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Meta-Analysis
. 2024 Jun;30(3):307-316.
doi: 10.1177/15910199221100796. Epub 2022 May 13.

Mechanical thrombectomy in anterior vs. posterior circulation stroke: A systematic review and meta-analysis

Gautam Adusumilli  1 , John M Pederson  2   3 , Nicole Hardy  2 , Kevin M Kallmes  2 , Kristen Hutchison  2 , Hassan Kobeissi  4 , Daniel M Heiferman  5 , Jeremy J Heit  1
Affiliations
Meta-Analysis

Mechanical thrombectomy in anterior vs. posterior circulation stroke: A systematic review and meta-analysis

Gautam Adusumilli et al. Interv Neuroradiol. 2024 Jun.

Abstract

Background: High-quality evidence exists for mechanical thrombectomy (MT) treatment of acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). The evidence for MT treatment of posterior circulation large vessel occlusion (PC-LVO) is weaker, largely drawn from lower quality studies specific to PC-LVO and extrapolated from findings in AC-LVO, and ambiguous with regards to technical success. We performed a systematic review and meta-analysis to compare the technical success and functional outcomes of MT in PC-LVO versus AC-LVO patients.

Methods: We identified comparative studies reporting on patients treated with MT in AC-LVO versus PC-LVO. The primary outcome of interest was thrombolysis in cerebral infarction (TICI) ≥ 2b. Secondary outcomes included rates of TICI 3, 90-day functional independence, first-pass-effect, average number of passes, and 90-day mortality. A separate random effects model was fit for each outcome measure.

Results: Twenty studies with 12,911 patients, 11,299 (87.5%) in the AC-LVO arm and 1612 (12.5%) in the PC-LVO arm, were included. AC-LVO and PC-LVO patients had comparable rates of successful recanalization [OR = 1.02 [95% CI: 0.79-1.33], p = 0.848). However, the AC-LVO group had greater odds of 90-day functional independence (OR = 1.26 [95% CI: 1.00; 1.59], p = 0.050) and lower odds of 90-day mortality (OR = 0.58 [95% CI: 0.43; 0.79], p = 0.002).

Conclusions: MT achieves similar rates of recanalization with a similar safety profile in PC-LVO and AC-LVO patients. Patients with PC-LVO are less likely to achieve functional independence after MT. Future studies should identify PC-LVO patients who are likely to achieve favourable functional outcomes.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JMP works for and holds equity in Nested Knowledge, Inc., and Superior Medical Experts, Inc. KH works for Nested Knowledge, Inc. KMK works for and holds equity in Nested Knowledge, Inc., works for Conway Medical LLC, and holds equity in Superior Medical Experts, Inc. NH works for and holds equity in Nested Knowledge, Inc. JJH is a consultant for Medtronic and MicroVention and is a member of the scientific and medical advisory board for iSchemaView.

Figures

Figure 1.
Figure 1.
PRISMA diagram of search records and included studies automatically generated by the autoLit platform. Of 666 studies initially identified in the PubMed search, 646 studies were excluded by means of automated screening and manual dual screening per our pre-defined inclusion and exclusion criteria. The resulting twenty comparative studies on mechanical thrombectomy in anterior versus posterior circulation stroke were included in our meta-analysis.
Figure 2.
Figure 2.
Forest plot of comparisons of successful recanalization. Mechanical thrombectomy was non-inferior at achieving recanalization of >50% of the occluded artery in posterior circulation stroke as in anterior circulation stroke.
Figure 3.
Figure 3.
Forest plot of comparisons of complete recanalization. In this limited analysis of four studies, mechanical thrombectomy was non-inferior at achieving 100% recanalization in posterior circulation stroke as in anterior circulation stroke.
Figure 4.
Figure 4.
(A) forest plot of comparisons of successful recanalization on first pass. (B) Forest plot of comparisons of number of endovascular passes. Mechanical thrombectomy was non-inferior in posterior circulation stroke compared to in anterior circulation stroke at achieving successful recanalization on first pass with a thrombectomy device. The average number of passes required to achieve successful recanalization was also not significantly different by stroke location.
Figure 5.
Figure 5.
Forest plot of comparisons of functional independence (mRS 0–2) at 90 days. Mechanical thrombectomy was inferior in patients with posterior circulation stroke at achieving functional independence at 90 days compared to in patients with anterior circulation stroke.
Figure 6.
Figure 6.
(A) forest plot of comparisons of mortality at 90 days. (B) Forest plot of comparisons of symptomatic intracranial hemorrhage. Mechanical thrombectomy was inferior in patients with posterior circulation stroke in terms of mortality rate compared to in patients with anterior circulation stroke, as a greater percentage of patients with posterior circulation stroke died by 90-day follow-up. By contrast, patients with posterior circulation stroke treated by mechanical thrombectomy were less likely to experience symptomatic intracranial hemorrhage compared to patients with anterior circulation stroke.
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