EVT remain uncertain in these subgroups. Moreover, with 70% of the pooled population drawn from Chinese trials, questions of generalizability to Western populations persist, especially given differences in stroke etiology, such as intracranial atherosclerosis.
Importantly, VERITAS provides a roadmap for future research, emphasizing the need to evaluate EVT in underrepresented populations, including women and those with isolated vertebral artery occlusions or extensive infarcts. The study also highlights the potential utility of posterior-specific scoring systems, such as the Posterior NIHSS, to refine patient selection.
In conclusion, VERITAS carries profound implications for clinical practice and stroke care guidelines. The findings strenghen the case for EVT as a first-line treatment for patients with moderate-to-severe VBAO, challenging clinicians to expand EVT access and improve early diagnosis in this patient population. Furthermore, the study provides insights into treatment timing, imaging thresholds, and stroke severity could shape protocols for patient triage and management.
References:
- Nogueira RG, Jovin TG, Liu X, Hu W, Langezaal LCM, Li C, Dai Q, Tao C, Mont’Alverne FJA, Ji X, Liu R, Li R, Dippel DWJ, Wu C, Zhu W, Xu P, van Zwam WH, Wu L, Zhang C, Michel P, Chen J, Wang L, Puetz V, Zhao W, Liu T, Audebert HJ, Chen Z, Pontes-Neto OM, Yi T, Moran TP, Doheim MF, Schonewille WJ; ATTENTION, BASICS, BAOCHE, and BEST Investigators. Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis. Lancet. 2025 Jan 4;405(10472):61-69. doi: 10.1016/S0140-6736(24)01820-8. Epub 2024 Dec 12. PMID: 39674187.
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