Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

Abstract

Background Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. Methods We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. Results There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. Conclusions Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

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

“…Endovascular therapy (EVT) represents a standard treatment for patients with acute ischemic strokes attributable to large vessel occlusions in the anterior circulation [6,7]. With advances in thrombectomy devices and techniques, the use of EVT is expanding to medium and distal vessel occlusions [8][9][10][11]. In addition, EVT is increasingly used to treat patients with isolated occlusions of the PCA.…”

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

“…The hyperdense vessel sign can also be identified in M2 occlusions (known as the "dot sign"), BAO, or any newly occluded blood vessel (Figure 4). [33][34][35][36] For patients who are unable to undergo non-invasive vascular imaging, the "hyperdense vessel sign" can guide decisions for EVT. 7 Knowledge of these clot factors can provide insights into stroke etiology and can impact the choice of revascularization techniques.…”

“…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.…”

“…Perfusion imaging can enable the detection of distal and posterior circulation vessel steno-occlusive disease using the Tmax maps. 36,48,81,82 Perfusion imaging may further help identify a subset of patients with a large region of established infarct who may benefit from EVT when there remains considerable tissue at risk. 83 In the event of multiple intracranial occlusions or stenosis, perfusion imaging may identify the symptomatic site (Figure 7), provided the reference artery selected for the arterial input function is physiologically appropriate.…”

Mechanical thrombectomy for acute fetal posterior cerebral artery occlusion with a hidden unruptured cerebral aneurysm: illustrative case

“…Use of mechanical thrombectomy (MT) for an FPCO has also been reported. 2 However, for safe use of MT, it is important to consider unruptured cerebral aneurysms, which can be hidden distal to the occluded vessels. Herein, we present a case of a hidden aneurysm that was confirmed at the occluded site after MT for an FPCO.…”