Perfusion imaging findings, and outcomes between computed tomography perfusion selected basilar artery occlusion and anterior circulation stroke patients undergoing endovascular treatment

Xiaofeng Cai

doi:10.1371/journal.pone.0353204

. 2026 Jul 14;21(7):e0353204. doi: 10.1371/journal.pone.0353204

Perfusion imaging findings, and outcomes between computed tomography perfusion selected basilar artery occlusion and anterior circulation stroke patients undergoing endovascular treatment

Xiaofeng Cai ^1,^*

Editor: Aldobrando Broccolini²

PMCID: PMC13367688 PMID: 42447105

Abstract

Background

Basilar artery occlusion (BAO) is a severe form of ischemic stroke associated with high morbidity and mortality. Whether BAO patients derive similar benefits from CT perfusion (CTP)-guided endovascular treatment (EVT) as those with anterior circulation stroke (ACS) remains unclear.

Aim

This study aimed to compare the efficacy and safety of EVT based on computed tomography (CT) perfusion between patients with BAO and those with ACS.

Methods

This analysis was conducted using data from a prospective multicenter Registry on International Stroke Perfusion Imaging. A total of 256 patients with 36 BAO and 220 ACS who received CTP-guided EVT were included. Propensity score matching (PSM) in a 1:2 ratio was performed to adjust for baseline imbalances. Multivariate logistic regression was used to identify independent predictors of mRS 3–6 at 90 days as poor functional outcome and mortality.

Results

Prior to matching, BAO patients had higher baseline NIHSS scores (24.0 ± 9.8 vs. 15.2 ± 6.4, p < 0.001), smaller ischemic core volumes (8.7 ± 11.4 mL vs. 33.2 ± 38.9 mL, p < 0.001), and higher mismatch ratios (0.9 ± 0.1 vs. 0.7 ± 0.2, p < 0.001) than ACS patients. After matching, BAO patients had significantly shorter door-to-reperfusion time (3.2 ± 1.1 vs. 4.3 ± 2.9 hours, p = 0.007) and lower rates of hemorrhagic transformation (19.4% vs. 48.6%, p = 0.006). Multivariate analysis identified baseline NIHSS score (OR = 1.052, 95% CI: 1.013–1.092, p = 0.009) and ASPECT score (OR = 0.813, 95% CI: 0.682–0.969, p = 0.021) as independent predictors of poor outcome, while age (OR = 1.037, 95%CI: 1.006–1.069, p = 0.020) and baseline NIHSS score (OR = 1.070, 95% CI: 1.024–1.119, p = 0.002) were independent predictors of mortality. No significant differences were observed in 90-day functional independence (mRS 0–2) or mortality between BAO group and ACS group.

Conclusions

Despite presenting with more severe neurological deficits, BAO patients treated with CTP-guided EVT achieved comparable functional outcomes and mortality to ACS patients, with shorter reperfusion times and fewer hemorrhagic complications. CTP-based selection may facilitate effective EVT in BAO.

Introduction

Endovascular treatment (EVT) for recanalizing large vessel occlusions (LVO) has become a critical component of standard care for managing patients with acute ischemic stroke (AIS). Several randomized clinical trials have demonstrated the safety and efficacy of EVT in select patients with proximal occlusions in anterior circulation stroke (ACS) [1–5]. However, about 5% of all patients who undergo thrombolysis for stroke have basilar artery occlusion (BAO), which is among the most severe medical conditions, with very high fatality rates even after reperfusion achieved by EVT [6,7].

Two multicenter RCTs failed to demonstrate a significant benefit of EVT over best medical management (BMM), though methodological limitations were later identified [8,9]. Emerging evidence from the Endovascular thrombectomy for acute basilar artery occlusion (ATTENTION) and Endovascular thrombectomy for acute basilar artery occlusion (BAOCHE) trials has established the superiority of EVT in BAO patients. Crucially, subgroup analyses indicated that the therapeutic benefit is predominantly driven by patients with moderate-to-severe baseline stroke severity (NIHSS ≥10), while patients with mild symptoms (NIHSS <10) did not demonstrate significant benefit [10–12].

This study aimed to investigate the efficacy and safety of EVT based on computed tomography (CT) perfusion in patients with BAO compared to those with ACS. Furthermore, we aimed to analyze the prognostic factors associated with poor outcomes and mortality, with the goal of providing valuable insights into the optimal management of these patients.

Methods

Study population

Data for this study were obtained from our site within the International Stroke Perfusion Imaging Registry, with central ethics approval from the Hunter New England Health District Ethics Committee (11/08/17/4.01). We retrospectively reviewed consecutive cases of acute large artery occlusion (LAO) within 24 hours of symptom onset in patients who underwent endovascular treatment (EVT) with computed tomography perfusion (CTP) scans. The dates were accessed for research purposes in Jan. 2026. Patients were included if they met the following criteria: (1) internal carotid artery (ICA), middle cerebral artery (MCA), anterior cerebral artery (ACA), or basilar artery (BA) occlusion confirmed on pretreatment four-dimensional CT angiography (4D-CTA) reconstructed from CTP; and (2) pre-stroke modified Rankin Scale (mRS) score ≤ 2. Patients were excluded if they had poor image quality owing to motion artifacts or were unable to undergo follow-up CT before discharge.

Patients were divided into two groups based on the occlusion location: the basilar artery occlusion (BAO) group and the anterior circulation stroke (ACS) group, which included patients with ICA, MCA, or ACA occlusions. Clinical and neuroimaging characteristics were evaluated, including patient age, sex, medical history (hypertension, diabetes mellitus, atrial fibrillation [AF], tobacco use, and hypercholesterolemia), baseline National Institutes of Health Stroke Scale (NIHSS) score, pre-stroke mRS score, Alberta Stroke Program Early CT Score (ASPECT), stroke etiology (cardioembolic vs. others), and treatment details (intravenous recombinant tissue plasminogen activator [rt-PA] use, device type, and procedural time intervals).

The protocols of the study had been approved by the local ethics committee of Zhejiang Provincial People’s Hospital. All clinical investigation has been conducted according to the principles expressed in the Declaration of Helsinki.

Imaging protocol

All patients underwent baseline non-contrast CT (NCCT) and CTP prior to reperfusion treatment, as well as follow-up NCCT before discharge. CT imaging was performed using a 320-detector row, 640-slice cone-beam multidetector CT scanner (Aquilion One, Toshiba Medical Systems). Whole-brain NCCT was acquired in a single rotation (detector width: 16 cm). CTP was performed following administration of 50 mL of contrast agent (Ultravist 370; Bayer HealthCare, Berlin, Germany) injected intravenously at a rate of 6 mL/s, followed by 50 mL of saline (acquisition parameters: 120 kV, 128 mA; scanning coverage = 240 mm; scanning width = 5 mm). A pulsed full-rotation scan protocol with 18 time points acquired over 60 seconds and a total pulse image acquisition time of 9.5 seconds was employed, commencing 7 seconds after contrast injection. The follow-up NCCT scanning protocol was identical to that used for baseline NCCT. The imaging manifestations of BAO and ACS patient before and after CTP guided EVT treatment were shown in Fig 1.

Fig 1 — (A) Preoperative CTA showed occlusion of the basilar artery and CTP showed low perfusion in the basal artery supply area, with the red area indicating the core infarct zone. (B) Postoperative CTA indicated recanalization of the basilar artery and CTP indicated the recovery of blood flow in the basal artery supply area. (C) Preoperative CTA showed occlusion of the upper trunk of the M1 segment of the left middle cerebral artery and CTP showed hypoperfusion in the left middle cerebral artery supply area, with the red area indicating the core infarct zone. (D) Postoperative CTA showed recanalization of the left middle cerebral artery and CTP indicated the recovery of blood flow in the left cerebral blood supply area.

Assessment of Hypoperfusion and Ischemic Core Volume CTP data were postprocessed using MIStar software (Apollo Medical Imaging Technology, Melbourne, Australia). The hypoperfusion volume was defined using a delay time (DT) threshold of >3 seconds. The ischemic core volume was calculated using a relative cerebral blood flow (rCBF) threshold of <30% [13]. The penumbra volume was defined as the hypoperfusion volume minus the ischemic core volume. The mismatch ratio was calculated as the penumbra volume divided by the total hypoperfusion volume, representing the proportion of potentially salvageable tissue within the total hypoperfused region. The present study applies established perfusion parameters but does not aim to validate or optimize CTP thresholds for posterior circulation stroke.

Outcome assessment

The primary outcomes were poor functional outcome (mRS 3–6) at 90 days and mortality. The NIHSS score was evaluated at three time points: baseline, 24 hours after admission, and 14 days. The Modified Rankin Scale (mRS) score was used to assess clinical outcomes at 90 days after onset. An mRS score of 0–2 was designated as a good outcome, and an mRS score of 3–6 was designated as a poor outcome. In-hospital mortality was defined as death occurring during hospitalization or within 24 hours after discharge. For 90-day outcome assessment, mortality was defined as death (mRS score of 6) occurring at any time within 90 days of symptom onset. Hemorrhagic transformation (HT) was classified as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) according to the European Cooperative Acute Stroke Study (ECASS) definition [14]. All outcomes, including HT, and functional outcomes, were adjudicated by a clinician with 10 years of experience in stroke management.

Statistical analysis

Statistical analyses were performed using Python version 3.10.19. Demographic, baseline clinical, and imaging characteristics were summarized using descriptive statistics. Continuous variables were expressed as mean ± standard deviation (SD) and compared between groups using independent-samples t-tests for normally distributed data or the Mann–Whitney U test for non-normally distributed data. Categorical variables were expressed as frequencies and percentages and compared using the chi-square test or Fisher’s exact test, as appropriate. Comparisons were performed in both the primary (unmatched) cohort and the PSM cohort. Univariate logistic regression analysis was performed to identify potential predictors of poor outcome (mRS 3–6 at 90 days) and mortality among all patients with LAO who underwent EVT. Collinearity among predictor variables was assessed prior to multivariate modeling (Supplementary Fig. 2). To account for potential confounding factors between the BAO and ACS groups, propensity score matching (PSM) was performed. Propensity scores were estimated using a logistic regression model incorporating the following baseline covariates: age, sex, hypertension, diabetes mellitus, atrial fibrillation, tobacco use, baseline mRS score, ASPECT, stroke etiology, and hypercholesterolemia. Each BAO patient was matched to two ACS patients (1:2 ratio) using nearest-neighbor matching without replacement. The caliper width was set at 0.2 standard deviations of the logit of the propensity score. Covariate balance after matching was assessed by comparing baseline characteristics between the two groups. Variables with P < 0.1 in univariate analysis were entered into a multivariate logistic regression model. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was set at P < 0.05 for multivariate analyses.

The protocols of the study had been approved by the local ethics committee of Zhejiang Provincial People’s Hospital Results.

Results

Patient characteristics

The study flowchart is shown in Fig 2. A total of 256 patients (mean age 67.8 ± 14.0 years, 50.4% male) met the inclusion criteria and were enrolled. Among them, 36 (14.1%) patients had BAO and 220 (85.9%) patients had ACS. Baseline clinical and neuroimaging characteristics of the primary cohort are presented in Table 1. There were 2 ACA, 77 ICA, and 141 MCA in ACS group. There was no no significant difference in their clinical characteristics (S1 Table). Therefore, classifying these patients into the ACS group and the analysis results of BAO are reliable.

Table 1. Baseline clinical characteristics of patients.

Variables	Primary Cohort			1:2 PSM Cohort
	BAO (n = 36)	ACS (n = 220)	P	BAO (n = 36)	ACS (n = 72)	P
Age, Mean ± SD	64.9 ± 13.0	68.3 ± 14.1	0.107	64.9 ± 13.0	68.1 ± 15.5	0.213
Sex			1.000			1.000
Male	18	111		18	36
Female	18	109		18	36
Hypertension			0.953			0.942
Yes	24	142		24	50
No	12	78		12	22
Diabetes mellitus			0.097			0.691
Yes	10	33		10	16
No	26	187		26	56
AF history			0.198			1.000
Yes	9	83		9	19
No	27	137		27	53
Tobacco use			0.512			0.330
Yes	6	51		6	6
No	30	169		30	66
Hypercholesterolemia			0.009			0.574
Yes	5	6		5	6
No	31	214		31	66
Baseline NIHSS Score, Mean ± SD	24.0 ± 9.8	15.2 ± 6.4	<0.001	24.0 ± 9.8	19.7 ± 6.9	<0.001
Baseline mRS Score, Mean ± SD	0.2 ± 0.4	0.4 ± 1.1	0.716	0.2 ± 0.4	0.2 ± 0.7	0.335
APECT, Mean ± SD	7.6 ± 2.0	7.9 ± 1.6	0.445	7.6 ± 2.0	7.8 ± 1.8	0.660
Stroke etiology			1.000			0.924
Cardioembolic	30	182		30	62
Others	6	38		6	10
Ischemic Core Volume, Mean ± SD	8.7 ± 11.4	33.2 ± 38.9	<0.001	8.7 ± 11.4	39.1 ± 42.6	<0.001
Hypoperfusion Volume, Mean ± SD	100.9 ± 42.5	120.9 ± 71.6	0.176	100.9 ± 42.5	130.7 ± 68.2	0.051
Mismatch Volume, Mean ± SD	92.2 ± 40.5	87.8 ± 61.0	0.275	92.2 ± 40.5	91.6 ± 54.0	0.835
Mismatch ratio, Mean ± SD	0.9 ± 0.1	0.7 ± 0.2	<0.001	0.9 ± 0.1	0.7 ± 0.2	<0.001

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In the primary cohort, patients with BAO tended to be younger than those with ACS, although the difference did not reach statistical significance (64.9 ± 13.0 vs. 68.3 ± 14.1 years, P = 0.107). There were no significant differences between the two groups in sex distribution, or in the prevalence of hypertension, atrial fibrillation, or tobacco use. Diabetes mellitus tended to be more common in the BAO group, though this difference was not statistically significant (27.8% vs. 15.0%, P = 0.097). Hypercholesterolemia was significantly more frequent in BAO patients compared with ACS patients (13.9% vs. 2.7%, P = 0.009). Cardioembolic etiology was similarly distributed between the two groups (83.3% vs. 82.7%, P = 1.000). The mean baseline NIHSS score was significantly higher in the BAO group compared with the ACS group (24.0 ± 9.8 vs. 15.2 ± 6.4, P < 0.001). There were no significant differences in pre-stroke mRS score or ASPECT between the two groups.

Regarding baseline neuroimaging, the mean ischemic core volume was significantly smaller in BAO patients compared with ACS patients (8.7 ± 11.4 mL vs. 33.2 ± 38.9 mL, P < 0.001). The hypoperfusion volume and mismatch volume did not differ significantly between the two groups. However, the mismatch ratio was significantly higher in BAO patients than in ACS patients (0.9 ± 0.1 vs. 0.7 ± 0.2, P < 0.001), indicating a greater proportion of salvageable tissue relative to the total hypoperfused region in the posterior circulation.

Propensity score–matched cohort

After 1:2 PSM, 36 BAO patients were matched with 72 ACS patients, yielding a well-balanced cohort (Table 1). In the PSM cohort, baseline demographic characteristics—including age (64.9 ± 13.0 vs. 68.1 ± 15.5 years, P = 0.213), sex distribution, and comorbidities—were comparable between the two groups. The baseline NIHSS score remained significantly higher in the BAO group (24.0 ± 9.8 vs. 19.7 ± 6.9, P < 0.001). The ischemic core volume remained significantly smaller in BAO patients (8.7 ± 11.4 mL vs. 39.1 ± 42.6 mL, P < 0.001), while the hypoperfusion volume showed a trend toward being smaller in BAO patients (100.9 ± 42.5 mL vs. 130.7 ± 68.2 mL, P = 0.051). The mismatch ratio remained significantly higher in the BAO group (0.9 ± 0.1 vs. 0.7 ± 0.2, P < 0.001).

Procedural characteristics

Treatment and procedural details are shown in Table 2. In the primary cohort, stent retriever thrombectomy was used as the sole device in the majority of patients in both groups (72.2% in BAO and 85.9% in ACS). Combined stent retriever and aspiration was more frequently used in BAO patients (16.7% vs. 5.9%), and the overall distribution of device use trended toward a difference between the two groups (P = 0.054). Rates of intravenous rt-PA administration were comparable between the BAO and ACS groups (16.7% vs. 20.9%, P = 0.717).

Table 2. Treatment and outcome characteristics of patients.

Variables	Primary Cohort			1:2 PSM Cohort
	BAO (n = 36)	ACS (n = 220)	P	BAO (n = 36)	ACS (n = 72)	P
Treatment Method, n(%)
Intravenous rt-PA	6(16.7%)	46(20.9%)	0.717	6(16.7%)	10(13.9%)	0.924
Device Use			0.054			0.086
Stent retriever	26(72.2%)	189(85.9%)		26(72.2%)	60(83.3%)
Stent + Aspiration	6(16.7%)	13(5.9%)		6(16.7%)	3(4.2%)
Aspiration only	4(11.1%)	18(8.2%)		4(11.1%)	9(12.5%)
Treatment Times, Mean ± SD
Onset-Door Time	5.1 ± 4.1	6.5 ± 5.6	0.231	5.1 ± 4.1	5.8 ± 4.9	0.632
Onset-Needle Time(rt-PA Only)	2.5 ± 1.6	3.5 ± 5.7	0.864	2.5 ± 1.6	2.2 ± 0.9	0.871
Onset-Puncture Time	7.2 ± 4.1	9.0 ± 6.1	0.169	7.2 ± 4.1	8.3 ± 5.3	0.492
Onset-Reperfusion Time	8.3 ± 4.3	10.5 ± 6.3	0.072	8.3 ± 4.3	10.1 ± 5.8	0.175
Door-Reperfusion Time	3.2 ± 1.1	4.0 ± 2.6	0.108	3.2 ± 1.1	4.3 ± 2.9	0.007
Complications, n (%)
Hemorrhagic Transformation	7(19.4%)	96(43.6%)	0.010	7(19.4%)	35(48.6%)	0.006
Parenchymal Hemorrhage	4(11.1%)	46(20.9%)	0.255	4(11.1%)	19(26.4%)	0.083
Clinical Outcomes
NIHSS at 24h, Mean±SD	19.4 ± 13.7	14.3 ± 11.1	0.046	19.4 ± 13.7	18.2 ± 12.7	0.772
NIHSS at 14 days, Mean±SD	17.5 ± 15.0	12.8 ± 12.7	0.133	17.5 ± 15.0	17.3 ± 13.9	0.912
Discharge mRS, Mean±SD	3.9 ± 1.5	3.6 ± 1.6	0.297	3.9 ± 1.5	4.1 ± 1.5	0.419
mRS 0–2 at 90 days, n(%)	15(41.7%)	96(43.6%)	0.968	15(41.7%)	23(31.9%)	0.433
Mortality, n(%)	6(16.7%)	31(14.1%)	0.879	6(16.7%)	12(16.7%)	1.000

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Procedural time intervals—including onset-to-door time, onset-to-needle time (among patients receiving rt-PA), onset-to-puncture time, and onset-to-reperfusion time—were not significantly different between the two groups in the primary cohort. In the PSM cohort, door-to-reperfusion time was significantly shorter in BAO patients compared with ACS patients (3.2 ± 1.1 hours vs. 4.3 ± 2.9 hours, P = 0.007), while other time intervals remained comparable.

Neurological outcomes

Outcome data are presented in Table 2 and S1 Fig. In the primary cohort, hemorrhagic transformation was significantly less frequent in BAO patients than in ACS patients (19.4% vs. 43.6%, P = 0.010). Parenchymal hemorrhage was observed in 11.1% of BAO patients and 20.9% of ACS patients, a difference that did not reach statistical significance (P = 0.255). In the PSM cohort, these findings were consistent: hemorrhagic transformation remained significantly lower in the BAO group (19.4% vs. 48.6%, P = 0.006), and parenchymal hemorrhage showed a trend toward being less frequent in BAO patients (11.1% vs. 26.4%, P = 0.083).

The mean NIHSS score at 24 hours was higher in BAO patients than in ACS patients in the primary cohort (19.4 ± 13.7 vs. 14.3 ± 11.1, P = 0.046), but this difference was no longer significant in the PSM cohort (19.4 ± 13.7 vs. 18.2 ± 12.7, P = 0.772). Similarly, 14-day NIHSS scores were comparable between the two groups in both the primary and PSM cohorts.

The distribution of mRS scores at 90 days is shown in S1 Fig. The rates of good functional outcome (mRS 0–2) at 90 days were similar between BAO and ACS patients in both the primary cohort (41.7% vs. 43.6%, P = 0.968) and the PSM cohort (41.7% vs. 31.9%, P = 0.433). The overall 90-day mortality rate was 14.5% (37/256) in the primary cohort. Ninety-day mortality was comparable between the BAO and ACS groups in both the primary cohort (16.7% vs. 14.1%, P = 0.879) and the PSM cohort (16.7% vs. 16.7%, P = 1.000).

Predictors of poor outcome and mortality

Collinearity among predictor variables was assessed prior to regression modeling (S2 Fig). Univariate and multivariate logistic regression analyses for poor outcome (mRS 3–6) at 90 days and mortality in patients with LAO undergoing EVT are presented in Table 3.

Table 3. The multivariate logistic regression analysis of mRS 3-6 at 90 days and mortality.

Variable	mRS 3–6 at 90 days				Mortality
Variable	Univariate Odds ratio (95% CI)	P-value	Multivariate Odds Ratio (95% CI)	P-value	Univariate Odds ratio (95% CI)	P-value	Multivariate Odds Ratio (95% CI)	P-value
Location	0.923	0.825	–	–	0.820	0.684	–	–
BAO vs ACS	0.452-1.884	0.825	–	–	0.316-2.132	0.684	–	–
Age	1.017	0.059	1.012	0.222	1.040	0.010	1.037	0.020
Per 1-year Increase	0.999-1.036	0.059	0.993-1.032	0.222	1.010-1.071	0.010	1.006-1.069	0.020
Male	0.823	0.439	–	–	1.535	0.235	–	–
Yes vs No	0.501-1.350	0.439	–	–	0.756-3.116	0.235	–	–
Hypertension	1.742	0.036	1.511	0.146	1.554	0.266	–	–
Yes vs No	1.037-2.925	0.036	0.866-2.636	0.146	0.715-3.376	0.266	–	–
Diabetes Mellitus	1.732	0.120	–	–	2.088	0.077	2.025	0.107
Yes vs No	0.867-3.462	0.120	–	–	0.924-4.714	0.077	0.858-4.780	0.107
AF History	1.140	0.619	–	–	1.257	0.529	–	–
Yes vs No	0.680-1.911	0.619	–	–	0.617-2.564	0.529	–	–
Tobacco Use	0.677	0.195	–	–	0.789	0.597	–	–
Yes vs No	0.375-1.222	0.195	–	–	0.327-1.904	0.597	–	–
Hypercholesterolemia	1.357	0.633	–	–	1.333	0.720	–	–
Yes vs No	0.387-4.756	0.633	–	–	0.276-6.431	0.720	–	–
Baseline mRS	1.170	0.236	–	–	1.299	0.053	1.291	0.078
Per 1-point Increase	0.903-1.517	0.236	–	–	0.997-1.692	0.053	0.971-1.716	0.078
Baseline NIHSS score	1.068	<0.001	1.052	0.009	1.074	<0.001	1.070	0.002
Per 1-point Increase	1.029-1.108	<0.001	1.013-1.092	0.009	1.030-1.120	<0.001	1.024-1.119	0.002
Cardioembolic Etiology	1.380	0.330	–	–	0.592	0.217	–	–
Yes vs No	0.721-2.650	0.330	–	–	0.257-1.362	0.217	–	–
Ischemic Core Volume	1.013	0.010	1.006	0.262	1.005	0.169	–	–
Per 1-mL Increase	1.003-1.022	0.010	0.996-1.016	0.262	0.998-1.013	0.169	–	–
Hypoperfusion Volume	1.004	0.090	1.001	0.558	1.004	0.104	–	–
Per 1-mL Increase	0.999-1.008	0.090	0.997-1.006	0.558	0.999-1.008	0.104	–	–
Mismatch Volume	1.001	0.776	–	–	1.003	0.293	–	–
Per 1-mL Increase	0.996-1.005	0.776	–	–	0.998-1.008	0.293	–	–
Mismatch Ratio	0.858	0.012	–	–	0.996	0.955	–	–
Per 0.1-unit Increase	0.762-0.967	0.012	–	–	0.854-1.161	0.955	–	–
ASPECT	0.747	<0.001	0.813	0.021	0.930	0.489	–	–
Per 1-point Increase	0.636-0.876	<0.001	0.682-0.969	0.021	0.757-1.142	0.489	–	–
Onset_door_time	1.032	0.186	–	–	0.986	0.687	–	–
Per 1-hour Increase	0.985-1.082	0.186	–	–	0.923-1.055	0.687	–	–
Intravenous_rt_PA	1.427	0.268	–	–	1.561	0.275	–	–
Yes vs No	0.761-2.674	0.268	–	–	0.702-3.473	0.275	–	–
Onset_puncture_time	1.023	0.308	–	–	0.982	0.567	–	–
Per 1-hour Increase	0.979-1.068	0.308	–	–	0.921-1.046	0.567	–	–
Onset-Reperfusion Time	1.034	0.129	–	–	0.978	0.482	–	–
Per 1-hour Increase	0.990-1.078	0.129	–	–	0.920-1.040	0.482	–	–
Door_reperfusion_time	1.045	0.412	–	–	0.927	0.405	–	–
Per 1-hour Increase	0.941-1.160	0.412	–	–	0.776-1.108	0.405	–	–
Device	0.840	0.714	–	–	1.119	0.863	–	–
Stent+Asp vs Sten	0.329-2.142	0.714	–	–	0.310-4.049	0.863	–	–
Device	0.611	0.272	–	–	0.569	0.460	–	–
Asp only vs Sten	0.254-1.471	0.272	–	–	0.127-2.541	0.460	–	–

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For poor functional outcome (mRS 3–6 at 90 days), univariate analysis identified the following variables as candidates (P < 0.1): age (OR 1.017; 95% CI, 0.999–1.036; P = 0.059), hypertension (OR 1.742; 95% CI, 1.037–2.925; P = 0.036), baseline NIHSS score (OR 1.068; 95% CI, 1.029–1.108; P < 0.001), ischemic core volume (OR 1.013; 95% CI, 1.003–1.022; P = 0.010), hypoperfusion volume (OR 1.004; 95% CI, 0.999–1.008; P = 0.090), and ASPECT (OR 0.747; 95% CI, 0.636–0.876; P < 0.001). Occlusion location (BAO vs. ACS) was not a significant predictor (OR 0.923; 95% CI, 0.452–1.884; P = 0.825). Although the mismatch ratio also reached significance in univariate analysis (OR 0.858 per 0.1-unit increase; 95% CI, 0.762–0.967; P = 0.012), it was excluded from the multivariate model owing to high collinearity with ischemic core volume and hypoperfusion volume, from which it is directly derived (S2 Fig). Multivariate logistic regression revealed that higher baseline NIHSS score (OR 1.052; 95% CI, 1.013–1.092; P = 0.009) and lower ASPECT (OR 0.813; 95% CI, 0.682–0.969; P = 0.021) were independent predictors of poor outcome.

For mortality, univariate analysis identified the following candidates (P < 0.1): age (OR 1.040; 95% CI, 1.010–1.071; P = 0.010), diabetes mellitus (OR 2.088; 95% CI, 0.924–4.714; P = 0.077), baseline mRS score (OR 1.299; 95% CI, 0.997–1.692; P = 0.053), and baseline NIHSS score (OR 1.074; 95% CI, 1.030–1.120; P < 0.001). Again, occlusion location was not a significant predictor (OR 0.820; 95% CI, 0.316–2.132; P = 0.684). In multivariate analysis, older age (OR 1.037; 95% CI, 1.006–1.069; P = 0.020) and higher baseline NIHSS score (OR 1.070; 95% CI, 1.024–1.119; P = 0.002) were independent predictors of mortality.

Discussion

This study aimed to compare the clinical characteristics and outcomes of patients with acute BAO and anterior circulation stroke (ACS) treated with endovascular procedures based on CT perfusion. The results showed significant differences in the pathogenesis of stroke and treatment procedures between BAO and ACS, which influenced clinical outcomes.

In this study, patients with LVO were classified as having cardioembolic stroke and other determined etiologies. Compared with patients with ACS, patients with BAO had a lower rate of cardioembolic stroke. The anatomical structure of the carotid artery may provide better access for the thrombus to enter anterior circulation. Additionally, the average age was higher in ACS patients, consistent with the evidence that atrial fibrillation (AF) is a risk factor for cardioembolism [15]. Previous studies have shown that cardioembolism is less common in posterior circulation stroke (PCS) [16]. These findings suggest that the anatomical structures of the anterior and posterior circulations are unique and distinct, leading to different stroke pathogeneses.

Consistent with previous studies comparing ACS and PCS [17–19], patients with BAO had higher baseline NIHSS scores and larger ischemic volume. Higher baseline NIHSS scores is partly due to the limitations of the NIHSS in assessing neurological deficits in patients with PCS, as it is highly weighted toward deficits occurring in ACS, such as aphasia and hemiparesis, while neglecting deficits such as unsteady gait, dysphagia, or oculomotor disorders [20]. Larger ischemic volume is partly due to limited collateral circulation in posterior circulation brain tissue [18]. This is also the reason excluding baseline NIHSS from the PMS model.

The time from onset to door and onset to picture did not differ between the BAO and ACS patients. However, the mismatch volume/penumbra volume ratio was significantly larger in patients with BAO. Salvageable brain tissue in the posterior circulation might persist beyond the time window for ACS because of a higher proportion of white matter in the brainstem and better collateral arterial flow [21]. It has been shown that patients with PCS also benefit from mechanical thrombectomy when performed beyond 6 hours after symptom onset [22]. This study provides new neuroimaging evidence, suggesting that extended time window thrombectomy based on CT perfusion might be a future research direction for BAO.

Hemorrhagic complications, including hemorrhagic transformation (HT) and parenchymal hematoma (PH), are common in ACS patients. This may be explained by the larger volume of ischemic tissue in the anterior circulation [23]. Another reasonable explanation could be the higher hemodynamic flow in the carotid artery than in the basilar artery, leading to higher vascular bed pressure in the anterior circulation. It has been hypothesized that a smaller infarct volume in PCS patients contributes to a lower rate of hemorrhage, and pretreatment permeability abnormalities of the blood-brain barrier rarely occur in acute PCS [24]. This study reinforces the finding that acute revascularization therapy with mechanical thrombectomy can be safely performed in patients with acute BAO. Further analysis showed that HT and PH were significantly associated with poor outcomes and mortality in LAO patients.

The time from onset to door, onset to puncture, onset to reperfusion, EVT procedure, and recanalization rates were similar between the BAO and ACS patients. The 3-month poor outcome and mortality rates were also similar between the two groups. Studies that have specifically focused on BAO have reported poorer outcomes and mortality in patients with acute basilar occlusion treated with intravenous thrombolysis (IVT) or intra-arterial thrombolysis (IAT) owing to low recanalization rates [25,26]. The introduction of mechanical thrombectomy for the treatment of vertebrobasilar occlusion results in a decrease in mortality and an increase in the likelihood of poor outcomes at 90 days [27–29]. While CT perfusion mismatch is predominantly used to assess eligibility in patients with ACS, it is less reliable in PCS. This study showed that CT perfusion is reliable for assessing infarcts in the posterior fossa or brainstem of patients with acute BAO. The mismatch volume/penumbra volume was significantly larger in BAO than in ACS, while the onset-to-picture time was similar between the two groups. Further studies are needed to explore the therapeutic window of opportunity for reperfusion treatment of BAO.

Although this study found that the location of the stroke (ACS vs. BAO) was not an independent predictor of poor outcomes and mortality, several factors, including age and baseline neurological deficits, were identified to affect functional outcomes and mortality after mechanical thrombectomy. Older age predicted poor functional outcomes at 90 days. The NIHSS score was a significant predictor of both poor outcomes and mortality. The NIHSS has limitations in assessing common posterior circulation stroke symptoms (such as unsteady gait, dysphagia, and oculomotor disorders). The mRS score, although the standard functional endpoint in stroke trials, may incompletely capture clinically meaningful residual deficits frequently observed after posterior circulation stroke. Consequently, comparable mRS outcomes may underestimate differences in the actual burden of disability between posterior and anterior circulation stroke patients. This relationship was observed when ACS and PCS thrombectomies were combined. Larger multicenter data are required to further study this effect in patients with BAO.

Limitations

This study has several important limitations. First, this was a single-center retrospective observational study, which may be subject to selection bias and unmeasured confounding. Second, the sample size of patients with BAO was relatively small compared with ACS group, which may limit the statistical power and generalizability of the results. Third, all patients included in this study underwent CTP imaging, and no control group treated without CTP guidance was available. Therefore, we cannot determine whether CTP-based selection improved patient eligibility, treatment decisions, or clinical outcomes compared with conventional non-perfusion imaging strategies. Fourth, despite the use of propensity score matching to balance baseline characteristics between groups, residual differences in baseline NIHSS scores persisted, which may introduce residual confounding that could not be fully adjusted for. This may affect the interpretation of the comparative effectiveness and safety of EVT between BAO and ACS patients. Finally, mRS as the primary functional outcome may incompletely capture posterior circulation–specific deficits such as dysphagia, ataxia, and dysarthria, which could lead to underestimation of the true disability burden in BAO patients.

These limitations should be considered when interpreting the comparative effectiveness and safety of EVT in patients with BAO versus ACS.

Conclusion

This study suggests that EVT based on CT perfusion in BAO is associated with a lower risk of HT and similar effectiveness to ACS. Patients with BAO also seem to benefit from EVT when started within 24 h after symptom onset. The study demonstrated that patients are generally younger and had a lower rate of cardioembolism and HT. The most important factors determining the clinical outcome of patients with LAO are age and initial stroke severity.

Supporting information

S1 Fig. Outcomes of patients with CTP-guided EVT.

(A) mRS score at 90 days of BAO patients and ACS patients. (B) Mortality of patients and ACS patients.

(TIF)

pone.0353204.s001.tif^{(188.5KB, tif)}

S2 Fig. Collinearity among predictor variables.

Collinearity among predictor variables.

(TIF)

pone.0353204.s002.tif^{(320.9KB, tif)}

S1 Table. Clinical characteristics between patients with ICA and MCA.

(DOCX)

pone.0353204.s003.docx^{(20KB, docx)}

S1 File. Supporting Information.

Research underlying data.

(XLSX)

pone.0353204.s004.xlsx^{(56.7KB, xlsx)}

Data Availability

All relevant data are within the paper and its Supporting Information file.

Funding Statement

This work was funded by the Project of the Zhejiang Traditional Chinese Medicine Administration (2023ZL259), the Medical Health Science and Technology Project of the Zhejiang Provincial Health Commission (Grant No. 2024KY637).

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PLoS One. doi: 10.1371/journal.pone.0353204.r001

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Reviewer #1: This manuscript addresses an important clinical question regarding the role of CT perfusion–guided endovascular treatment in basilar artery occlusion compared with anterior circulation stroke. The topic is clinically relevant; however, several methodological concerns should be addressed to improve the robustness and interpretability of the findings.

Major Comments

Major Comment 1: The comparison between basilar artery occlusion (BAO) and anterior circulation stroke (ACS) raises important methodological concerns that should be addressed to strengthen the validity of the study. The anterior circulation group includes a heterogeneous mix of occlusion locations (internal carotid artery, middle cerebral artery, and anterior cerebral artery). These occlusion types differ substantially in infarct size, collateral circulation, procedural complexity, and clinical outcomes. Pooling these distinct occlusion sites into a single ACS group may introduce significant heterogeneity and limit the interpretability of comparisons with BAO. Providing the distribution of occlusion locations within the ACS group and performing subgroup or sensitivity analyses according to occlusion site (e.g., ICA vs MCA vs ACA, or proximal vs distal occlusions) would significantly improve the robustness of the analysis. The relatively small sample size of the BAO group (n = 36) also represents an important limitation, particularly when evaluating outcomes such as mortality and hemorrhagic transformation, where statistical power may be insufficient to detect clinically meaningful differences. The implications of this limited sample size should be discussed more explicitly when interpreting the absence of significant differences between groups.

Major Comment 2: While the study addresses an important clinical question, several methodological aspects should be clarified to improve the transparency and interpretability of the findings. Although propensity score matching was performed to balance baseline characteristics between groups, it would be helpful to provide a more detailed discussion of residual differences between groups after matching and their potential impact on outcome interpretation. In particular, some clinically relevant variables remained different between groups after matching, and the implications of these differences should be more clearly acknowledged in the discussion. Given the retrospective nature of the analysis and the observational design, the possibility of residual confounding cannot be excluded. This limitation should be emphasized more explicitly when interpreting the results, particularly when drawing conclusions regarding the comparative effectiveness and safety of EVT between BAO and ACS. Overall, a more cautious interpretation of the results and a clearer acknowledgment of methodological limitations would improve the scientific rigor of the manuscript.

Minor Comments

Minor Comment 1: The Introduction would benefit from updating the discussion of randomized controlled trials in basilar artery occlusion. Several important trials, including BASICS, BEST, ATTENTION, and BAOCHE, have been published in recent years and should be incorporated to provide a more current context for the study rationale.

Minor Comment 2: Given the heterogeneity of stroke mechanisms and anatomical differences between anterior and posterior circulation territories, the discussion would benefit from a more cautious interpretation of the similarities in outcomes between BAO and ACS groups.

Minor Comment 3: The Data Availability Statement should be clarified. The manuscript indicates that data are available in a public repository, but no specific repository name, URL, or accession number is provided. Please provide explicit details to allow readers to access the underlying dataset in accordance with PLOS data-sharing requirements.

Reviewer #2: This study, based on a case-control study, compared the outcomes of endovascular therapy (EVT) in patients with vertebrobasilar artery occlusion (BAO) versus those with anterior circulation stroke (ACS) using computed tomography perfusion (CTP). The results indicate that the efficacy of EVT in CTP-selected BAO patients is similar to that in ACS patients. BAO patients can also benefit from EVT initiated within 24 hours of symptom onset.

1.Did this study exclude patients with tandem lesions? If not, were subgroup analyses or sensitivity analyses performed for these patients to control for confounding effects?

2.In the assessment based on computed tomography perfusion (CTP), were quantitative parameters such as cerebral blood flow (CBF) and cerebral blood volume (CBV) specifically included? Can these parameters be used for patient selection or as prognostic predictors?

3. Given that the time of admission or imaging detection for patients with posterior circulation infarction is often later than for those with anterior circulation occlusion, I would suggest that the authors perform a stratified analysis based on the time from symptom onset to randomization (or to EVT initiation) to better assess whether the treatment effect differs across different time windows.

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PLoS One. 2026 Jul 14;21(7):e0353204. doi: 10.1371/journal.pone.0353204.r002

Author response to Decision Letter 1

15 May 2026

Dear editor:

Please find our revision for the above reference manuscript entitled: “Endovascular treatment based on computer tomography perfusion for basilar artery occlusion compared with anterior circulation stroke” for consideration for publishing in PLOS ONE as an original article.

We have revised our manuscript based upon the comments from the editor. We would like to take this opportunity to thank you and the reviewers for taking the time to review our submission, and for your thoughtful comments and suggestions to improve the quality of our manuscript.

We provide a point-by point response to the reviewers’ comments below.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response:

Thanks for your correction. We have rewritten the manuscript to meet PLOS ONE's style requirements.

Response:

Thanks for your correction. We have rewritten this paragraph as “The protocols of the study had been approved by the local ethics committee of Zhejiang Provincial People’s Hospital.”

3. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Response:

Thanks for your correction. We had checked the funding information.

4. Thank you for stating the following financial disclosure:

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Response:

Thanks for your correction. We had deleted the funding information in the revised manuscript and add the information in revised cover letter.

6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Response:

Thanks for your correction. We had moved the paragraph to the Methods section of our manuscript.

7. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF.

Response:

Thanks for your correction. We had removed the pictures in revised manuscript.

Response:

Thanks for your attention. We had add the supporting information in the end of revised manuscript.

Response:

Thanks for your attention. We will review and evaluate these publications.

Dear reviewer 1:

We have revised our manuscript based upon the comments from the reviewer. We would like to take this opportunity to thank you and the reviewers for taking the time to review our submission, and for your thoughtful comments and suggestions to improve the quality of our manuscript.

We provide a point-by point response to the reviewers’ comments below.

Major Comments

Response�

There were 2 ACA, 77 ICA, and 141 MCA in ACS group. Therefore, we analyzed the differences between ICA and MCA patients and found no significant difference in their clinical characteristics (supplementary materials). Therefore, classifying these patients into the ACS group and the analysis results of BAO are reliable.

Also, the author has revised the discussion according to your request to add the content of limitation of the small sample size.

Response�

As the reviewer pointed out, due to the retrospective nature of the analysis and observation design, the possibility of residual confounding cannot be ruled out. The author has modified the interpretation and discussion of the results by cautiously stating the limitations and clinical application prospects of the conclusions.

Minor Comments

Response�

Thank you for your suggestion. We had add the paragraph described as “ Two multicenter RCTs failed to demonstrate a significant benefit of EVT over best medical management (BMM), though methodological limitations were later identified. Emerging evidence from the ATTENTION and BAOCHE trials has established the superiority of EVT in BAO patients. Crucially, subgroup analyses indicated that the therapeutic benefit is predominantly driven by patients with moderate-to-severe baseline stroke severity (NIHSS ≥10), while patients with mild symptoms (NIHSS <10) did not demonstrate significant benefit.”

References

Yang P, Zhang Y, Xu L, et al. Endovascular thrombectomy for acute basilar artery occlusion: the ATTENTION randomized clinical trial. JAMA. 2023;330(15):1459-1467.

Feng L, Tong Y, Bai Y, et al. Endovascular thrombectomy for acute basilar artery occlusion: the BAOCHE randomized clinical trial. JAMA. 2023;330(15):1468-1476.

Goyal N, Tsivgoulis G, Alexandrov AV, et al. Endovascular thrombectomy for acute ischemic stroke: the VERITAS individual patient data meta-analysis. Lancet Neurol. 2024;23(4):350-362.

Liu X, Dai Q, Ye R, et al. Endovascular treatment for acute basilar artery occlusion: the BEST randomized clinical trial. JAMA Neurol. 2021;78(10):1183-1190.

Blum CA, Ringleb PA, Bendszus M, et al. Endovascular treatment for acute basilar artery occlusion: the BASICS randomized clinical trial. Lancet Neurol. 2023;22(11):1031-1041

Response�

Thank you for your suggestion. The author has modified the interpretation and discussion of the results by cautiously stating the limitations and clinical application prospects of the conclusions.

Response�

Thank you. This study used data from our site within the International Stroke Perfusion Imaging Registry (https://astn.net.au/inspire/). We had add the description in cover letter.

Dear reviewer 2:

We provide a point-by point response to the reviewers’ comments below.

This study, based on a case-control study, compared the outcomes of endovascular therapy (EVT) in patients with vertebrobasilar artery occlusion (BAO) versus those with anterior circulation stroke (ACS) using computed tomography perfusion (CTP). The results indicate that the efficacy of EVT in CTP-selected BAO patients is similar to that in ACS patients. BAO patients can also benefit from EVT initiated within 24 hours of symptom onset.

1.Did this study exclude patients with tandem lesions? If not, were subgroup analyses or sensitivity analyses performed for these patients to control for confounding effects?

Response:

Thank you for your question. There are only two tandem lesions patients in BAO group which combined with vertebral artery occlusion. All patients including BAO and ACS were reperfusion. So Our study did not exclude the patients with tandem lesions.

Response:

Thank you for your question. These parameters were including to evaluate patients before EVT. The hypoperfusion volume was defined using a delay time (DT) threshold of >3 seconds. The ischemic core volume was calculated using a relative cerebral blood flow (rCBF) threshold of <30%.(Described in paragraph “Imaging protocol”). However we did not use these to patient selection or as prognostic predictors delectly. Maybe we could study the relationships between these quantitative parameters and clinical outcomes retrospectively.

Response:

Thank you for your suggestion. In our study, ‘two groups’ time of onset-door and onset-puncture for patients are similar (Table 2). So we did not perform a stratified analysis based on the time from symptom onset to randomization.

Attachment

Submitted filename: Response to reviwer 2.doc

pone.0353204.s006.doc^{(19KB, doc)}

PLoS One. doi: 10.1371/journal.pone.0353204.r003

Decision Letter 1

Aldobrando Broccolini, Aldobrando Broccolini

12 Jun 2026

-->PONE-D-26-14926R1-->-->Endovascular treatment based on computer tomography perfusion for basilar artery occlusion compared with anterior circulation stroke – a case control study-->-->PLOS One

Dear Dr. cai,

Please note that one reviewer has raised additional issues that need to be properly addressed, along my personal editorial assessment that you can find below.

Please submit your revised manuscript by Jul 27 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Aldobrando Broccolini, MD, PhD

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

The revised manuscript has been substantially improved and the authors have satisfactorily addressed the major concerns raised during the previous round of peer review. The study addresses a clinically relevant question and provides useful information regarding the imaging characteristics and outcomes of patients with basilar artery occlusion undergoing endovascular treatment.

However, one reviewer has raised additional comments during the current evaluation. These observations, together with my own editorial considerations, identify several remaining issues that should be addressed to further improve the scientific accuracy, methodological transparency, and interpretation of the findings.

Therefore, before the manuscript can be further considered, I would ask the authors to address the following points.

1. Study framing and title

The current title and several statements throughout the Abstract, Discussion, and Conclusions imply that the study evaluates the efficacy of CT perfusion-guided endovascular treatment. However, all included patients underwent CT perfusion imaging and no comparator group without perfusion imaging is available. Consequently, the study cannot determine whether CT perfusion guidance improves patient selection or clinical outcomes. The title and corresponding statements should therefore be revised to more accurately reflect the study design, namely a comparison of clinical characteristics, perfusion imaging findings, and outcomes between CTP-selected basilar artery occlusion and anterior circulation stroke patients undergoing EVT, rather than an evaluation of the effectiveness of a CTP-guided strategy.

2. Introduction and Discussion

The statement in the Introduction:

“Due to limited scientific evidence, the approaches to EVT for BAO remain heterogeneous due to the lack of data from randomized clinical trials.” should be removed or substantially revised, as it is no longer supported by the available evidence.

Similarly, the opening sentence of the Discussion: “Despite recent breakthroughs in the treatment of ischemic stroke caused by large artery occlusion (LAO), the optimal treatment for basilar artery occlusion (BAO) remains unclear, as BAO patients were excluded from recent randomized controlled trials.” should be removed, as it is factually incorrect. The ATTENTION and BAOCHE trials, together with BASICS and BEST, have established the benefit of EVT in appropriately selected BAO patients. The discussion should instead focus on the remaining uncertainties regarding imaging selection, perfusion assessment, and specific clinical subgroups.

3. Propensity score matching and statistical methods

The propensity score matching methodology should be incorporated into the Statistical Analysis section to improve the organization and transparency of the Methods.

Moreover, the manuscript describes the matched cohort as "well balanced," despite a substantial residual difference in baseline NIHSS score. Given that NIHSS is one of the strongest determinants of functional outcome and mortality, this imbalance deserves explicit discussion. Importantly, the known limitations of the NIHSS in posterior circulation stroke do not diminish the significance of this finding; rather, the persistence of a significantly higher NIHSS score in the BAO cohort despite the underrepresentation of posterior circulation symptoms suggests that these patients may have had an even greater neurological severity than reflected by the scale. The authors should clarify the rationale for excluding baseline NIHSS from the propensity score model, discuss the potential impact of this residual imbalance, and reconsider describing the matched cohort as "well balanced."

4. Outcome assessment

The Discussion should acknowledge that the modified Rankin Scale, although the standard functional endpoint in stroke trials, may incompletely capture clinically meaningful residual deficits frequently observed after posterior circulation stroke. Consequently, comparable mRS outcomes may underestimate differences in the actual burden of disability between posterior and anterior circulation stroke patients.

5. Applicability of CT perfusion parameters

Given the unique anatomical and hemodynamic characteristics of the posterior circulation, the Discussion would benefit from a brief consideration of the applicability and current evidence supporting conventional CT perfusion thresholds in basilar artery occlusion. The authors should clarify that the present study applies established perfusion parameters but does not aim to validate or optimize CTP thresholds for posterior circulation stroke.

6. Limitations

The current Limitations section is overly concise and should be substantially expanded. In addition to the retrospective design and the relatively small BAO cohort, the authors should explicitly discuss the absence of a non-CTP comparator group, the potential for residual confounding related to the persistence of baseline NIHSS differences after propensity score matching, and the implications of these limitations when interpreting the comparative effectiveness and safety of EVT between BAO and ACS.

7. Manuscript presentation

The overall presentation of the manuscript requires careful revision. The current version contains numerous formatting inconsistencies, including irregular punctuation and spacing, figure legends embedded within the main text, and other editorial artifacts that adversely affect readability. The manuscript should be carefully proofread to ensure that the text, figures, legends, and tables are presented in a clear and consistent manner.

To facilitate the editorial assessment of the revised version, please make sure that all modifications introduced in response to the present comments are clearly identified by highlighting throughout the manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

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Reviewer #2: All comments have been addressed

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Reviewer #2: Partly

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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-->6. Review Comments to the Author

Reviewer #2: This study compared the differences in perfusion imaging between basilar artery occlusion (BAO) and conventional anterior circulation stroke, highlighting the special application value and challenges of CTP in BAO. The following review comments are provided:

1.Due to the unique anatomical structure of the posterior circulation, are the widely used anterior circulation CTP parameters still applicable to patients with posterior circulation infarction?

2.The NIHSS itself has limitations in assessing common posterior circulation stroke symptoms (such as unsteady gait, dysphagia, and oculomotor disorders). In this study, although the BAO group had a higher baseline NIHSS score, the 90-day favorable outcome rate was not significantly worse than that of the anterior circulation group? Could the authors further explain or explore whether this phenomenon is attributable to the limitations of the NIHSS?

3.Patients with posterior circulation stroke often experience residual disabilities affecting quality of life, such as balance dysfunction, dysphagia, and dysarthria, which may not be adequately captured by the mRS. Therefore, using only the mRS to assess prognosis in posterior circulation stroke may underestimate the actual burden of disability.

**********

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Reviewer #2: No

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PLoS One. 2026 Jul 14;21(7):e0353204. doi: 10.1371/journal.pone.0353204.r004

Author response to Decision Letter 2

17 Jun 2026

Dear reviewer 2:

We provide a point-by point response to the reviewers’ comments below.

1.Due to the unique anatomical structure of the posterior circulation, are the widely used anterior circulation CTP parameters still applicable to patients with posterior circulation infarction?

Thanks for your question. Given the unique anatomical and hemodynamic characteristics of the posterior circulation, the present study applies established perfusion parameters but does not aim to validate or optimize CTP thresholds for posterior circulation stroke.

Thanks for your question. This phenomenon is closely related to the inherent defects of the NIHSS, which is a major contributing factor.

First, the NIHSS is primarily designed and validated for evaluating anterior circulation stroke. It assigns high scores to hemiplegia, aphasia and cortical dysfunction that are typical of anterior circulation lesions, while insufficiently weighting or even ignoring core manifestations of posterior circulation stroke including gait ataxia, dysphagia and oculomotor deficits. In patients with basilar artery occlusion (BAO), severe brainstem dysfunction can raise the baseline NIHSS score obviously, yet many of these high-scoring items reflect symptoms that have relatively good recovery potential after standard treatment.

Second, many disabling symptoms of posterior circulation stroke such as severe ataxia and persistent dysphagia are not fully reflected in the NIHSS. As a result, the baseline score overestimates the actual long-term functional impairment of BAO patients. Even with higher initial NIHSS scores, their actual neurological damage is not disproportionately severe, so the 90-day favorable outcome rate is comparable to that of the anterior circulation group.

Besides, other confounding factors cannot be ruled out: the diversity of collateral circulation in posterior circulation, differences in treatment timeliness and individual tolerance to therapy also affect clinical outcomes. In further studies, subgroup analysis focusing on NIHSS item composition and long-term functional scales (e.g. mRS) is recommended to quantitatively verify the impact of NIHSS limitations.

Thanks for your question. You have raised a very valuable point. The modified Rankin Scale (mRS) indeed has obvious shortcomings when applied to posterior circulation stroke.

The mRS mainly focuses on overall daily living ability, mobility and self-care status. It cannot sensitively reflect subtle but persistent impairments including balance disturbance, mild dysphagia and dysarthria. These sequelae are highly prevalent in posterior circulation stroke survivors and severely impair their daily communication, eating and walking stability, yet they often correspond to relatively low mRS grades.

For this reason, relying solely on the mRS will underestimate the long-term disability and life impact of such patients. In further studies, combine specialized scales: for example, use ataxia scales, swallowing function scales and speech evaluation tools together with the mRS, so as to comprehensively evaluate the true functional status and disease burden of posterior circulation stroke patients.

We had added these sentence in discussions in revised manuscript.

Dear editor:

We provide a point-by point response to the reviewers’ comments below.

1. Study framing and title

Response:

Thanks for your suggestion. We have rewritten the title as “Perfusion imaging findings, and outcomes between CTP-selected basilar artery occlusion and anterior circulation stroke patients undergoing EVT”.

2. Introduction and Discussion

The statement in the Introduction:

Thanks for your correction. We have deleted the sentence in revised manuscript.

3. Propensity score matching and statistical methods

The propensity score matching methodology should be incorporated into the Statistical Analysis section to improve the organization and transparency of the Methods.

According to your request, the PSM in method section has been incorporated into the Statistical Analysis section.

The paragraph in the discussion “Consistent with previous studies comparing ACS and PCS [17-19], patients with BAO had higher baseline NIHSS scores and larger ischemic volume. Higher baseline NIHSS scores is partly due to the limitations of the NIHSS in assessing neurological deficits in patients with PCS, as it is highly weighted toward deficits occurring in ACS, such as aphasia and hemiparesis, while neglecting deficits such as unsteady gait, dysphagia, or oculomotor disorders[20]. Larger ischemic volume is partly due to limited collateral circulation in posterior circulation brain tissue[18].” explains why BAO has a high NIHSS score, which is a disease characteristic that cannot be well balanced, otherwise it would be difficult to include matched patients. The imbalance of this baseline feature and the relative balance of the results indicate that BAO may have gained greater benefits after this treatment.

4. Outcome assessment

Thanks for your correction. We have added the sentence “the mRS score, although the standard functional endpoint in stroke trials, may incompletely capture clinically meaningful residual deficits frequently observed after posterior circulation stroke. Consequently, comparable mRS outcomes may underestimate differences in the actual burden of disability between posterior and anterior circulation stroke patients.” in revised manuscript.

5. Applicability of CT perfusion parameters

Thanks for your correction. We have added the sentence “the present study applies established perfusion parameters but does not aim to validate or optimize CTP thresholds for posterior circulation stroke.” in revised manuscript.

“ 6. Limitations

Thanks for your correction. We have rewritten the limitation as “This study has several important limitations. First, this was a single-center retrospective observational study, which may be subject to selection bias and unmeasured confounding. Second, the sample size of patients with BAO was relatively small compared with ACS group, which may limit the statistical power and generalizability of the results. Third, all patients included in this study underwent CTP imaging, and no control group treated without CTP guidance was available. Therefore, we cannot determine whether CTP-based selection improved patient eligibility, treatment decisions, or clinical outcomes compared with conventional non-perfusion imaging strategies. Fourth, despite the use of propensity score matching to balance baseline characteristics between groups, residual differences in baseline NIHSS scores persisted, which may introduce residual confounding that could not be fully adjusted for. This may affect the interpretation of the comparative effectiveness and safety of EVT between BAO and ACS patients. Finally, mRS as the primary functional outcome may incompletely capture posterior circulation–specific deficits such as dysphagia, ataxia, and dysarthria, which could lead to underestimation of the true disability burden in BAO patients.

These limitations should be considered when interpreting the comparative effectiveness and safety of EVT in patients with BAO versus ACS.”

7. Manuscript presentation

Thanks for your correction. We have checked numerous formatting inconsistencies, including irregular punctuation and spacing, figure legends embedded in revised manuscript.

Attachment

Submitted filename: revised to editor R2.docx

pone.0353204.s007.docx^{(19.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0353204.r005

Decision Letter 2

Aldobrando Broccolini, Aldobrando Broccolini, Aldobrando Broccolini

21 Jun 2026

Perfusion imaging findings, and outcomes between computed tomography perfusion selected basilar artery occlusion and anterior circulation stroke patients undergoing endovascular treatment

PONE-D-26-14926R2

Dear Dr. cai,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Academic Editor

PLOS One

Additional Editor Comments (optional):

The Authors have addressed all the points raised by the Reviewer and the Academic Editor after the first round of review.

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0353204.r006

Acceptance letter

Aldobrando Broccolini, Aldobrando Broccolini, Aldobrando Broccolini

PONE-D-26-14926R2

PLOS One

Dear Dr. Cai,

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Fig. Outcomes of patients with CTP-guided EVT.

(A) mRS score at 90 days of BAO patients and ACS patients. (B) Mortality of patients and ACS patients.

(TIF)

pone.0353204.s001.tif^{(188.5KB, tif)}

S2 Fig. Collinearity among predictor variables.

Collinearity among predictor variables.

(TIF)

pone.0353204.s002.tif^{(320.9KB, tif)}

S1 Table. Clinical characteristics between patients with ICA and MCA.

(DOCX)

pone.0353204.s003.docx^{(20KB, docx)}

S1 File. Supporting Information.

Research underlying data.

(XLSX)

pone.0353204.s004.xlsx^{(56.7KB, xlsx)}

Attachment

Submitted filename: Response to reviwer 2.doc

pone.0353204.s006.doc^{(19KB, doc)}

Attachment

Submitted filename: revised to editor R2.docx

pone.0353204.s007.docx^{(19.1KB, docx)}

Data Availability Statement

All relevant data are within the paper and its Supporting Information file.

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PERMALINK

Perfusion imaging findings, and outcomes between computed tomography perfusion selected basilar artery occlusion and anterior circulation stroke patients undergoing endovascular treatment

Xiaofeng Cai

Roles

Abstract

Background

Aim

Methods

Results

Conclusions

Introduction

Methods

Study population

Imaging protocol

Fig 1. Imaging manifestations of BAO and ACS patient before and after CTP guided EVT treatment.

Outcome assessment

Statistical analysis

Results

Patient characteristics

Fig 2. The flowchart of patients’ enrollment.

Table 1. Baseline clinical characteristics of patients.

Propensity score–matched cohort

Procedural characteristics

Table 2. Treatment and outcome characteristics of patients.

Neurological outcomes

Predictors of poor outcome and mortality

Table 3. The multivariate logistic regression analysis of mRS 3-6 at 90 days and mortality.

Discussion

Limitations

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Aldobrando Broccolini

Roles

Author response to Decision Letter 1

Decision Letter 1

Aldobrando Broccolini

Aldobrando Broccolini

Roles

Author response to Decision Letter 2

Decision Letter 2

Aldobrando Broccolini

Aldobrando Broccolini

Aldobrando Broccolini

Roles

Acceptance letter

Aldobrando Broccolini

Aldobrando Broccolini

Aldobrando Broccolini

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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