Comparison of Risk Factors, Safety, and Efficacy Outcomes of Mechanical Thrombectomy in Posterior vs. Anterior Circulation Large Vessel Occlusion

Abstract

Background and Purpose: It is believed that stroke occurring due to posterior circulation large vessel occlusion (PCLVO) and that occurring due to anterior circulation large vessel occlusion (ACLVO) differ in terms of their pathophysiology and the outcome of their acute management in relation to endovascular mechanical thrombectomy (MT). Limited sample size and few randomized controlled trials (RCTs) with respect to PCLVO make the safety and efficacy of MT, which has been confirmed in ACLVO, difficult to assess in the posterior circulation. We therefore conducted a meta-analysis to study to which extent MT in PCLVO differs from ACLVO.Materials and Methods: We searched the databases PubMed, Cochrane, and EMBASE for studies published between 2010 and January 2021, with information on risk factors, safety, and efficacy outcomes of MT in PCLVO vs. ACLVO and conducted a systematic review and meta-analysis; we compared baseline characteristics, reperfusion treatment profiles [including rates of intravenous thrombolysis (IVT) and onset-to-IVT and onset-to-groin puncture times], recanalization success [Thrombolysis In Cerebral Infarction scale (TICI) 2b/3], symptomatic intracranial hemorrhage (sICH), and favorable functional outcome [modified Rankin Score (mRS) 0–2] and mortality at 90 days.Results: Sixteen studies with MT PCLVO (1,172 patients) and ACLVO (7,726 patients) were obtained from the search. The pooled estimates showed higher baseline National Institutes of Health Stroke Scale (NIHSS) score (SMD 0.32, 95% CI 0.15–0.48) in the PCLVO group. PCLVO patients received less often IVT (OR 0.65, 95% CI 0.53–0.79). Onset-to-IVT time (SMD 0.86, 95% CI 0.45–1.26) and onset-to-groin puncture time (SMD 0.59, 95% CI 0.33–0.85) were longer in the PCLVO group. The likelihood of obtaining successful recanalization and favorable functional outcome at 90 days was comparable between the two groups. PCLVO was, however, associated with less sICH (OR 0.56, 95% CI 0.37–0.85) but higher mortality (OR 1.92, 95% CI 1.46–2.53).Conclusions: This meta-analysis indicates that MT in PCLVO may be comparably efficient in obtaining successful recanalization and 90 day favorable functional outcome just as in ACLVO. Less sICH in MT-treated PCLVO patients might be the result of the lower IVT rate in this group. Higher baseline NIHSS and longer onset-to-IVT and onset-to-groin puncture times may have contributed to a higher 90 day mortality in PCLVO patients.

Prognostic factors for acute posterior circulation cerebral infarction patients after endovascular mechanical thrombectomy

“…Neurological deficits caused by PCCI was described as catastrophic with severe disability and death. [ 56 ] Due to the rarity of PCCI cases, it is challenge for obtaining a large sample size to study the prognosis of those patients. It is essential to deep understanding more detailed prognostic factors of this disease.…”

“…In clinic, when cerebral infarction occurs in posterior circulation, it is still very difficult to deal with. Neurological deficits caused by PCCI was described as catastrophic with severe disability and death [56] . Due to the rarity of PCCI cases, it is challenge for obtaining a large sample size to study the prognosis of those patients.…”

General anesthesia vs. non-general anesthesia for vertebrobasilar stroke endovascular therapy

“…The highly effective reperfusion using multiple endovascular devices (HERMES) collaboration ( 21 ), for example, the time interval between randomization and reperfusion was 20 min later in patients who had GA vs. patients who had non-GA during EVT in anterior circulation ischemic stroke. However, in the present study, puncture to reperfusion times were significantly longer in the GA group that did not confer a disadvantage to patients with VBAO compared to non-GA. A recent meta-analysis showed that in spite of the longer onset-to-EVT and onset-to-groin puncture times in VBAO, favorable functional outcome at 90 days in VBAO was comparably no difference just as in anterior circulation large vessel occlusion during EVT ( 22 ). This could be supported by the hypothesis that benefit of recanalization is less time-dependent in VBAO than in anterior circulation large vessel occlusion due to the anatomical vascular layout of the brainstem being different from that in usual anterior circulation stroke ( 23 ).…”

Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry‐Endovascular Treatment

“…All in all, the majority of observational studies showed a benefit of EVT in LVO posterior circulation strokes [9][10][11][12][13][14]. A recent meta-analysis of 16 studies indicated comparable rates of successful reperfusion and good clinical outcome comparing anterior and posterior circulation strokes [15]. However, two large prospective observational studies did not support the superiority of EVT over IVT in patients with BAO, demonstrating relatively poor outcome despite successful reperfusion [2,16].…”