Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study

Hamza Adel Salim^{1

2}, Benjamin Pulli³, Vivek Yedavalli¹, Basel Musmar⁴, Nimer Adeeb⁴, Dhairya Lakhani¹, Muhammed Amir Essibayi⁵, Kareem El Naamani⁶, Nils Henninger⁷, Sri Hari Sundararajan⁸, Anna Luisa Kühn⁹, Jane Khalife¹⁰, Sherief Ghozy¹¹, Luca Scarcia¹², Inayat Grewal¹³, Benjamin Yq Tan^{14

15}, Robert W Regenhardt¹³, Jeremy J Heit³, Nicole M Cancelliere¹⁶, Joshua D Bernstock¹⁷, Aymeric Rouchaud¹⁸, Jens Fiehler¹⁹, Sunil Sheth²⁰, Ajit S Puri⁹, Christian Dyzmann²¹, Marco Colasurdo²², Xavier Barreau²³, Leonardo Renieri²⁴, João Pedro Filipe²⁵, Pablo Harker²⁶, Răzvan Alexandru Radu²⁷, Mohamad Abdalkader²⁸, Piers Klein²⁸, Thomas R Marotta¹⁶, Julian Spears¹⁶, Takahiro Ota²⁹, Ashkan Mowla³⁰, Pascal Jabbour⁶, Arundhati Biswas³¹, Frédéric Clarençon³², James E Siegler¹⁰, Thanh N Nguyen²⁸, Ricardo Varela³³, Amanda Baker⁵, David Altschul⁵, Nestor R Gonzalez³⁴, Markus A Möhlenbruch³⁵, Vincent Costalat²⁷, Benjamin Gory^{36

37}, Christian Paul Stracke³⁸, Mohammad Ali Aziz-Sultan¹⁷, Constantin Hecker³⁹, Hamza Shaikh¹⁰, Christoph J Griessenauer³⁹, David S Liebeskind⁴⁰, Alessandro Pedicelli⁴¹, Andrea M Alexandre⁴¹, Illario Tancredi⁴², Tobias D Faizy⁴³, Erwah Kalsoum¹², Boris Lubicz⁴⁴, Aman B Patel¹³, Vitor Mendes Pereira¹⁶, Max Wintermark², Adrien Guenego⁴⁴, Adam A Dmytriw^{13

16}

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, USA.
³ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
⁴ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA.
⁵ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁷ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁸ Department of Endovascular Neurosurgery and Neuroradiology, NJMS, Newark, NJ, USA.
⁹ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁰ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹¹ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹² Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹³ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁵ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁶ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada.
¹⁷ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
²⁹ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
³⁰ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
³¹ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³² Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast. Sorbonne University, Paris VI, Paris, France.
³³ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁴ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁵ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁶ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁷ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁸ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
³⁹ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.
⁴⁰ UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴⁴ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39431327
PMCID: PMC11556534
DOI: 10.1177/23969873241291465

Comparative Study

Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study

Hamza Adel Salim et al. Eur Stroke J. 2025 Jun.

. 2025 Jun;10(2):387-396.

doi: 10.1177/23969873241291465. Epub 2024 Oct 21.

Authors

Affiliations

¹ Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, USA.
³ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
⁴ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA.
⁵ Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁷ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁸ Department of Endovascular Neurosurgery and Neuroradiology, NJMS, Newark, NJ, USA.
⁹ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
¹⁰ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA.
¹¹ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹² Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹³ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁴ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹⁵ Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹⁶ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada.
¹⁷ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁸ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁹ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁰ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
²¹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²² Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
²³ Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
²⁴ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²⁵ Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²⁶ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁷ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁸ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
²⁹ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
³⁰ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
³¹ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
³² Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; GRC BioFast. Sorbonne University, Paris VI, Paris, France.
³³ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³⁴ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁵ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁶ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁷ INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France.
³⁸ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
³⁹ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.
⁴⁰ UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴¹ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Italy.
⁴² Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴³ Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴⁴ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

PMID: 39431327
PMCID: PMC11556534
DOI: 10.1177/23969873241291465

Abstract

Background: Despite the proven effectiveness of endovascular therapy (EVT) in acute ischemic strokes (AIS) involving anterior circulation large vessel occlusions, isolated posterior cerebral artery (PCA) occlusions (iPCAo) remain underexplored in clinical trials. This study investigates the comparative effectiveness and safety of EVT against medical management (MM) in patients with iPCAo.

Methods: This multinational, multicenter propensity score-weighted study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. We included iPCAo patients treated with either EVT or MM. The primary outcome was the modified Rankin Scale (mRS) at 90 days, with secondary outcomes including functional independence, mortality, and safety profiles such as hemorrhagic complications.

Results: A total of 177 patients were analyzed (88 MM and 89 EVT). EVT showed a statistically significant improvement in 90-day mRS scores (OR = 0.55, 95% CI = 0.30-1.00, p = 0.048), functional independence (OR = 2.52, 95% CI = 1.02-6.20, p = 0.045), and a reduction in 90-day mortality (OR = 0.12, 95% CI = 0.03-0.54, p = 0.006) compared to MM. Hemorrhagic complications were not significantly different between the groups.

Conclusion: EVT for iPCAo is associated with better neurological outcomes and lower mortality compared to MM, without an increased risk of hemorrhagic complications. Nevertheless, these results should be interpreted with caution due to the study's observational design. The findings are hypothesis-generating and highlight the need for future randomized controlled trials to confirm these observations and establish definitive treatment guidelines for this patient population.

Keywords: Acute ischemic stroke; endovascular therapy; medical management; posterior cerebral artery; propensity score analysis.

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Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading), and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro, and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson, and Phenox (paid lectures), all not directly related to the present work. Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc, and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular, and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy, and NTI. Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr. Jabbour is a consultant for Medtronic, Microvention, and Cerus.

Figures

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Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study

Affiliations

Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical