Endovascular therapy versus no endovascular therapy in patients receiving best medical management for acute isolated occlusion of the posterior cerebral artery: A systematic review and meta‐analysis

Abstract

Background and purpose Endovascular therapy (EVT) is increasingly reported for treatment of isolated posterior cerebral artery (PCA) occlusions although its clinical benefit remains uncertain. This study‐level meta‐analysis investigated the functional outcomes and safety of EVT and best medical management (BMM) compared to BMM alone for treatment of PCA occlusion stroke. Methods We conducted a literature search in PubMed, Web of Science and Embase for studies in patients with isolated PCA occlusion stroke treated with EVT + BMM or BMM including intravenous thrombolysis. There were no randomized trials and all studies were retrospective. The primary outcome was modified Rankin Scale score of 0–2 at 3 months, while safety outcomes included mortality rate and incidence of symptomatic intracranial hemorrhage (sICH). Results Twelve studies with a total of 679 patients were included in the meta‐analysis: 338 patients with EVT + BMM and 341 patients receiving BMM alone. Good functional outcome at 3 months was achieved in 58.0% (95% confidence interval [CI] 43.83–70.95) of patients receiving EVT + BMM and 48.1% (95% CI 40.35–55.92) of patients who received BMM alone, with respective mortality rates of 12.6% (95% CI 7.30–20.93) and 12.3% (95% CI 8.64–17.33). sICH occurred in 4.2% (95% CI 2.47–7.03) of patients treated with EVT + BMM and 3.2% (95% CI 1.75–5.92) of patients treated with BMM alone. Comparative analyses were performed on studies that included both treatments and these demonstrated no significant differences. Conclusions Our results demonstrate that EVT represents a safe treatment for patients with isolated PCA occlusion stroke. There were no differences in clinical or safety outcomes between treatments, supporting randomization of future patients into distal vessel occlusion trials.

Basilar Artery Occlusion Thrombectomy Technique: An International Survey of Practice Patterns

“…Responses from 88.4% of neurointerventionalists indicated that they would proceed to EVT in a patient with an occlusion of any segment of the basilar artery, and 52.4% would additionally proceed to EVT with an occlusion of the V4 segment of the vertebral artery or of the P1 segment of the posterior cerebral artery. 22,23 The opinions of neurointerventionalists in this survey align closely with the inclusion criteria of the ATTENTION trial, suggesting the results of this trial may align with current clinical practice. Neurointerventionalists in this survey were permissive of treating patients with increased premorbid status.…”

Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy

“…CTA can aid in understanding the underlying pathophysiology of the stroke, including arterial dissection, carotid or intracranial atherosclerosis, carotid web, and intracranial vasculopathy (Figure 6). 35,36,[47][48][49] The ability to discern carotid pseudo-occlusion from a carotid terminus occlusion versus tandem proximal internal carotid artery (ICA) atherosclerotic occlusion remains a limitation of CTA, even when adjudicated by experienced radiologists. 50 CTA evaluating the head and neck vessels informs neurointerventionalists who are planning an endovascular procedure on the access of an intracranial target, including bovine or hostile aortic arch and whether radial or femoral arterial access is more appropriate.…”

“…However, single phase CTA is often timed at peak arterial phase when the contrast may not have yet opacified collateral vessels and may therefore underestimate the extent of collateral blood flow. CTA can aid in understanding the underlying pathophysiology of the stroke, including arterial dissection, carotid or intracranial atherosclerosis, carotid web, and intracranial vasculopathy ( Figure 6 ) [ 35 , 36 , 47 - 49 ]. The ability to discern carotid pseudo-occlusion from a carotid terminus occlusion versus tandem proximal internal carotid artery (ICA) atherosclerotic occlusion remains a limitation of CTA, even when adjudicated by experienced radiologists [ 50 ].…”

Endovascular Therapy or Medical Management Alone for Isolated Posterior Cerebral Artery Occlusion: A Multicenter Study

“…Currently, a few observational studies have compared BMM+EVT and BMM alone in this population, all reporting similar 3-month functional outcome in the 2 treatment groups. 3,4,9–11 However, these studies were limited by moderate sample sizes, 3,9,10 or the exclusion of patients with the most proximal occlusion (ie, first segment of the PCA) where a benefit of EVT may be more likely. 4…”