| Summary: | Background: Endovascular thrombectomy is the primary treatment for acute basilar artery occlusion (BAO), with direct aspiration (DA) and stent retriever (SR) as the main techniques. This updated meta-analysis aims to compare these two techniques in terms of efficacy and safety outcomes. Methods: A search was performed across PubMed, Embase, and Cochrane databases on December 23, 2024. Primary outcomes included good and favorable functional outcomes. Secondary outcomes included procedural outcomes, such as successful and complete recanalization, and safety outcomes, including symptomatic intracranial hemorrhage and mortality at 90 days. Leave-one-out sensitivity analysis was used to assess each study's influence on the pooled effect by systematically excluding one study at each time. Results: Out of 4,424 studies initially screened, a total of 14 studies with 1,851 patients were ultimately included (DA = 830, SR = 1,021). There were no significant differences in favorable and good functional outcomes (OR 1.07; 95% CI 0.82–1.39; P = 0.626; OR 1.19; 95% CI 0.94–1.50; P = 0.152, respectively) nor mortality (OR 0.83; 95% CI 0.63–1.09; P = 0.177). A significant difference was observed in complete recanalization rates in sensitivity analyses, favoring DA, which was not evident in the successful recanalization rates. The DA group also demonstrated a lower risk of sICH (OR 0.56; 95% CI 0.34–0.93; P = 0.025). Conclusion: Our meta-analysis shows that DA and SR techniques for BAO thrombectomy each have distinct procedural trade-offs. Due to data heterogeneity and observational design, neither method can be definitively recommended. Treatment decisions should be individualized until high-quality randomized data are available.
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