Posterior Cerebral Artery Occlusion Research Articles

Derivation and Validation of a Scoring System for Predicting Poor Outcome After Posterior Circulation Ischemic Stroke in China.

Guidelines for posterior circulation ischemic stroke (PCIS) treatment are lacking and outcome prediction is crucial for patients and clinicians. We aimed to develop and validate a prognostic score to predict the poor outcome for patients with PCIS. The score was developed from a prospective derivation cohort named the Third China National Stroke Registry (August 2015-March 2018) and validated in a spatiotemporal independent validation cohort (December 2017-March 2023) in China. Patients with PCIS with acute infarctions defined as hyperintense lesions on diffusion-weighted imaging were included in this study. The poor outcome was measured as modified Rankin scale (mRS) score 3-6 at 3 months after PCIS. Multivariable logistic regression analysis was used to identify predictors for poor outcome. The prognostic score, namely PCIS Outcome Score (PCISOS), was developed by assigning points to variables based on their relative β-coefficients in the logistic model. The PCISOS was derived from 3,294 patients (median age 62 [interquartile range (IQR) 55-70] years; 2,250 [68.3%] men) and validated in 501 patients (median age 61 [IQR 53-68] years; 404 [80.6%] men). Among them, 384 (11.7%) and 64 (12.8%) had poor outcome 3 months after stroke in respective cohorts. Age, mRS before admission, NIH Stroke Scale on admission, ischemic stroke history, infarction distribution, basilar artery, and posterior cerebral artery stenosis or occlusion were identified as independent predictors for poor outcome and included in PCISOS. This easy-to-use integer scoring system identified a marked risk gradient between 4 risk groups. PCISOS performed better than previous scores, with an excellent discrimination (C statistic) of 0.80 (95% CI 0.77-0.83) in the derivation cohort and 0.81 (95% CI 0.77-0.84) in the validation cohort. Calibration test showed high agreement between the predicted and observed outcomes in both cohorts. PCISOS can be applied for patients with PCIS with acute infarctions to predict functional outcome at 3 months post-PCIS. This simple tool helps clinicians to identify patients with PCIS with higher risk of poor outcome and provides reliable outcome expectations for patients. This information might be used for personalized rehabilitation plan and patient selection for future clinical trials to reduce disability and mortality.

Endovascular therapy of isolated posterior cerebral artery occlusion stroke with and without general anesthesia

BackgroundThe optimal anesthetic strategy for endovascular therapy (EVT) in acute ischemic stroke is still under debate. The aim of this study was to compare the clinical outcomes of patients with...

Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke.

Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.

Endovascular thrombectomy for treatment of isolated posterior cerebral artery occlusion: a real-world analysis of hospitalizations in the United States.

Despite renewed interest and recently demonstrated efficacy for endovascular thrombectomy (EVT) for treatment of acute ischemic stroke (AIS) of the posterior circulation, to date, no randomized clinical trials have been conducted to evaluate EVT for isolated occlusions of the posterior cerebral artery (IPCA). Hospitalizations for adult patients with primary admission diagnoses of IPCA occlusion were identified in the National Inpatient Sample registry during the period of 2016-2020. The study exposure was treatment with EVT, and primary clinical endpoints included favorable functional outcome (defined as discharge disposition to home without services, previously shown to have high concordance with modified Rankin scale scores 0-2), in-hospital mortality, and any intracranial hemorrhage (ICH). Inverse probability of treatment weighting (IPTW) was performed to balance baseline clinical characteristics between those receiving EVT or medical management (MM). This analysis identified 34,880 IPCA occlusion hospitalizations, 730 (2.1%) of which documented treatment with EVT. Following IPTW adjustment, EVT was associated with favorable outcome in IPCA patients presenting with mild deficits (M-D) (NIHSS < 6) [adjusted odds ratio (aOR) 2.36, 95% confidence interval (CI) 2.27, 2.45; p < 0.001] and in those presenting with moderate-to-severe deficits (M-S-D) (NIHSS 6-42) (aOR 2.00, 95% CI 1.86, 2.15; p < 0.001). Mortality rates did not differ among those with M-S-D [EVT 4.8% vs. MM 4.7%, p = 0.742], while ICH rates were lower. Retrospective analysis of a large administrative registry in the Unites States demonstrates an association of EVT with favorable outcomes following IPCA occlusion, without concomitant risk of hemorrhagic transformation or mortality.

391 Intraarterial Verapamil for Neuroprotection in Ischemic Stroke

INTRODUCTION: Verapamil is an FDA-approved calcium channel blocker administered for the standard-of-care treatment of vasospasm. Preclinical studies have shown that verapamil reduces inflammation and protects penumbra neurons from further damage and eventual death. METHODS: Patients were recruited based on inclusion and exclusion criteria in a clinical protocol reviewed and approved by two institutional review boards. The final cohort comprised 42 emergency care patients with an acute onset focal neurological deficit consistent with ischemic stroke and/or a computed tomographic scan consistent with acute cerebral ischemia. All patients were 18 years of age or older that presented within 24 hours of symptom onset and had a significant but not severe neurological deficit, measured by a National Institutes of Health Stroke Scale (NIHSS) score greater than four but less than 22. All patients received a mechanical thrombectomy intervention after identifying a large vessel occlusion (LVO). RESULTS: The Verapamil-treated group (N = 23) included 22 patients with middle cerebral artery (MCA) occlusions and 1 with a basilar posterior cerebral artery (PCA) occlusion. In these patients, investigators administered 10 mg of Verapamil intraarterially following mechanical thrombectomy. Patients exposed to control conditions (N = 19) were matched for age, biological sex, admission NIHSS score, occlusion location, administration of tPA, and achieved TICI score. Intraarterial Verapamil treatment did not significantly increase sICH, hemorrhagic transformation, or death compared to standard of care treatment, demonstrating safety in an acute ischemic stroke patient population. Verapamil treatment was associated with significantly greater changes in mRS score, improved recovery time, and shortened length of hospital stay compared to standard-of-care treatment. CONCLUSIONS: This study suggests that verapamil is a safe and effective neuroprotective drug in ischemic stroke clinical populations that require mechanical thrombectomy for treatment.

Posterior Cerebral Artery–to–Superior Cerebellar Artery Side-to-Side Bypass via Extreme Lateral Supracerebellar Infratentorial Approach: Technical Note

Background and objectiveDifficult-to-treat aneurysms of the distal posterior cerebral artery (PCA) can often be treated by parent artery occlusion. A cerebrovascular bypass can complement PCA occlusion to curb the risk of ischemic complications.An in-situ bypass may be considered when the occipital artery or superficial temporal artery cannot serve as a bypass donor.This paper describes the use of a side-to-side bypass of superior cerebellar artery (SCA) as a donor to the posterior cerebral artery (PCA) via an extreme lateral supracerebellar infratentorial (ELSCIT) approach. This bypass approach can be a useful surgical strategy for PCA revascularization. MethodsA 40-year-old female patient underwent a side-to-side PCA-SCA bypass via the ELSCIT approach for the treatment of a complex and previously coiled PCA aneurysm.Bypass was followed by endovascular aneurysm and parent artery occlusion. ResultsPostoperatively, the patient experienced transient, partial trochlear nerve palsy of the left eye without ischemic lesions on MRI. The clinical condition was stable and angiography showed a patent bypass and complete aneurysm occlusion 12 months after surgery. ConclusionThe ELSCIT-approach offers access to the medial and distal PCA that is well suitable for a side-to-side PCA-SCA bypass. This type of approach and bypass may be of value when revascularization of a P2-P3 portion of the PCA is needed, but a suitable occipital artery (OA) or superficial temporal artery (STA) is not available.

Is Thrombectomy Worth It for Isolated Posterior Cerebral Artery Occlusion? Meta‐Analysis and Trial Sequential Analysis

Background Thrombectomy is well‐established management for acute ischemic stroke involving large vessel occlusion. However. the potential efficacy of thrombectomy for isolated posterior cerebral artery occlusion remains limited. The study aims to evaluate the benefits of thrombectomy for isolated posterior cerebral artery occlusion. Methods We searched PubMed, Cochrane, and Embase for articles published until September 2023. The primary outcome was good functional outcome at 3 months. The secondary outcomes included excellent functional outcome at 3 months and early neurological improvement. The safety outcomes were symptomatic intracerebral hemorrhage, and mortality at 3 months. Results Seven retrospective studies involving 2560 patients with isolated posterior cerebral artery occlusion were included (876 patients receiving thrombectomy). The odds ratio (OR) of good functional outcome at 3 months was 0.93 (95% CI, 0.68–1.28) between 2 groups. The OR of excellent functional outcome (OR 1.23; 95% CI 0.92–1.64) and early neurological improvement (OR 1.82; 95% CI 0.97–3.40) were not different between the 2 groups. Compared with patients with best medical management, those with thrombectomy demonstrated a significantly increased risk of mortality (OR 1.81; 95% CI 1.24–2.65), whereas the risk of symptomatic intracerebral hemorrhage (OR 2.033; 95% CI 0.996–4.148) did not show an increase. Additionally, the results of trial sequential analysis indicated all outcomes were inconclusive. Conclusion Thrombectomy stands as an available procedure for patients with isolated posterior cerebral artery occlusion; however, it shows no notable benefits in reducing symptomatic intracerebral hemorrhage risk or enhancing function and may raise mortality compared with standard medical management. Further randomized controlled trials are necessary to yield more conclusive evidence.

Abstract WP199: Outcomes Following Posterior Cerebral Artery Thrombolysis vs Medical Management in those with Atrial Fibrillation

Background: The benefits of endovascular thrombectomy (EVT) for posterior cerebral artery (PCA) occlusion remain controversial, but intravenous thrombolysis (IVT) has proven benefit across nearly all ischemic stroke types. We isolated a cohort of patients with likely embolic PCA occlusions (those with atrial fibrillation) and compared outcomes associated with IVT and EVT versus medical management (MM). Methods: The National Inpatient Sample (2015-2020) was retrospectively queried for patients with a primary diagnosis of a PCA occlusion (without a concomitant basilar occlusion, BAO) with a secondary diagnosis of atrial fibrillation. Descriptive statistics and propensity score matching for IVT with multivariable logistic regression were used to determine the odds of routine discharge, hospital length of stay, and death between those treated with IVT and EVT versus MM. Results: Of the 107,525 screened patients with a primary diagnosis of a PCA occlusion, 27730(25.7%) had a secondary diagnosis of atrial fibrillation, of whom 3010 underwent IVT. In a 1:1 matched cohort(n=3010 per group), patients treated with IVT had greater odds of discharge to home (adjusted OR 1.87,95% CI 1.22 to 2.87) with no difference in length of hospital stay (adjusted β 0.26, 95% -0.71 to 1.22) or in-hospital death (adjusted OR 0.81, 95% CI 0.27 to 2.47) as compared to patients treated with MM. These trends were preserved in a secondary analysis of unmatched patients in multi variable regression models, and no significant benefit of EVT for these outcomes (OR 1.75, 95%CI 0.62-4.93). Patterns were also similar when patients with a concomitant BAO were included (routine discharge adjusted OR for IVT: 1.57, 95% CI:1.03-2.38). Conclusion: Our findings show a potential real-world benefit for IVT in patients with a PCA occlusion secondary to presumed cardio embolism, but no significant advantage with EVT.

Abstract TP321: Real World Outcomes in Patients With a Posterior Cerebral Artery Occlusion With a Low NIHSS

Introduction: Observational studies have reported improved outcomes following endovascular treatment (EVT) for posterior cerebral artery (PCA) occlusions. Whether there is a benefit of EVT in patients with NIHSS &lt;6 is less well understood. Methods: The National Inpatient Sample (2015-2020) was retrospectively queried for patients with a primary PCA occlusion with a NIHSS &lt;6 and age&gt;17 without a concomitant basilar artery occlusion (BAO). A secondary analysis including patients with a BAO was also performed. Treatment with best medical management (BMM) versus endovascular therapy (EVT) was compared using propensity score matching. Results: In this time frame, 31,175 patients presented with a PCA occlusion as the primary diagnosis and had a NIHSS&lt;6. Of these patients, 8.8% of patients were treated with EVT. 31,050 patients did not have a concomitant BAO. In a propensity matched cohort of primary PCA and patients without a concomitant BAO, 2720 were treated with EVT and 2720 were treated with BMM. Patients treated with EVT had greater odds of routine discharge (adjusted OR 1.34, 95% CI 1.02 to 1.77, p=0.036) with no difference in length of hospital stay (adjusted β -0.35, 95% -0.83 to 0.13, p=0.15) or in-hospital death (adjusted OR 0.77, 95% CI 0.15 to 3.99, p=0.76) as compared to patients treated with BMM. Patterns were also similar when patients with a concomitant BAO were present (routine discharge adjusted OR: 1.67, 95% CI: 1.28-2.19, p&lt;0.001). Conclusions: Our findings suggest potential real-world benefit for EVT in patients with a PCA occlusion with a low NIHSS, irrespective of concomitant BAO.

Thrombectomy or medical management for isolated posterior cerebral artery occlusion: A systematic review and a meta-analysis

Thrombectomy or medical management for isolated posterior cerebral artery occlusion: A systematic review and a meta-analysis

First‐Line Stent Retriever Versus Contact Aspiration or Combined Technique for Endovascular Therapy of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study

Background The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. We compared clinical and technical outcomes with first‐line stent retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion. Methods This international case–control study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion presenting within 24 hours of time last seen well from January 2015 to August 2022. The primary outcome was the first‐pass effect (FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3 on the first pass. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression. Results There were 326 patients who met inclusion criteria, 56.1% male, median age 75 (interquartile range 65–82) years, and median National Institutes of Health Stroke Scale score 8 (5–12). Occlusion segments were PCA‐P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First‐line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. FPE was lower in patients treated with first‐line CA or combined technique compared with SR (CA versus SR: adjusted odds ratio 0.45 [0.19–1.06]; P =0.07; combined versus SR: adjusted odds ratio 0.35 [0.016–0.80]; P =0.01). There were lower odds of functional independence (modified Rankin scale score 0–2) in the first‐line CA versus SR alone group (adjusted odds ratio 0.52 [0.28–0.95]; P =0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0–2: 58% versus 43.4%; P =0.01; modified Rankin scale score 0–1: 36.6% versus 25.8%; P =0.05). Overall, symptomatic intracranial hemorrhage was present in 5.6% (18/326) and mortality in 10.9% (35/326) without difference between first‐line technique. Conclusion In patients with isolated PCA occlusion, SR was associated with a higher rate of FPE compared with CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90 days was more likely with first‐line SR compared with CA. FPE was associated with better 90‐day clinical outcomes.

Abstract 104: Fetal Posterior Cerebral Artery (PCA) Occlusion from Occluded Cavernous ICA Stent

Introduction Posterior Cerebral Artery (PCA) is a medium vessel occlusion (MVO) which is 5‐10% of all acute ischemic events. Safety and efficacy of mechanical thrombectomy in posterior circulation MVO is unclear compared to medical treatment only (1). There is concern that fragility of distal, smaller vessels may have an increased risk of procedural complications (e.g., arterial dissection and or perforations). More people are getting flow divertors over the years and rate of flow diverter of ICA occlusion is 0.05%‐0.08% (2). Here we present a case of embolic fetal PCA stroke with ICA stent occlusion. Methods We report a case of fetal origin posterior cerebral artery occlusion from ICA with literature search of Pubmed. Results 77 years old female with left cavernous‐ICA stent presented from a rehab facility with complaints of word finding difficulty, confusion, right hemiparesis, right sided neglect, and visual disturbance. In the emergency department (ED), her NIHSS was 28. ED presentation was 2.5 hrs after the last known well (LKW). Of note, patient had a with left cavernous‐ICA stent placement a month before the presentation and was noncompliant to antiplatelets. CT head was negative for intracranial bleeding and ASPECT score was 7. CT angiography head and neck was obtained, showing new complete interval occlusion of the intracranial extradural left ICA with reconstitution of distal branches through anterior communicating artery. Patient received IV thrombolytics, intubated for airway protection and was transferred to a comprehensive stroke center for possible mechanical thrombectomy. Time of the arrival was approximately 6 hours after the LKW, reexamination was hindered by the sedation and intubation but was concerning for possible PCA occlusion rather than ICA occlusion. As the localization of ischemic area was unclear, CT perfusion (CTP) was obtained. CTP showed 27 ml penumbra without core infarct in left PCA territory. As fetal origin of left PCA from ICA is occluded, without ability to access through occluded stent, noted risk of left ICA complications with attempts to recanalize stent for noted PCA hypoperfusion outweigh the benefits. With the exam improvement post thrombolytics administration and small penumbra, mechanical thrombectomy was not indicated. Conclusion In acute large vessel occlusion, utility of CT perfusion (CTP) usually recommended after 6 hours from last well known. In this case, patient presented within the 6 hours but the reexamination post thrombolytics was not localizing to suggest large vessel occlusion (LVO) and the territory at risk was unclear. We described a left intracranial ICA flow diversion occlusion without anterior circulation ischemia and left PCA ischemia demonstrated. In this case, CTP was employed to differentiate the territory at risk for triage to appropriate intervention, to differentiate the LVO vs MVO.

Abstract 012: First‐line Stent Retriever Versus Contact Aspiration or Combined Technique for Posterior Cerebral Artery Occlusion EVT

Introduction The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. Previous studies in LVO and MeVO have demonstrated a correlation between good clinical outcomes and the first pass effect (FPE, eTICI 2c/3 on the first pass) but no differences in FPE rates or clinical outcomes between first‐line endovascular therapy techniques.1‐6 We compared clinical and technical outcomes with first‐line stent‐retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion. Methods This international cohort study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion and pre‐stroke modified Rankin Scale (mRS) 0‐3, presenting within 24 hours of time last seen well from January 2015 to August 2022.7 The primary outcome was the first‐pass effect (FPE), defined as eTICI 2c/3 on the first pass. Secondary outcomes included final successful reperfusion (eTICI 2b‐3), 90‐day excellent outcome (mRS 0 to 1), 90‐day functional independence (mRS 0 to 2), sICH, and 90‐day mortality. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression. This study was registered under NCT05291637. Results There were 326 patients who met inclusion criteria, consisting of 56.1% male, median age 75 (IQR 65‐82) years and median NIHSS 8 (5‐12). Occlusion segments were PCA P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First‐line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. Compared to SR, FPE was lower in patients treated with first‐line combined technique and similar in patients treated with first‐line CA (combined vs. SR: aOR 0.35 [0.016‐0.80], p=0.01; CA vs. SR: aOR 0.45 [0.19‐1.06], p=0.07). Final successful reperfusion (eTICI 2b‐3) was present in 81% of cases with no differences between treatment groups. Excellent outcome (mRS 0‐1) occurred in 30.7% of patients and functional independence (mRS 0‐2) occurred in 50.0% of patients. There were lower odds of functional independence in the first‐line CA versus SR alone group (aOR 0.52 [0.28‐0.95], p=0.04). FPE was associated with higher rates of favorable outcomes (mRS 0‐2: 58% vs. 43.4%, p=0.01; mRS 0‐1: 36.6% vs. 25.8%, p=0.05). sICH was observed in 5.6% (18/326) and mortality in 10.9% (35/326) with no differences between first‐line technique. Conclusion In patients with isolated PCA occlusion undergoing EVT, first line SR was associated with a higher rate of FPE compared to CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90‐days was more likely with first‐line SR compared to CA in adjusted analyses. FPE was associated with higher rates of 90‐day excellent outcomes and functional independence. No difference in sICH or mortality was noted across the three techniques. As the endovascular field evolves to treat patients with distal vessel occlusion and milder severity of stroke, optimizing the efficacy and safety of the procedure is essential.8

Abstract 089: A Case of Complicated Dissection: Vertebral Artery Sacrifice for Recurrent Stroke Prevention

Introduction Posterior circulation strokes account for 20% of ischemic strokes (1). Optimal management for posterior circulation strokes has been studied less than for anterior circulation strokes (2). Endovascular parent vessel sacrifice is an established technique used to treat vascular pathologies. There is limited evidence for parent artery sacrifice for recurrent strokes and there is no current guideline for standard of care. Methods '‐ Results 51‐year‐old gentleman with history of tobacco use presented with left homonymous hemianopsia, onset 1.5 hours prior to arrival. CT brain showed no bleed and patient received IV tissue‐plasminogen activator (tPA). CT angiography (CTA) demonstrated occlusion of the right posterior cerebral artery (PCA) and dissection of the left vertebral artery (V2 segment) with distal reconstitution. He underwent emergent thrombectomy for right P2 thrombus with complete reperfusion TICI 3 (Thrombolysis in Cerebral Infarction Score). Less than 24 hours later, he developed a right homonymous hemianopsia, and was found to have a new occlusion of the left P1 segment of the left PCA. Emergent thrombectomy was performed with complete reperfusion (TICI3). MRI brain demonstrated bilateral PCA territory infarcts. Within 12 hours of the second thrombectomy, his neurological exam deteriorated, and interval imaging revealed a basilar trunk thrombus, for which he underwent a successful endovascular thrombectomy complete reperfusion (TICI3). His antiplatelet regimen was optimized with Aspirin. Heparin was considered as treatment but was not provided because of the hemorrhagic conversion of his ischemic strokes. Given the persistent recurrence of thromboemboli in the posterior circulation despite being on optimal medical management, and evidence of hemorrhagic conversion, a decision was made to perform endovascular coil embolization of the left vertebral artery V2 segment at the site of dissection. Angiographic imaging demonstrated antegrade blood flow through the dissection as the source of recurrent embolic strokes. Six Stryker Target coils were deployed spanning the region of dissection within the left V2 segment via a right radial access with the guide catheter in the right vertebral artery. Post coil embolization angiographic runs demonstrated complete occlusion of the left vertebral V2 segment at the region of dissection which was confirmed via a left vertebral injection from a left femoral arterial access. There was preservation of ascending cervical collaterals beyond the dissection with patency of the contralateral vertebral artery supplying the intracranial circulation. Following embolization, repeat imaging showed no new infarcts and no new or worsening hemorrhage. He was continued on Aspirin monotherapy. It is notable that though his neurological exam deteriorated during each recurrent thromboembolic event, his neurologic exam at the time of discharge significantly improved with NIHSS of 3. He is currently being followed at our neuroscience institute. Conclusion Cervical arterial dissections pose increased risk for ischemic strokes (3). Vertebral artery dissection accounts for approximately 2%, of which, 10‐25% occur in middle‐aged and younger patients (4). This is a case of a young patient that exemplifies a successful role for vertebral artery sacrifice with coil embolization to prevent recurrent thromboembolic posterior circulation strokes. However controlled studies are needed for safety and efficacy of these interventions.

Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis.

Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO. We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model. Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29). In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.

April 2023 Stroke Highlights.

April 2023 Stroke Highlights.

Abstract WMP90: Is Endovascular Thrombectomy More Effective Than IV-tPA For Distal Vessel Occlusions? Propensity Score-matched Analysis From K-net Registry

Background and Purpose: The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke due to primary distal vessel occlusions is unclear. We assessed whether outcome of acute ischemic stroke patients treated with EVT for primary distal vessel occlusions was better than intravenous tissue-type plasminogen activator (IV-tPA) alone. Materials and Methods: We investigated data from K-NET Registry, which is a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV t-PA in Kanagawa, Japan. We evaluated the patients who had primally distal vessel occlusion and were treated with EVT (with or without IV-tPA) or IV tPA alone. Distal vessel occlusion was defined as middle cerebral artery M2-M3, anterior cerebral artery or posterior cerebral artery occlusion. Propensity score-matched analysis was conducted to compare outcomes between EVT and IV-tPA alone. Primary outcome was good outcome at 90 days, defined as mRS of 0 to 2 or not worsening compared to pre-stroke mRS. Safety outcome was the occurrence of all hemorrhage and symptomatic hemorrhage. Results: 703 patients with distal vessel occlusion (MCA M2, 436 cases, M3, 167 cases, ACA 48 cases, PCA 52 cases) were included in this study. 461 cases were treated with EVT and 242 were IV-tPA alone. Propensity-score matching paired 110 patients with EVT and 110 patients with IV-tPA. There were no significant differences in good clinical outcome (EVT 65.4%, IV-tAP 60.0%), all hemorrhage (EVT 15.4%, IV-tAP 11.8%) and symptomatic hemorrhage (EVT 4.5%, IV-tAP 1.8%). Dividing EVT group into EVT with IV-tPA and EVT alone, there were no significant differences in outcomes compared to IV-tPA alone. Conclusions: The benefit of EVT for acute primary distal vessel occlusions was similar as IV-tPA alone. Although IV-tPA is a first line treatment for primary distal vessel occlusions, EVT is a feasible treatment for patients who have contraindication to IV-tPA.

Abstract 89: Mechanical Thrombectomy Or Medical Management Alone For Isolated Posterior Cerebral Artery Occlusion. An International Multicentric Observational Study.

Introduction: Whether endovascular therapy (EVT) added on best medical management (BMM, including intravenous thrombolysis [IVT] if indicated), as compared to BMM alone, is beneficial in acute ischemic stroke (AIS) with isolated posterior cerebral artery occlusion is unknown. Methods: We conducted a multicenter international observational study of consecutive AIS patients admitted within 6hrs from last seen well in 26 stroke centers in France, Switzerland and USA with isolated proximal posterior cerebral artery strokes (P1 or P2 occlusions) and treated either with EVT+BMM or BMM alone. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month good functional outcome (modified Rankin score [mRS] 0-2). Secondary outcomes were excellent functional outcome (mRS 0-1) and symptomatic intracranial hemorrhage (sICH) at 24hrs. We searched for an interaction between treatment group and (1) occlusion site (P1 vs . P2), (2) NIHSS score (&lt;10 vs. ≥10), and (3) IVT use. Results: Overall, 810 AIS patients were included (180 and 630 in the EVT+BMM and BMM alone groups, respectively). Median age was 74yo (IQR 63-83), 352 (44%) were female, median NIHSS was 6 (IQR 4-10), 594 (73%) received IVT, and occlusion site was P1 in 205 (25%) and P2 in 605 (75%) patients. Baseline clinical and radiological data were similar between the 2 groups following propensity-score weighting. EVT was not associated with good (adjusted OR=0.86; 95%CI: 0.67-1.09; P =0.21) or excellent (adjusted OR=1.10; 95%CI: 0.87-1.39; P =0.42) functional outcome but was associated with higher risk of sICH (OR=2.71; 95%CI: 1.41-5.21; P =0.003). No interaction was found between EVT effect and (1) NIHSS score, (2) occlusion site, or (3) IVT use for either outcome. Conclusion: In our population of AIS patients with isolated P1 or P2 occlusion, EVT was not associated with higher rates of good or excellent functional outcome as compared to BMM alone. However, EVT was associated with higher rates of sICH. Randomized trials are warranted.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.