Editorial: Challenges in Posterior Circulation Ischemic Stroke

Puetz, Volker; Strbian, Daniel; Nguyen, Thanh N.; Nagel, Simon

doi:10.3389/fneur.2021.789836

Cited by 6 publications

(5 citation statements)

References 21 publications

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“…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.…”

Section: Although Clinical Symptoms Of Pca Infarcts May Results In a Lowmentioning

confidence: 99%

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

Berberich

Finitsis

Strambo

et al. 2022

Euro J of Neurology

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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.

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Section: Although Clinical Symptoms Of Pca Infarcts May Results In a Lowmentioning

confidence: 99%

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

Berberich

Finitsis

Strambo

et al. 2022

Euro J of Neurology

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“…In a patient presenting late with a severe stroke syndrome and LVO, the NCCT showing no major ischemic changes or good ASPECTS may have already done all the necessary screening work for decisionmaking to EVT. The DAWN and DEFUSE 3 trials may have over-selected late presenting patients (ie, the late window paradox), 45 as suggested by the better outcomes, greater difference in treatment effect, and their much lower number needed to treat compared with the trials of early LVO presentations. 46 It is unlikely that taking precious time to perform additional imaging with CTP or MRI will improve patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…This survey did not address late window imaging selection for basilar artery occlusion patients to EVT, 44 therefore these findings are not generalizable to the posterior circulation. In ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) 45 and BAOCHE (Basilar Artery Occlusion Chinese Endovascular Trial), 46 patients presenting with basilar artery occlusion were selected mainly by CT with PC ASPECTS in the late window up to 24 hours from estimated symptom onset. As detection of early ischemic changes is known to be more difficult to discriminate in the posterior circulation with CT, 47 the results of these 2 basilar artery occlusion trials, which were predominantly based on CT PC ASPECTS, 48,49 may lower thresholds to utilization of CT paradigms for late window selection of patients for EVT.…”

Section: Limitationsmentioning

confidence: 99%

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

Nguyen

Klein

Berberich

et al. 2023

SVIN

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BACKGROUND Current stroke guidelines recommend advanced imaging (computed tomography [CT] perfusion or magnetic resonance imaging) prior to endovascular therapy (EVT) in patients with late presentation of large vessel occlusion. Adherence to guidelines may be constrained by resources or timely access to imaging. We sought to understand the factors which influence late window imaging selection for EVT candidates with large vessel occlusion. METHODS We conducted an international survey from January to May 2022. The questions aimed to identify advanced imaging and treatment decisions based on access to imaging, time delays, and simulated patient scenarios. RESULTS There were 3000 invited participants and 1506 respondents, the majority (89.6%) from comprehensive stroke centers in high‐income countries. Neurointerventionalists comprised 31.8% and noninterventionalists 68.2% of respondents. Overall, 70.7% reported routine use of advanced imaging for late EVT selection, and 63.6% reported its usage in every case. There was greater availability of advanced imaging in comprehensive stroke centers versus primary stroke centers (67.0% versus 33.7%; P <0.0001), and high‐ versus low‐middle income countries (70.5% versus 44.5%; P <0.0001). When presented with a late window patient, 41.6% would complete CT perfusion or magnetic resonance imaging prior to EVT, 25.4% would perform CT perfusion or magnetic resonance imaging prior to IVT and EVT, and 25.8% would refer to EVT without advanced imaging. If advanced imaging was not readily available, 70.1% would refer a patient to EVT based on CT in the late window. Additional time delay within 20 minutes to obtain advanced imaging was considered acceptable in 77.7% of respondents. CONCLUSION Current guidelines for imaging late window EVT candidates are inconsistent with imaging decisions by physicians. Most respondents consider an imaging delay of greater than 20 minutes unacceptable. Access to advanced imaging was greater in comprehensive stroke centers and high‐income countries. In the case of limited access most respondents would consider EVT based on CT only.

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“…31 81 These findings reflect better efficacy of IVT in BAO compared with the anterior circulation LVO: the recanalization rates are superior in equal-length thrombi, 79 and BMT in the BASICS trial resulted more frequently in recanalization compared with the studies of anterior circulation LVO (56 vs. 33–43%). 21 24 29 82 Furthermore, the risk of sICH after IVT seems to be lower. 8 20 Observational data based on IVT up to 48 hours have shown 3-month mRS of 0 to 3 in 48% of patients.…”

Section: Basilar Artery Occlusionmentioning

confidence: 99%

What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke?

Räty,

Nguyen,

Nagel

et al. 2023

Semin Neurol

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Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.

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Editorial: Challenges in Posterior Circulation Ischemic Stroke

Cited by 6 publications

References 21 publications

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

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

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke?

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