BAOCHE Trial: Basilar EVT 6-24 Hours
In acute basilar artery occlusion 6–24 hours after last-known-well, does endovascular thrombectomy improve mRS 0–3 at 90 days compared with standard medical care? (Primary outcome was amended mid-trial from mRS 0–4 to mRS 0–3 before unblinding.)
Jovin et al. (NEJM 2022) · doi:10.1056/NEJMoa2207576 · 217 patients
Population
Included
- Age 18–80
- Acute basilar artery or bilateral intracranial vertebral occlusion
- 6–24 hours from last-known-well
- NIHSS ≥6 (post-amendment; initially ≥10)
- PC-ASPECTS ≥6, Pons-Midbrain Index ≤2, pre-stroke mRS 0–1
- Posterior circulation AIS within 6-24 hours from symptom onset/last seen well where patient is ineligible for i.v. thrombolytic treatment, or patient has received i.v. thrombolytic therapy without recanalization
- Occlusion (TIMI 0-1) of the basilar artery or intracranial segments of both vertebral arteries as evidenced by CT angiography, MR angiography or angiogram
- Age ≥18 and ≤80 years
- Baseline NIHSS score obtained prior to randomization must be equal to or higher than 6 points
- No significant pre-stroke functional disability (mRS ≤ 1)
- Patient treatable within 24 hours from time last seen well. Isolated vertigo with nausea and/or vomiting is not considered onset of symptom
- Informed consent obtained from patient or acceptable patient surrogate
Excluded
- Anterior circulation LVO
- Pre-stroke mRS ≥2
- PC-ASPECTS <6 or Pons-Midbrain Index >2
- Recent ICH or amyloid angiopathy
- Age >80
General
- Known hemorrhagic diathesis, coagulation factor deficiency, or oral anticoagulant therapy with INR > 3.0
- Baseline platelet count < 50,000/µL
- Baseline blood glucose < 50 mg/dL or > 400 mg/dL
- Severe, sustained hypertension (SBP > 220 mm Hg or DBP > 110 mm Hg)
- Patients in sedation and/or intubated could not be included if baseline NIHSS is not obtained by a neurologist or emergency physician prior to sedation/intubation
- Seizures at stroke onset which would preclude obtaining a baseline NIHSS
- Serious, advanced, or terminal illness with anticipated life expectancy of less than one year
- History of life-threatening allergy (more than rash) to contrast medium
- Subjects who received i.v. tissue plasminogen activator beyond 4.5 hours from symptom onset
- Acute stroke within the first 48 hours after percutaneous cardiac, cerebrovascular interventions and major surgery
- Renal insufficiency with creatinine ≥ 3 mg/dl
- Woman of childbearing potential known to be pregnant or lactating or with a positive pregnancy test
- Subject participating in a study involving an investigational drug or device that would impact this study
- Cerebral vasculitis
- Pre-existing neurological or psychiatric disease that would confound evaluations; baseline mRS must be ≤ 1
- Unlikely to be available for 90 days follow-up
Neuroimaging
- Hypodensity amounting to a posterior-circulation ASPECTS (pc-ASPECTS) < 6 and Pons-midbrain-index ≥ 3 on CTA source images, MR-DWI, or NCCT
- CT or MR evidence of hemorrhage (presence of microbleeds on MRI is allowed)
- Complete cerebellar infarct on CT or MRI with significant mass effect and compression of the fourth ventricle
- Complete unilateral or bilateral thalamic infarction on CT or MRI
- Evidence of vertebral occlusion, high-grade stenosis or arterial dissection in the extracranial or intracranial segment that cannot be treated or will prevent access, or excessive tortuosity precluding device delivery
- Subjects with occlusions in both anterior and posterior circulation
- Evidence of intracranial tumor (except small meningioma)
Source: ClinicalTrials.gov NCT02737189· Retrieved 2026-06-08
Primary Outcome
Protocol amendment: Primary outcome changed from mRS 0–4 to mRS 0–3 mid-trial (before unblinding). The original mRS 0–4 result was NEGATIVE (RR 1.21, 95% CI 0.95–1.54). Trial stopped early for efficacy at planned interim — effect size may be overestimated.
mRS 0–3 at 90 Days (revised primary)
Study Arms
- Agent
- Endovascular thrombectomy with Solitaire stent retriever (Medtronic), added to standard medical care
- Route
- Endovascular
- Frequency
- Single index procedure
- Duration
- 6–24 h after symptom onset / last known well
- Co-interventions
- Standard medical care per current Chinese guidelines; IV thrombolysis if arrived within the 4.5 h window and met safety criteria, used in 14% of thrombectomy-group patients (Jovin NEJM 2022 p.1373,1375)
Solitaire device (retrievable self-expanding stent). Rescue reperfusion with other devices/pharmacologic agents NOT permitted except balloon angioplasty or stenting of the vertebral/basilar artery. Procedural complications 11% (p.1375).
- Agent
- Standard medical care alone (medical therapy only)
- Route
- Medical
- Duration
- 90-day follow-up
- Co-interventions
- Standard medical care per current Chinese guidelines; IV thrombolysis if within the 4.5 h window and met safety criteria, used in 21% of control-group patients (Jovin NEJM 2022 p.1373,1375)
Control = standard medical care alone, no EVT. Enrollment halted early at prespecified interim for superiority of thrombectomy (p.1373).
Safety
Symptomatic ICH (SITS-MOST, primary safety)
6%
1%
6/102 EVT vs 1/88 control (RR 5.18, 95% CI 0.64–42.18). Trending higher but not statistically significant.
90-day mortality
31%
42%
34/110 EVT vs 45/107 control (adjusted RR 0.75, 95% CI 0.54–1.04). Direction favorable but NOT statistically significant. Do not claim mortality benefit for BAOCHE alone.
Trial Design
Type
- Multicenter randomized open-label trial
- Conducted in China
- Late window (6-24 hours)
- 1:1 allocation (Thrombectomy vs. Medical)
- Stopped early at interim for efficacy (Apr 2022) after 212/318 planned patients
Timeline
Enrolled Aug 2016 – Jun 2021 (stopped early Apr 2022 for efficacy)
N
217
Enrollment
217 patients (110 EVT / 107 control, 1:1 ITT) in China. Enrolled Aug 2016 – Jun 2021. Stopped early Apr 2022 at planned interim for efficacy. Published NEJM 2022.
ClinicalTrials.gov
NCT02737189Bedside Pearl
For basilar artery occlusion 6–24 hours after last-known-well with NIHSS ≥6, PC-ASPECTS ≥6, and Pons-Midbrain Index ≤2, EVT is reasonable. Note: primary outcome was amended mid-trial (mRS 0–4 → mRS 0–3); the original mRS 0–4 result was NEGATIVE. Trial stopped early, so effect size is likely overestimated.
See also
Trial lineage
Endovascular therapy for basilar artery occlusion
BEST and BASICS were the first two RCTs in basilar-artery occlusion and both failed their primary frame — driven by substantial crossover in BEST and a control arm in BASICS that frequently received alteplase. ATTENTION and BAOCHE, both in Chinese populations, established benefit in 0-12 h and 6-24 h windows respectively and shifted guideline support toward EVT for basilar LVO.
- 2020BEST TrialNEUTRAL
First RCT of EVT for basilar artery occlusion. ITT primary (mRS 0-3 at 90 days): 42% vs 32% (OR 1.74, CI 0.81–3.74, p=0.23). Terminated early for crossover and low enrollment. Preceded ATTENTION (2022).
- 2021BASICS TrialNEUTRAL
Multinational RCT of EVT for basilar artery occlusion within 6 hours. Primary (mRS 0-3 at 90 days): 44.2% EVT vs 37.7% medical (RR 1.18, CI 0.92–1.50, P=0.19). Statistically negative; CI did not rule out meaningful benefit. Preceded ATTENTION (2022).
- 2022ATTENTION TrialPOSITIVE
Basilar artery thrombectomy within 12 hours; China trial.
- 2022BAOCHE Trial· this pagePOSITIVE
Basilar EVT 6–24 hours with imaging selection.