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Strambo D, Michel P, Nguyen TN, Abdalkader M, Qureshi MM, Strbian D, Herweh C, Möhlenbruch MA, Räty S, Olivé-Gadea M, Ribo M, Psychogios M, Fischer U, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Kühne Escolà J, Demeestere J, Lemmens R, Vandewalle L, Yaghi S, Shu L, Puetz V, Kaiser DP, Kaesmacher J, Mujanovic A, Marterstock DC, Engelhorn T, Requena M, Dasenbrock HH, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Souza Viana L, Cunha B, Fragata I, Romoli M, Diana F, Hu W, Zhang C, Virtanen P, Lauha R, Jesser J, Clark J, Matsoukas S, Fifi JT, Sheth SA, Salazar-Marioni S, Marto JP, Ramos JN, Miszczuk M, Riegler C, Poli S, Poli K, Jadhav AP, Desai SM, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Masoud HE, Suryadareva N, Mokin M, Thanki S, Alpay K, Ylikotila P, Siegler JE, Linfante I, Dabus G, Asdaghi N, Saini V, Nolte CH, Siebert E, Serrallach BL, Weyland CS, Hanning U, Meyer L, Berberich A, Ringleb PA, Nogueira RG, Nagel S. Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site. Stroke 2024; 55:1787-1797. [PMID: 38753954 PMCID: PMC11198954 DOI: 10.1161/strokeaha.124.047383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Acute ischemic stroke with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO acute ischemic stroke is modified by initial stroke severity (baseline National Institutes of Health Stroke Scale [NIHSS]) and arterial occlusion site. METHODS Based on the multicenter, retrospective, case-control study of consecutive iPCAO acute ischemic stroke patients (PLATO study [Posterior Cerebral Artery Occlusion Stroke]), we assessed the heterogeneity of EVT outcomes compared with medical management (MM) for iPCAO, according to baseline NIHSS score (≤6 versus >6) and occlusion site (P1 versus P2), using multivariable regression modeling with interaction terms. The primary outcome was the favorable shift of 3-month modified Rankin Scale (mRS). Secondary outcomes included excellent outcome (mRS score 0-1), functional independence (mRS score 0-2), symptomatic intracranial hemorrhage, and mortality. RESULTS From 1344 patients assessed for eligibility, 1059 were included (median age, 74 years; 43.7% women; 41.3% had intravenous thrombolysis): 364 receiving EVT and 695 receiving MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (Pinteraction=0.312) but did with functional independence (Pinteraction=0.010), with a similar trend on excellent outcome (Pinteraction=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS score >6 (mRS score 0-1, 30.6% versus 17.7%; adjusted odds ratio [aOR], 2.01 [95% CI, 1.22-3.31]; mRS score 0 to 2, 46.1% versus 31.9%; aOR, 1.64 [95% CI, 1.08-2.51]) but not in those with NIHSS score ≤6 (mRS score 0-1, 43.8% versus 46.3%; aOR, 0.90 [95% CI, 0.49-1.64]; mRS score 0-2, 65.3% versus 74.3%; aOR, 0.55 [95% CI, 0.30-1.0]). EVT was associated with more symptomatic intracranial hemorrhage regardless of baseline NIHSS score (Pinteraction=0.467), while the mortality increase was more pronounced in patients with NIHSS score ≤6 (Pinteraction=0.044; NIHSS score ≤6: aOR, 7.95 [95% CI, 3.11-20.28]; NIHSS score >6: aOR, 1.98 [95% CI, 1.08-3.65]). Arterial occlusion site did not modify the association of EVT with outcomes compared with MM. CONCLUSIONS Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS score >6) had more favorable disability outcomes with EVT than MM, despite increased mortality and symptomatic intracranial hemorrhage.
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Affiliation(s)
- Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Thanh N. Nguyen
- Neurology (T.N.N., J.C.), Boston Medical Center, MA
- Radiology (T.N.N., M.A., M.M.Q., P.K., H.D.), Boston Medical Center, MA
| | | | - Muhammad M. Qureshi
- Radiology (T.N.N., M.A., M.M.Q., P.K., H.D.), Boston Medical Center, MA
- Radiation Oncology (M.M.Q.), Boston Medical Center, MA
| | - Daniel Strbian
- Neurology (D. Strbian, S.R.), Helsinki University Hospital, University of Helsinki, Finland
| | - Christian Herweh
- Neuroradiology (C.H., M.A.M., J.J.), Heidelberg University Hospital, Germany
| | | | - Silja Räty
- Neurology (D. Strbian, S.R.), Helsinki University Hospital, University of Helsinki, Finland
| | - Marta Olivé-Gadea
- Neurology, Hospital Universitario Vall d’Hebron, Barcelona, Spain (M.O.-G., M. Ribo, M. Requena)
| | - Marc Ribo
- Neurology, Hospital Universitario Vall d’Hebron, Barcelona, Spain (M.O.-G., M. Ribo, M. Requena)
| | - Marios Psychogios
- Radiology, Basel University Hospital, University of Basel, Switzerland (M.P., A.N.)
| | - Urs Fischer
- Department of Neurology, University Hospital and University of Bern, Switzerland (U.F.)
- Department of Neurology, University Hospital and University of Basel, Switzerland (U.F.)
| | - Anh Nguyen
- Radiology, Basel University Hospital, University of Basel, Switzerland (M.P., A.N.)
| | | | - David Haupenthal
- Neurology (J.B.K, D.H.), University of Erlangen-Nuremberg, Germany
| | - Martin Köhrmann
- Neurology, Institute of Diagnostic and Interventional Radiology (M. Köhrmann, J.K.E.), University Hospital Essen, Germany
| | | | - Jordi Kühne Escolà
- Neurology, Institute of Diagnostic and Interventional Radiology (M. Köhrmann, J.K.E.), University Hospital Essen, Germany
| | - Jelle Demeestere
- Neurology, UZ Leuven, Belgium (J.D., R. Lemmens, L.V.)
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R. Lemmens, L.V.)
| | - Robin Lemmens
- Neurology, UZ Leuven, Belgium (J.D., R. Lemmens, L.V.)
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R. Lemmens, L.V.)
| | - Lieselotte Vandewalle
- Neurology, UZ Leuven, Belgium (J.D., R. Lemmens, L.V.)
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R. Lemmens, L.V.)
| | - Shadi Yaghi
- Neurology, Rhode Island Hospital (S.Y., L.S.)
| | - Liqi Shu
- Neurology, Rhode Island Hospital (S.Y., L.S.)
| | - Volker Puetz
- Neurology (V.P.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden University Stroke Center (V.P., D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Daniel P.O. Kaiser
- Neuroradiology (D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden University Stroke Center (V.P., D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J.K., A. Mujanovic, B.S.)
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J.K., A. Mujanovic, B.S.)
| | | | - Tobias Engelhorn
- Neuroradiology (D.C.M., T.E.), University of Erlangen-Nuremberg, Germany
| | - Manuel Requena
- Neuroradiology (D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Piers Klein
- Radiology (T.N.N., M.A., M.M.Q., P.K., H.D.), Boston Medical Center, MA
| | - Diogo C. Haussen
- Neurology, Grady Memorial Hospital (D.C.H., M.H.M., H.A., L.S.V.)
| | | | - Hend Abdelhamid
- Neurology, Grady Memorial Hospital (D.C.H., M.H.M., H.A., L.S.V.)
| | | | - Bruno Cunha
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
- NOVA Medical School, Universidade Nova de Lisboa, Portugal (I.F.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli)
| | - Francesco Diana
- Neuroradiology, University Hospital ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno, Italy (F.D.)
| | - Wei Hu
- Neurology, The First Affiliated Hospital of USTC, Hefei, China (W.H., C.Z.)
| | - Chao Zhang
- Neurology, The First Affiliated Hospital of USTC, Hefei, China (W.H., C.Z.)
| | - Pekka Virtanen
- Radiology (P.V., R. Lauha, K.L.), Helsinki University Hospital, University of Helsinki, Finland
| | - Riikka Lauha
- Radiology (P.V., R. Lauha, K.L.), Helsinki University Hospital, University of Helsinki, Finland
| | - Jessica Jesser
- Neuroradiology (C.H., M.A.M., J.J.), Heidelberg University Hospital, Germany
| | - Judith Clark
- Neurology (T.N.N., J.C.), Boston Medical Center, MA
| | | | | | - Sunil A. Sheth
- Neurology, McGovern Medical School at UTHealth, TX (S.A.S., S.S.-M.)
| | | | - João Pedro Marto
- Neurology (J.P.M.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal
| | - João Nuno Ramos
- Neuroradiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal
| | - Milena Miszczuk
- Neuroradiology (M. Miszczuk, E.S.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Christoph Riegler
- Departement of Neurology and Experimental Neurology, and Center for Stroke Research Berlin (C.R., C.H.N.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Sven Poli
- Department of Neurology and Stroke (S.P., K.P.), University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research (S.P., K.P.), University of Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology and Stroke (S.P., K.P.), University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research (S.P., K.P.), University of Tübingen, Germany
| | - Ashutosh P. Jadhav
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Shashvat M. Desai
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Volker Maus
- Radiology, Neuroradiology, and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M.K.)
- Institute of Radiology and Neuroradiology, Klinikum Aschaffenburg, Germany (V.M.)
| | - Maximilian Kaeder
- Radiology, Neuroradiology, and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M.K.)
| | - Adnan H. Siddiqui
- Radiology (T.N.N., M.A., M.M.Q., P.K., H.D.), Boston Medical Center, MA
| | - Andre Monteiro
- Neurosurgery, University of Buffalo, NY (A.H.S., A. Monteiro)
| | | | - Neil Suryadareva
- Neurology, University of Pittsburgh Medical Center, PA (N.S., R.G.N.)
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - Shail Thanki
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - Kemal Alpay
- Radiology (K.A.), Turku University Hospital, Finland
| | | | | | | | | | - Negar Asdaghi
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Vasu Saini
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Christian H. Nolte
- Departement of Neurology and Experimental Neurology, and Center for Stroke Research Berlin (C.R., C.H.N.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Eberhard Siebert
- Neuroradiology (M. Miszczuk, E.S.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Bettina L. Serrallach
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J.K., A. Mujanovic, B.S.)
| | | | - Uta Hanning
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | | | - Peter A. Ringleb
- Neurology (P.A.R., S.N.), Heidelberg University Hospital, Germany
| | - Raul G. Nogueira
- Neurology, University of Pittsburgh Medical Center, PA (N.S., R.G.N.)
| | - Simon Nagel
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Switzerland (D. Strambo, P.M.)
- Neurology (T.N.N., J.C.), Boston Medical Center, MA
- Radiology (T.N.N., M.A., M.M.Q., P.K., H.D.), Boston Medical Center, MA
- Radiation Oncology (M.M.Q.), Boston Medical Center, MA
- Neurology (D. Strbian, S.R.), Helsinki University Hospital, University of Helsinki, Finland
- Radiology (P.V., R. Lauha, K.L.), Helsinki University Hospital, University of Helsinki, Finland
- Neuroradiology (C.H., M.A.M., J.J.), Heidelberg University Hospital, Germany
- Neurology (P.A.R., S.N.), Heidelberg University Hospital, Germany
- Neurology, Hospital Universitario Vall d’Hebron, Barcelona, Spain (M.O.-G., M. Ribo, M. Requena)
- Radiology, Basel University Hospital, University of Basel, Switzerland (M.P., A.N.)
- Neurology (J.B.K, D.H.), University of Erlangen-Nuremberg, Germany
- Neuroradiology (D.C.M., T.E.), University of Erlangen-Nuremberg, Germany
- Neurology, Institute of Diagnostic and Interventional Radiology (M. Köhrmann, J.K.E.), University Hospital Essen, Germany
- Neuroradiology (C.D.), University Hospital Essen, Germany
- Neurology, UZ Leuven, Belgium (J.D., R. Lemmens, L.V.)
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., R. Lemmens, L.V.)
- Neurology, Rhode Island Hospital (S.Y., L.S.)
- Neurology (V.P.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Neuroradiology (D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden University Stroke Center (V.P., D.P.O.K.), University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J.K., A. Mujanovic, B.S.)
- Neurology, Grady Memorial Hospital (D.C.H., M.H.M., H.A., L.S.V.)
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
- NOVA Medical School, Universidade Nova de Lisboa, Portugal (I.F.)
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli)
- Neuroradiology, University Hospital ‘San Giovanni di Dio e Ruggi d’Aragona’, Salerno, Italy (F.D.)
- Neurology, The First Affiliated Hospital of USTC, Hefei, China (W.H., C.Z.)
- Neurosurgery, Mount Sinai Health System (S.M., J.T.F.)
- Neurology, McGovern Medical School at UTHealth, TX (S.A.S., S.S.-M.)
- Neurology (J.P.M.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal
- Neuroradiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal
- Neuroradiology (M. Miszczuk, E.S.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
- Departement of Neurology and Experimental Neurology, and Center for Stroke Research Berlin (C.R., C.H.N.), Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
- Department of Neurology and Stroke (S.P., K.P.), University of Tübingen, Germany
- Hertie Institute for Clinical Brain Research (S.P., K.P.), University of Tübingen, Germany
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
- Radiology, Neuroradiology, and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M.K.)
- Institute of Radiology and Neuroradiology, Klinikum Aschaffenburg, Germany (V.M.)
- Neurosurgery, University of Buffalo, NY (A.H.S., A. Monteiro)
- Neurology, New York Upstate Medical University (H.E.M.)
- Neurology, University of Pittsburgh Medical Center, PA (N.S., R.G.N.)
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
- Radiology (K.A.), Turku University Hospital, Finland
- Neurology (P.Y.), Turku University Hospital, Finland
- Neurology, University of Chicago, IL (J.E.S.)
- Miami Neuroscience Institute, FL (I.L., G.D.)
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
- Department of Neurology, University Hospital and University of Bern, Switzerland (U.F.)
- Department of Neurology, University Hospital and University of Basel, Switzerland (U.F.)
- Neuroradiology, University Hospital RWTH Aachen, Germany (C.S.W.)
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
- Neurology, Klinikum Ludwigshafen, Germany (A.B., S.N.)
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Chowdhury A, Killingsworth MC, Calic Z, Bhaskar SM. Meta-analysis of clinical and safety profiles after reperfusion therapy in acute posterior circulation strokes: insights and implications. Acta Radiol 2024:2841851241255313. [PMID: 38839085 DOI: 10.1177/02841851241255313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Posterior circulation stroke (PCS) accounts for approximately 20% of all acute ischemic strokes. The optimal reperfusion therapy for PCS management remains uncertain. PURPOSE To evaluate the prevalence and outcomes of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and bridging therapy in PCS patients. MATERIAL AND METHODS We conducted a meta-analysis of 19 studies examining reperfusion therapy outcomes in PCS patients, including 9765 individuals. We pooled prevalence data and assessed associations between reperfusion therapies and clinical, safety, and recanalization outcomes using random-effects models. RESULTS The pooled prevalence of reperfusion therapies post-acute PCS was 39% for IVT, 54% for EVT, and 48% for bridging therapy. EVT was associated with significantly higher odds of favorable functional outcomes (modified Rankin Score [mRS] 0-3) at 90 days compared to standard medical therapy (odds ratio [OR] = 5.68; 95% confidence interval [CI]=2.07-15.59; P = 0.001). Conversely, bridging therapy was linked to reduced odds of favorable functional outcomes at 90 days compared to EVT (OR = 0.35; 95% CI=0.26-0.47; P < 0.001). Bridging therapy was also significantly associated with lower odds of good functional outcomes (mRS 0-2) (OR = 0.25; 95% CI=0.11-0.54; P < 0.001), reduced risk of symptomatic intracranial hemorrhage (OR = 0.26; 95% CI=0.07-0.68; P = 0.009), lower mortality (OR = 0.13; 95% CI=0.04-0.44; P = 0.001), and less successful recanalization (OR = 0.35; 95% CI=0.13-0.94; P = 0.038) relative to EVT. CONCLUSION Our meta-analysis underscores the favorable outcomes associated with EVT in PCS cases. With notable reperfusion rates, understanding factors influencing PCS outcomes can inform patient selection and prognostic considerations.
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Affiliation(s)
- Ashek Chowdhury
- Global Health Neurology Lab, Sydney, NSW, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Murray C Killingsworth
- Global Health Neurology Lab, Sydney, NSW, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Cell-Based Disease Intervention Group, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- NSW Health Pathology, NSW Brain Clot Bank, Sydney, NSW, Australia
- Department of Anatomical Pathology, NSW Health Pathology; Cell-Based Disease Intervention Research Group, Ingham Institute for Applied Medical Research and Liverpool Hospital, Liverpool, NSW, Australia
| | - Zeljka Calic
- Global Health Neurology Lab, Sydney, NSW, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Cell-Based Disease Intervention Group, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- NSW Health Pathology, NSW Brain Clot Bank, Sydney, NSW, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District, Sydney, NSW, Australia
| | - Sonu Mm Bhaskar
- Global Health Neurology Lab, Sydney, NSW, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW, Australia
- Cell-Based Disease Intervention Group, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- NSW Health Pathology, NSW Brain Clot Bank, Sydney, NSW, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District, Sydney, NSW, Australia
- Department of Neurology, Division of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita, Osaka, Japan
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Oliveira M, Barros P, Rodrigues M, Ribeiro M, Afreixo V, Gregório T. Endovascular therapy for posterior cerebral artery occlusion: systematic review with meta-analysis. Intern Emerg Med 2024; 19:1143-1150. [PMID: 38600317 DOI: 10.1007/s11739-024-03581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/07/2024] [Indexed: 04/12/2024]
Abstract
Endovascular therapy (EVT) is a highly effective stroke treatment, but trials validating this intervention did not include patients with posterior cerebral artery (PCA) occlusion. The aim of this systematic review with meta-analysis was to assess the efficacy and safety of EVT for acute PCA occlusion. PubMed, Scopus, ISI, and CENTRAL were searched for studies assessing EVT in adult patients with PCA occlusion. Outcomes of interest were recanalization, symptomatic intracerebral haemorrhage (sICH), mortality, functional independence, and excellent functional outcome at 90 days. Frequencies and odds ratios (ORs) were pooled using random effect models and heterogeneity was measured using the I2 statistic and explored by means of meta-regression. Fifteen studies were included, all observational. Recanalization rates were high [81%, 95% CI (73-88%)] and sICH rates low [2%, 95% CI (1-4%)]. Heterogeneity was high for recanalization (I2 = 80%) but not for sICH, and not accounted for by any of the moderators tested. Compared to best medical treatment, EVT was associated with higher chances of sICH [OR = 2.04, 95% CI (1.12-3.71)] and no effect in functional independence [OR = 0.98, 95% CI (0.63-1.54)], with a tendency to higher chances of excellent functional outcome [OR = 1.29, 95% CI (0.90-1.86)] and mortality [OR = 1.56, 95% CI (0.84-2.90)]. EVT for acute PCA occlusion is technically feasible but associated with higher chance of sICH. There is no evidence to support this treatment to achieve higher rates of functional independence, but other gains that can impact patients' quality of life cannot be excluded. More studies are required with robust design, better patient selection, and comprehensive outcome evaluation.
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Affiliation(s)
- Marta Oliveira
- Department of Internal Medicine, Hospital CUF Porto, Estr. da Circunvalação 14341, 4100-180, Porto, Portugal.
| | - Pedro Barros
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Marta Rodrigues
- Cerebrovascular Interventional Neuroradiology Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Manuel Ribeiro
- Cerebrovascular Interventional Neuroradiology Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Vera Afreixo
- Center for Research and Development in Mathematics and Applications, University of Aveiro. Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
| | - Tiago Gregório
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
- CINTESIS, University of Porto. R. Dr. Plácido Costa, 4200-450, Porto, Portugal
- MEDCIDS, University of Porto. R. Dr. Plácido Costa, 4200-450, Porto, Portugal
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Chen H, Khunte M, Colasurdo M, Malhotra A, Gandhi D. Thrombectomy vs Medical Management for Posterior Cerebral Artery Stroke: Systematic Review, Meta-Analysis, and Real-World Data. Neurology 2024; 102:e209315. [PMID: 38626383 PMCID: PMC11175628 DOI: 10.1212/wnl.0000000000209315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/07/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There is a paucity of high-level evidence for endovascular thrombectomy (EVT) in posterior cerebral artery (PCA) strokes. METHODS The MEDLINE, Embase, and Web of Science databases were queried for well-conducted cohort studies comparing EVT vs medical management (MM) for PCA strokes. Outcomes of interest included 90-day functional outcomes, symptomatic intracranial hemorrhage (sICH), and death. The level of evidence was determined per the Oxford Centre for Evidence-Based Medicine criteria. We also conducted a propensity score matched (PSM) analysis of the 2016-2020 National Inpatient Sample (NIS) to provide support for our findings with real-world data. RESULTS A total of 2,095 patients (685 EVT and 1,410 MM) were identified across 5 well-conducted cohort studies. EVT was significantly associated with higher odds of no disability at 90 days (odds ratio [OR] 1.25, 95% CI 1.04-1.50, p = 0.015) but not functional independence (OR 0.87, 95% CI 0.72-1.07, p = 0.18). EVT was also associated with higher odds of sICH (OR 2.48, 95% CI 1.55-3.97, p < 0.001) and numerically higher odds of death (OR 1.32, 95% CI 0.73-2.38; p = 0.35). PSM analysis of 95,585 PCA stroke patients in the NIS showed that EVT (n = 1,540) was associated with lower rates of good discharge outcomes (24.4% vs 30.7%, p = 0.037), higher rates of in-hospital mortality (8.8% vs 4.9%, p = 0.021), higher rates of ICH (18.2% and 11.7%, p = 0.008), and higher rates of subarachnoid hemorrhage (3.9% vs 0.6%, p < 0.001). Among patients with moderate to severe strokes (NIH Stroke Scale 5 or greater), EVT was associated with significantly higher rates of good outcomes (21.7% vs 13.8%, p = 0.023) with similar rates of mortality (7.6% vs 6.6%, p = 0.67) and ICH (17.8% vs, 13.1%, p = 0.18). DISCUSSION Our meta-analysis revealed that while EVT may be effective in alleviating disabling deficits due to PCA strokes, it is not associated with different odds of functional independence and may be associated with higher odds of sICH. These findings were corroborated by our large propensity score matched analysis of real-world data in the United States. Thus, the decision to pursue PCA thrombectomies should be carefully individualized for each patient. Future randomized trials are needed to further explore the efficacy and safety of EVT for the treatment of PCA strokes. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in patients with acute PCA ischemic stroke, treatment with EVT compared with MM alone was associated with higher odds of no disabling deficit at 90 days and higher odds of sICH.
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Affiliation(s)
- Huanwen Chen
- From the National Institute of Neurological Disorders and Stroke (H.C.), NIH, Bethesda, MD; Warren Alpert Medical School of Brown University (M.K.), Providence, RI; Department of Radiology (M.C.), University of Maryland Medical Center, Baltimore; Department of Radiology (A.M.), Yale New Haven Hospital, CT; and Departments of Radiology, Neurology, and Neurosurgery (D.G.), University of Maryland Medical Center, Baltimore
| | - Mihir Khunte
- From the National Institute of Neurological Disorders and Stroke (H.C.), NIH, Bethesda, MD; Warren Alpert Medical School of Brown University (M.K.), Providence, RI; Department of Radiology (M.C.), University of Maryland Medical Center, Baltimore; Department of Radiology (A.M.), Yale New Haven Hospital, CT; and Departments of Radiology, Neurology, and Neurosurgery (D.G.), University of Maryland Medical Center, Baltimore
| | - Marco Colasurdo
- From the National Institute of Neurological Disorders and Stroke (H.C.), NIH, Bethesda, MD; Warren Alpert Medical School of Brown University (M.K.), Providence, RI; Department of Radiology (M.C.), University of Maryland Medical Center, Baltimore; Department of Radiology (A.M.), Yale New Haven Hospital, CT; and Departments of Radiology, Neurology, and Neurosurgery (D.G.), University of Maryland Medical Center, Baltimore
| | - Ajay Malhotra
- From the National Institute of Neurological Disorders and Stroke (H.C.), NIH, Bethesda, MD; Warren Alpert Medical School of Brown University (M.K.), Providence, RI; Department of Radiology (M.C.), University of Maryland Medical Center, Baltimore; Department of Radiology (A.M.), Yale New Haven Hospital, CT; and Departments of Radiology, Neurology, and Neurosurgery (D.G.), University of Maryland Medical Center, Baltimore
| | - Dheeraj Gandhi
- From the National Institute of Neurological Disorders and Stroke (H.C.), NIH, Bethesda, MD; Warren Alpert Medical School of Brown University (M.K.), Providence, RI; Department of Radiology (M.C.), University of Maryland Medical Center, Baltimore; Department of Radiology (A.M.), Yale New Haven Hospital, CT; and Departments of Radiology, Neurology, and Neurosurgery (D.G.), University of Maryland Medical Center, Baltimore
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Räty S, Nguyen TN, Nagel S, Strambo D, Michel P, Herweh C, Qureshi MM, Abdalkader M, Virtanen P, Olive-Gadea M, Ribo M, Psychogios M, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Escolà JK, Demeestere J, Lemmens R, Vandewalle L, Yaghi S, Shu L, Puetz V, Kaiser DP, Kaesmacher J, Mujanovic A, Marterstoc DC, Engelhorn T, Berberich A, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Fragata I, Cunha B, Romoli M, Hu W, Song J, Fifi JT, Matsoukas S, Sheth SA, Salazar-Marioni SA, Marto JP, Ramos JN, Miszczuk M, Riegler C, Poli S, Poli K, Jadhav AP, Desai S, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Kokkonen T, Diana F, Masoud HE, Suryadareva N, Mokin M, Thanki S, Ylikotila P, Alpay K, Siegler JE, Linfante I, Dabus G, Yavaghal D, Saini V, Nolte CH, Siebert E, Möhlenbruch MA, Ringleb PA, Nogueira RG, Hanning U, Meyer L, Fischer U, Strbian D. Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke. J Stroke 2024; 26:290-299. [PMID: 38836276 PMCID: PMC11164587 DOI: 10.5853/jos.2024.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE 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. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marta Olive-Gadea
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marc Ribo
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anh Nguyen
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - David Haupenthal
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | | | | | | | | | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Liqi Shu
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniel P.O. Kaiser
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Anne Berberich
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Diogo C. Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Hend Abdelhamid
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Bruno Cunha
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianlon Song
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Johanna T. Fifi
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | | | - Sunil A. Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | | | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Milena Miszczuk
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Sven Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Khouloud Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Ashutosh P. Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Shashvat Desai
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Maximilian Kaeder
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | | | - Andre Monteiro
- Department of Neurosurgery, University of Buffalo, Buffalo, NY, USA
| | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Francesco Diana
- Department of Interventional Neuroradiology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Hesham E. Masoud
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Neil Suryadareva
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Shail Thanki
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Pauli Ylikotila
- Department of Neurology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kemal Alpay
- Department of Radiology, Turku University Hospital and University of Turku, Turku, Finland
| | - James E. Siegler
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | | | - Dileep Yavaghal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vasu Saini
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christian H. Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Eberhart Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | | | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raul G. Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Dicpinigaitis AJ, Syed SA, Al-Mufti J, Medicherla C, Kaur G, Gandhi CD, Al-Mufti F. Endovascular thrombectomy for treatment of isolated posterior cerebral artery occlusion: a real-world analysis of hospitalizations in the United States. Acta Neurochir (Wien) 2024; 166:191. [PMID: 38656712 DOI: 10.1007/s00701-024-06050-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/17/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND 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). METHODS 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). RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Alis J Dicpinigaitis
- Department of Neurology, New York Presbyterian - Weill Cornell Medical Center, New York, NY, USA
| | - Shoaib A Syed
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jude Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Chaitanya Medicherla
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA.
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Jhou HJ, Yang LY, Chen PH. Comment on the article 'Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis'. Eur Stroke J 2024; 9:274-275. [PMID: 38009691 PMCID: PMC10916817 DOI: 10.1177/23969873231216814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua
- School of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Li-Yu Yang
- School of Medicine, Kaohsiung Medical University, Kaohsiung
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City
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Alkhiri A, Alamri AF, Alharbi AR, Almaghrabi AA, Alansari N, Niaz AA, Alghamdi BA, Sarraj A, Alhazzani A, Al-Ajlan FS. Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis. Eur Stroke J 2024; 9:69-77. [PMID: 37752802 PMCID: PMC10916830 DOI: 10.1177/23969873231201715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulelah A Niaz
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Salerno A, Michel P, Strambo D. Revascularization of arterial occlusions in posterior circulation acute ischemic stroke. Curr Opin Neurol 2024; 37:26-31. [PMID: 38085602 DOI: 10.1097/wco.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review highlights the latest advancements achieved in the revascularization of arterial occlusions associated with an acute ischemic stroke affecting the posterior circulation. It delves into the frequency and outcomes based on specific arterial segments and presents current evidence supporting revascularization treatments, including intravenous thrombolysis and endovascular thrombectomy. RECENT FINDINGS Comprehensive evidence for treatment across major arterial segments of the posterior circulation -- vertebral artery, basilar artery, posterior cerebral artery, cerebellar arteries, and multilevel posterior occlusions -- is provided. Additionally, the latest findings from randomized clinical trials on basilar artery occlusion are explored alongside results from extensive retrospective analyses of isolated vertebral and posterior cerebral artery occlusions. SUMMARY Current research supports the treatment decision in acute ischemic strokes of the posterior circulation using both intravenous thrombolysis and endovascular thrombectomy. This review also emphasizes existing knowledge gaps in the management of these strokes and advocates for more randomized clinical trials, notably concerning the posterior cerebral artery (currently ongoing), isolated vertebral artery, and multilevel posterior circulation occlusions.
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Affiliation(s)
- Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Shafique MA, Ali SMS, Mustafa MS, Aamir A, Khuhro MS, Arbani N, Raza RA, Abbasi MB, Lucke-Wold B. Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion. Clin Neurol Neurosurg 2024; 236:108070. [PMID: 38071760 DOI: 10.1016/j.clineuro.2023.108070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.
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Affiliation(s)
| | | | | | - Ali Aamir
- Department of Medicine, Dow University of Health Sciences, Pakistan.
| | | | - Naeemullah Arbani
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
| | - Rana Ali Raza
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
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