Acute occlusion of the fetal posterior cerebral artery: diagnosis and management paradigms

Abstract

Background and purpose The diagnosis and management of acute fetal posterior cerebral artery occlusion are challenging. While endovascular treatment is established for anterior circulation large vessel occlusion stroke, little is known about the course of acute fetal posterior cerebral artery occlusions. We report the clinical course, radiological findings and management considerations of acute fetal posterior cerebral artery occlusion stroke. Methods We performed a retrospective review of consecutive patients presenting with acute large vessel occlusion who underwent cerebral angiogram and/or mechanical thrombectomy between January 2015 and January 2021. Patients diagnosed with fetal posterior cerebral artery occlusion were included. Demographic data, clinical presentation, imaging findings and management strategies were reviewed. Results Between January 2015 and January 2021, three patients with fetal posterior cerebral artery occlusion were identified from 400 patients who underwent angiogram and/or mechanical thrombectomy for acute stroke (0.75%). The first patient presented with concomitant fetal posterior cerebral artery and middle cerebral artery occlusions. Thrombectomy was performed with recanalisation of the fetal posterior cerebral artery but the patient died from malignant oedema. The second patient presented with isolated fetal posterior cerebral artery occlusion. No endovascular intervention was performed and the patient was disabled from malignant posterior cerebral artery infarct. The third patient presented with carotid occlusion and was found to have fetal posterior cerebral artery occlusion after internal carotid artery recanalisation. No further intervention was performed. The patient was left with residual contralateral homonymous hemianopia and mild left sided weakness. Conclusion Fetal posterior cerebral artery occlusion is a rare, but potentially disabling, cause of ischaemic stroke. Endovascular treatment is feasible. Further investigation is needed to compare the efficacy of medical versus endovascular management strategies.

Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

“…There were 25 patients (44% [11/25] female and 56% [14/25] male patients) who underwent MT of FPCA occlusion in the setting of acute ischemic stroke. Three out of the included 25 patients were already published as separate case reports 15,16 . The median age was 75 years (interquartile range [IQR] 59–77 years).…”

“…All 4 patients who died presented initially with severe stroke (NIHSS>20) and * Patients have been already published as separate case reports. 15,16 had FPCA associated with MCA or ICA occlusion. More technical details and outcomes are provided in Table 1.…”

Flow dynamics in acute ischemic stroke due to embolic occlusion of a fetal posterior cerebral artery treated with endovascular thrombectomy - report of two cases

“…Though in both cases recanalisation of the fPCA was achieved quickly by ivTL and cTE respectively, a severe lack of collateral blood flow together with the postulated unfavourable shift of the embolic trajectory from the cranial ICA to the fPCA seems to potentially limit the success of treatment in case of an occluded fPCA. Concordantly, reported success rates for endovascular and intravenous treatment of fPCA occlusions remain variable, ranging from successful stable recanalisation to fatal courses of ischemia due to malignant brain oedema [ 1 , 14 , 17 ]. Unlike than in occlusion of large cerebral vessels, namely, the intracranial ICA, the proximal MCA or the basilar artery, endovascular treatment of an occluded fPCA is currently not explicitly recommended [18] .…”

“…However, especially in case of a proven large critically perfused fPCA-territory, as shown here, endovascular treatment is feasible and should be considered, because outcome may be fatal without a stable successful recanalisation. Though meanwhile endovascular treatment of various types of fPCA occlusions was reported feasible in literature, reliable data from prospective trials are still pending [ 1 , 14 , 17 ]. Furthermore, the choice of the most appropriate technique for cTE (direct thrombus aspiration, use of a stent retriever etc.)…”

Editorial: Challenges in Posterior Circulation Ischemic Stroke

“…Their main conclusion was that EVT in isolated posterior cerebral artery occlusion appears safe and at least immediately effective, however further data from prospective or randomized studies are needed, especially on the longterm outcome activities of daily living. EVT for fetal PCA thrombectomy is another posterior circulation frontier that is also being explored in patients presenting with disabling stroke ( 19 ). Lastly, Kaiser et al show that a regular thrombus surface (defined as smoothly straight, convex, or concave) is associated with a higher chance for successful first pass reperfusion in patients with acute basilar artery occlusion which confirms previous findings in patients with acLVO ( 20 ).…”