To compare the efficacy and safety of direct aspiration (DA) versus stent retriever thrombectomy (SRT) in the treatment of acute basilar artery occlusion (BAO).

 Acute BAO, a rare but critical type of stroke, accounts for 1%–4% of cases and poses a high mortality risk. Timely restoration of blood flow is essential, with endovascular treatments like SRT and DA emerging as options but which one is more efficient and safer is under debate.

PubMed, ScienceDirect and Cochrane Library were searched till September 2024. Risk Ratios (RR) and Mean Difference (MD) were pooled for dichotomous and continuous outcomes in Review Manager 5.4.1 utilizing a random effects model. Primary outcomes included postoperative successful recanalization (TICI score 2b or 3) and complete recanalization (TICI 3). Secondary outcomes included postoperative mortality, symptomatic intracerebral hemorrhage (sICH), favorable functional outcomes (mRS 0-2 or 0-3), postoperative rescue therapy, and procedural duration. The study quality was evaluated using the Newcastle Ottawa Scale and publication bias through funnel plots. A sensitivity analysis was conducted to investigate heterogeneity.

This meta-analysis of fifteen observational cohort studies (n=1978) compared direct aspiration (DA; n=953) and stent retriever thrombectomy (SRT; n=1025). DA was superior to SRT in terms of postoperative successful recanalization (RR=1.04, 95% CI:[1.01-1.07], p=0.008, I²=0%), complete recanalization (RR=1.19, 95% CI:[1.03-1.38], p=0.02, I²=53%), sICH (RR=0.65, 95% CI:[0.44-0.97], p=0.04, I²=0%), and procedural duration (MD= -35.17min, 95% CI:[-47.97, -22.37], p<0.00001, I²=85%). The two groups were comparable regarding postoperative mortality (RR=0.89, 95% CI: [0.71-1.12], p=0.32, I²=21%), favorable functional outcome (RR=1.11, 95% CI: [0.99-1.25], p=0.07, I²=0%), and postoperative rescue therapy (RR=1.51, 95% CI: [0.84-2.72], p=0.17, I²=73%).

DA may offer better recanalization rates, lower rates of symptomatic intracerebral hemorrhage, and shorter procedural duration compared to SRT in acute BAO treatment. These findings support further investigation into direct aspiration as a first-line option.