Endovascular treatment for isolated posterior cerebral artery occlusion stroke in the MR CLEAN registry

Abstract

BackgroundEndovascular treatment (EVT) is standard of care in anterior circulation large vessel occlusions. In posterior circulation occlusions, data on EVT in isolated posterior cerebral artery (PCA) occlusions are limited, although PCA occlusions can cause severe neurological deficit.ObjectiveTo describe in a prospective study the clinical manifestations, outcomes, and safety of EVT in isolated PCA occlusions.MethodsWe used data (2014–2017) from the MR CLEAN Registry, a nationwide, prospective cohort of EVT-treated patients in the Netherlands. We included patients with acute ischemic stroke (AIS) due to an isolated PCA occlusion on CT angiography. Patients with concurrent occlusion of the basilar artery were excluded. Outcomes included change in National Institutes of Health Stroke Scale (ΔNIHSS) score, modified Rankin Scale (mRS) score 0–3 after 90 days, mortality, expanded Thrombolysis in Cerebral Infarction (eTICI), and periprocedural complications.ResultsTwenty (12%) of 162 patients with posterior circulation occlusions had an isolated PCA occlusion. Median age was 72 years; 13 (65%) were women. Median baseline NIHSS score was 13 (IQR 5–21). Six (30%) patients were comatose. Twelve patients (60%) received IVT. Median ΔNIHSS was −4 (IQR −11–+1). At follow-up, nine patients (45%) had mRS score 0–3. Seven (35%) died. eTICI 2b-3 was achieved in 13 patients (65%). Nine patients (45%) had periprocedural complications. No symptomatic intracranial hemorrhages (sICH) occurred.ConclusionsEVT should be considered in selected patients with AIS with an isolated PCA occlusion, presenting with moderate–severe neurological deficits, as EVT was technically feasible in most of our patients and about half had good clinical outcome. In case of lower NIHSS score, a more conservative approach seems warranted, since periprocedural complications are not uncommon. Nonetheless, EVT seems reasonably safe considering the absence of sICH in our study.

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

“…Twelve studies were included in the analysis [5, 12–16, 18, 19, 21, 25, 26, 29]. The search strategy is shown in Figure S1.…”

“…In addition, EVT is increasingly used to treat patients with isolated occlusions of the PCA. Several recent studies demonstrated the feasibility and safety of EVT in these patients [5,[12][13][14][15][16][17][18][19][20][21]. However, randomized clinical trials demonstrating the efficacy of EVT in the treatment of isolated PCA occlusions are lacking.…”

“…Four of the 12 articles reported on both patients treated with EVT + BMM and patients receiving BMM, including IVT if administered, in both groups [5, 12, 13, 19]. Five studies reported only on patients treated with EVT + BMM [14–16, 18, 21], and three articles described only patients with BMM including IVT for treatment of isolated PCA occlusion [25, 26, 29].…”

“…Secondary safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality at 3 months. sICH was defined according to the European Cooperative Acute Stroke Study (ECASS) II or III criteria in most of the studies [5, 13, 15, 16, 19, 23–26]; the studies by Herweh et al and Brouwer et al used the Heidelberg bleeding classification for definition of sICH [12, 21, 27]. Information extracted from each study included sample size, age, sex, percentage of patients receiving IVT, NIHSS score at admission, time from onset of symptoms to acute treatment (IVT or puncture), rate of successful reperfusion, rate of sICH, clinical outcomes and mortality at 3 months.…”

“…the studies [5,13,15,16,19,[23][24][25][26]; the studies by Herweh et al and Brouwer et al used the Heidelberg bleeding classification for definition of sICH [12,21,27]. Information extracted from each study included sample size, age, sex, percentage of patients receiving IVT, NIHSS score at admission, time from onset of symptoms to acute treatment (IVT or puncture), rate of successful reperfusion, rate of sICH, clinical outcomes and mortality at 3 months.…”