Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion

Strambo, Davide; Bartolini, Bruno; Beaud, Valérie; Marto, João Pedro; Gaia, Silvia; Dunet, Vincent; Saliou, Guillaume; Nannoni, Stefania; Michel, Patrik

doi:10.1161/strokeaha.119.026907

Cited by 85 publications

(97 citation statements)

References 30 publications

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“…There is only one other study so far comparing clinical outcome between these groups in patients with acute occlusions of the proximal PCA, i.e., in the P1 and P2 segment. The patient cohort in this retrospective study by Strambo et al ( 14 ) is similar to the present one in terms of patient numbers and demographic parameters. The initial symptom severity was equivalent, and there was a similar proportion of patients with premorbid disability, i.e., a mRS >2.…”

Section: Discussionsupporting

confidence: 63%

“…Imaging was primarily performed with computed tomography (CT) in 118 (91%) and CT angiography in 106 (81.5%) of the patients, while 32 (24.6%) had an MRI (21 patients had both consecutively, i.e., CT and MRI). Perfusion imaging with either MRI or CT was performed in 31 (23.8%) of the patients, and 23 (74%) of them had a visual mismatch, either on MRI ( 6 ) or on CT ( 14 ).…”

Section: Resultsmentioning

confidence: 99%

“…Especially in PCAO, this is a sophisticated approach since these features are proprietary to the PCA territory and underrecognized by the NIHSS and even more by the mRS at the same time. Importantly, Strambo et al observed better visual outcomes after EVT only ( 14 ). Unfortunately, the local databases that were accessed for our analysis were lacking these specific neurological outcome features, and hence, we were not able to reproduce the above finding.…”

Section: Discussionmentioning

confidence: 99%

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Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery

et al. 2021

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Introduction: Endovascular therapy (EVT) is established as first-line treatment for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation. For basilar artery occlusion, recent randomized clinical trials demonstrated not only equipoise but also advantages for EVT under particular circumstances. It remains unclear whether EVT offers an advantage over best medical management (BMM) including thrombolysis (IVT) in isolated occlusion of the proximal posterior cerebral artery (PCAO).Methods: Patients with AIS due to PCAO proven by CT or MR angiography were retrospectively identified from local databases at four comprehensive stroke centers in Germany, USA, and Taiwan between 2012 and 2020. Demographic and clinical data were collected, and imaging characteristics including pretherapeutic, interventional, and follow-up imaging were reviewed locally at each center. Patients were grouped according to therapy, i.e., BMM including IVT alone vs. BMM and EVT. Efficacy endpoints were early neurological improvement (ENI) after 24 h or at discharge, good outcome (modified Rankin scale 0–2) after 3 months, as well as hemorrhagic complications and in-house deaths as safety endpoints.Results: We included 130 patients of whom 23 (17.7%) received EVT. EVT patients had more proximal occlusions (69.9 vs. 43%, p = 0.023) and had a better premorbid function [premorbid mRS, 0 (0–4) vs. 1 (0–3), p < 0.01] when compared to BMM patients. IVT showed a trend toward being less performed in the EVT group (21.7 vs. 41.1%, p = 0.1), while other baseline parameters were balanced. Successful reperfusion was achieved in 52% of EVT patients. ENI was more frequent in the EVT group (61 vs. 35.5%, p = 0.034). Good outcome at 90 days and safety endpoints did not differ. In a bivariate analysis, ENI was independently predicted by the use of EVT (OR, 2.76; CI, 1.055–7.04) and the baseline National Institutes of Health Stroke Scale (NIHSS) (OR, 1.082; CI, 1.027–1.141 per point increase).Discussion: EVT in isolated PCAO appears safe and feasible. Positive effects on clinical outcome are primarily on ENI but also depend on the initial stroke severity. Further prospective or randomized studies are needed to better describe the potential long-term clinical benefits of EVT for PCAO as compared with best medical management.

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Section: Discussionsupporting

confidence: 63%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery

et al. 2021

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“…Ultimately, 4 studies met the inclusion criteria and were included in this review (Table 1). [18][19][20][21] Details of the study flow are illustrated in Fig. 1.…”

Section: Resultsmentioning

confidence: 99%

“…Only 3 studies reported a mortality rate at 90 days. [18][19][20] No difference in mortality at long-term follow-up was demonstrated in the meta-analysis of pooled data (Fig. 4), with low heterogeneity (OR 1.73, 95% CI 0.66-4.55; p = 0.263; I 2 = 0%).…”

Section: Clinical Outcomesmentioning

confidence: 92%

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Waqas

Kuo

Dossani

et al. 2021

Neurosurgical Focus

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OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

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Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke

et al. 2021

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IMPORTANCE Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse.OBJECTIVE To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice. DESIGN, SETTING, AND PARTICIPANTSThis multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching. INTERVENTIONS Mechanical thrombectomy or standard medical treatment with or without IVT.MAIN OUTCOMES AND MEASURES Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up. RESULTSOf 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was −2.4 points (95% CI, −3.2 to −1.6) in the standard medical treatment cohort and −3.9 points (95% CI, −5.4 to −2.5) in the mechanical thrombectomy cohort, with a mean difference of −1.5 points (95% CI, 3.2 to −0.8; P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, −5.6; 95% CI, −10.9 to −0.2; P = .04) and in the subgroup of patients without IVT (mean difference, −3.0; 95% CI, −5.0 to −0.9; P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort.CONCLUSIONS AND RELEVANCE This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.

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Thrombectomy and Thrombolysis of Isolated Posterior Cerebral Artery Occlusion

Cited by 85 publications

References 30 publications

Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery

Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke

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