Endovascular Therapy Versus Medical Management in Posterior Cerebral Artery Stroke: Neurological Gains Without Functional Superiority: A Meta-analysis
Ibraheem Alkhawaldeh1, Mostafa Hossam El Din Moawad2, Ahmed Farid Gadelmawla3, Hamza A. Abdul-Hafez4, Mohammed Khaled Mohammed5, Mohamed Abouzaid6
1Mutah university - jordan hospital, 2Alexandria Main University Hospital, Alexandria, Egypt Faculty of Medicine, Suez Canal University, Ismailia, Egypt, 3Menoufia University, 4An-Najah National University, 5Cairo university, 6Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St., 60-806 Poznan, Poland - Doctoral School, Poznan University of Medical Sciences, 60-812 Poznan, Poland
Objective:

To compare the effectiveness and safety of EVT versus medical management (MM) in patients with acute PCA occlusion

Background:

Posterior cerebral artery (PCA) infarctions represent 5–10% of all acute ischemic strokes, often manifesting with visual and cognitive deficits that can substantially impair quality of life. Although endovascular thrombectomy (EVT) is an established treatment for large-vessel occlusions, its role in isolated PCA occlusion remains uncertain, with limited evidence and heterogeneous outcomes across studies.

Design/Methods:

A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science were searched until July 2025. Eligible studies included randomized or cohort studies comparing EVT with MM in PCA occlusion. Primary outcomes were excellent (modified Rankin Scale [mRS] 0–1) and favorable (mRS 0–2) functional outcomes at 90 days. Secondary outcomes included change in National Institutes of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Risk of bias was assessed with the Newcastle–Ottawa Scale. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models.

Results:

Nine high-quality cohort studies including 57,287 patients (EVT=2475; MM=54,812) were analyzed. EVT was not associated with significant improvement in excellent (RR=1.05; 95% CI, 0.91–1.21) or favorable (RR=0.94; 95% CI, 0.84–1.05) functional outcomes compared to MM. Mortality (RR=1.33; 95% CI, 0.99–1.80) and sICH (RR=1.60; 95% CI, 0.87–2.93) rates were comparable between groups. However, EVT was associated with short-term neurological improvement on NIHSS at discharge (MD=-1.21; 95% CI, -1.96 to -0.46; p=0.002).

 

Conclusions:

EVT for PCA occlusion offers short-term neurological improvement compared to medical management, with similar mortality and sICH rates. However, this benefit does not extend to long-term functional outcomes (mRS), likely due to PCA stroke’s visual and cognitive deficits not captured by global scales. Randomized trials with domain-specific outcomes are needed to clarify EVT’s role.

10.1212/WNL.0000000000217371
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