Calculated plasma volume status is associated with poor outcomes in acute ischemic stroke treated with endovascular treatment

You described a problem, offered NO solution. YOU'RE FIRED!

Calculated plasma volume status is associated with poor outcomes in acute ischemic stroke treated with endovascular treatment

Dixia Zhang Qiuru Li Jun Liu Lijuan Ma Jing Ye Guifen Hu Guangzong Li^*

• Department of Neurology, The Sixth People's Hospital of Chengdu, Chengdu, China

Background and purpose: The impact of calculated plasma volume status (PVS) on the prognosis of acute ischemic stroke treated with endovascular treatment (EVT) remains undetermined. This study aimed to investigate the association between PVS and 90 days functional outcomes after EVT.

Methods: We enrolled patients treated with EVT in the anterior circulation from a prospective registry. The endpoint was a modified Rankin scale score of ≥3 points at 90 days after EVT. We used multivariable logistic regression models to investigate the association between PVS and poor outcomes. We used the restricted cubic spline to present the linearity between PVS and poor outcomes.

Results: Among the 187 enrolled patients (median age, 65 years; 35.8% women), a total of 81 patients (43.3%) experienced poor outcomes at 90 days. In multivariable analyses, PVS was associated with poor outcomes despite increasing confounding factors (odds ratio, 3.157; 95% confidence interval, 1.942–5.534; P < 0.001). The restricted cubic spline revealed a positive correlation between PVS and the risk of poor outcomes after EVT (P for nonlinearity = 0.021).

Conclusion: Our study found that an elevated PVS value was associated with poor outcomes after EVT. Further prospective cohorts were warranted to evaluate the utility of PVS in AIS treated with EVT.

Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study

So you described a problem and even suggested there might be solutions but did nothing to even write down some the possibilities. Useless. I'd have you all fired.

Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study

Wouter van der Steen,

Nadinda A.M. van der Ende,

Katinka R. van Kranendonk,

Vicky Chalos,

Robert J. van Oostenbrugge,

Wim H. van Zwam,

Yvo B.W.E.M. Roos,

… See all authors

and on behalf of the MR CLEAN Trial and MR CLEAN Registry Investigators

Originally published8 Jun 2022https://doi.org/10.1161/STROKEAHA.121.036195Stroke. 2022;53:2818–2827

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Abstract

Background:

Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.

Methods:

We retrospectively analyzed data from the Dutch MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and MR CLEAN registry. We included adult patients with a large vessel occlusion in the anterior circulation who underwent endovascular treatment within 6.5 hours of stroke onset. We used univariable and multivariable logistic regression analyses to identify determinants of overall sICH occurrence, sICH within infarcted brain tissue, and sICH outside infarcted brain tissue.

Results:

SICH occurred in 203 (6%) of 3313 included patients and was located within infarcted brain tissue in 50 (25%), outside infarcted brain tissue in 23 (11%), and both within and outside infarcted brain tissue in 116 (57%) patients. In 14 patients (7%), data on location were missing. Prior antiplatelet use, baseline systolic blood pressure, baseline plasma glucose levels, post-endovascular treatment modified treatment in cerebral ischemia score, and duration of procedure were associated with all outcome parameters. In addition, determinants of sICH within infarcted brain tissue included history of myocardial infarction (adjusted odds ratio, 1.65 [95% CI, 1.06–2.56]) and poor collateral score (adjusted odds ratio, 1.42 [95% CI, 1.02–1.95]), whereas determinants of sICH outside infarcted brain tissue included level of occlusion on computed tomography angiography (internal carotid artery or internal carotid artery terminus compared with M1: adjusted odds ratio, 1.79 [95% CI, 1.16–2.78]).

Conclusions:

Several factors, some potentially modifiable, are associated with sICH occurrence. Further studies should investigate whether modification of baseline systolic blood pressure or plasma glucose level could reduce the risk of sICH. In addition, determinants differ per location of sICH, supporting the hypothesis of varying underlying mechanisms.

Registration:

URL: https://www.isrctn.com/; Unique identifier: ISRCTN10888758.

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The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

 I have no clue what this is trying to say so ask your doctor for a 10th grade version.

The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

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Wen Sun, Zuowei Duan, Pengfei Xu, ...

First Published August 13, 2022 Research Article 

https://doi.org/10.1177/17562864221114627

Article information

Abstract

Background:

Whether endovascular treatment (EVT) is safe and effective for vertebrobasilar artery occlusion (VBAO) is yet incompletely understood. Two RCTs, the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST) trail and the Basilar Artery International Cooperation Study (BASICS), concentrating on this field were recently reported.

Objective:

We use real-world registry data of VBAO to compare the outcome of EVT inside and outside the inclusion and exclusion criteria of the BEST and BASICS study to testify the feasibility of the selection paradigms of VBAO in these trials.

Methods:

Consecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. The safety outcomes [3-month mortality, symptomatic intracranial hemorrhage (sICH), and effectiveness outcomes (the proportion of 3-month functional independence (mRS of 0–2) and favorable outcome (mRS of 0–3)] were compared between VBAO patients who meet or failed to meet the BEST/BASICS selection criteria for EVT.

Results:

Our study cohort consisted of 577 VBAO patients who underwent EVT. Of them, 446 patients had pc-ASPECTS ≧8. Successful reperfusion (mTICI 2b or 3) was achieved in 85.4% (n = 493). There were 418 patients fulfilling the BEST criterion for EVT and 194 fulfilling the BASICS criterion. Regression analysis indicated that adherence to BEST or BASICS criterion for EVT was not independently related to most of the safety and effectiveness outcome except that adherence to BEST was significantly associated with the 3-month favorable outcome (OR_BEST: 1.742, 95% CI: 1.087–2.790). However, when we put pc-ASPECTS into both criteria with a cut-off value of 8, meeting both BEST criterion plus pc-ASPECTS and BASICS criterion plus pc-ASPECTS was independently related to 3-month functional independence (OR_BEST: 1.687, 95% CI: 1.077–2.644; OR_BASIC: 1.653, 95% CI: 1.038–2.631) and favorable outcome (OR_BEST: 2.280, 95% CI: 1.484–3.502; OR_BASIC: 2.153, 95% CI: 1.372–3.378).

Conclusion:

Our study indicated that, based on real-world data of EVT, adherence to BEST or BASICS criterion for EVT was not independently associated with the safety and effectiveness outcome except that adherence to BEST was significantly related to the 3-month favorable outcome. However, the BEST or BASICS selection criterion and pc-ASPECTS ≧8 might be better paradigms for EVT patient selection.

Keywords

endovascular treatment, inclusive criteria, outcomes, stroke, vertebrobasilar artery occlusions

Introduction

Acute vertebrobasilar artery occlusion (VBAO), accounting for about 1% of all ischemic strokes, is associated with high mortality and disability of up to 70%, which represents the most devastating type of ischemic stroke.^1–4

Previous large trials had indicated an overwhelming benefit of endovascular treatment (EVT) for treating acute anterior circulation ischemic stroke due to emergent large vessel occlusion.^5–8 However, whether EVT is safe and effective for patients with acute VBAO is yet incompletely understood.^9–11

Recently, two multicenter, randomized controlled trials (RCTs), the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion trial (BEST) and the Basilar Artery International Cooperation Study (BASICS), failed to indicate the superiority of EVT over standard medical treatment.^12,13 Despite that, it is still believed in clinical practice that EVT might be helpful for VBAO in case of proper patient selection. We hypothesized that the inclusion and exclusion protocols for EVT in BEST and BASICS are suboptimal for selecting the real patients who need EVT, which might partly explain the negative results of both studies. We therefore use a real-world multicenter database to compare the safety and effectiveness of EVT for patients with VBAO according to the current BEST/BASICS selection criteria for EVT.

Furthermore, the Acute Stroke Prognosis Early Computed Tomography Score (ASPECTS) is a standardized semi-quantitative computed tomographic (CT) grading system used to assess early ischemic changes and predict functional outcomes and ischemic core volumes in patients with acute anterior circulation ischemic stroke.¹⁴ Low ASPECTS has been reported to be associated with poor functional outcome after reperfusion and was adopted as one of the exclusion criteria in several trails in acute anterior circulation ischemic stroke.^6,15–17 The posterior circulation ASPECTS (pc-ASPECTS), first proposed by Puetz et al., was considered as one of the factors associated with functional outcome and mortality in patients with acute VBAO.¹⁸ Several studies have shown that pc-ASPECTS <8 could also identify patients unlikely to achieve favorable outcomes despite successful reperfusion of the basilar artery.^18,19 However, neither the BEST nor the BASICS trial investigators included pc-ASPECTS evaluation in the inclusion criteria. Therefore, we further tried to consider pc-ASPECTS ≧8 as an additional selection criterion and analyzed the safety and effectiveness of EVT divided by the new selection criterion.

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People of East Asian descent have more vessels reclog after endovascular treatment

 SO WHAT THE FUCK IS THE SOLUTION? Wringing your hands?

People of East Asian descent have more vessels reclog after endovascular treatment

Among people who received endovascular therapy to mechanically remove a clot in their large brain artery, those who had a rare genetic variant found primarily in people of East Asian descent (Japanese, Chinese and Korean) were more likely to have the vessel reclog during or shortly after the procedure, according to a small study published today in Stroke: Vascular and Interventional Neurology.

"In the field of acute stroke, genetic testing has not been considered important. However, since our study found that a specific genetic variant substantially affects the outcome of endovascular therapy, physicians involved in acute stroke medicine, especially in East Asian countries and in western countries where many East Asian descendants are living, need to know these findings," said senior study author Masafumi Ihara, M.D., Ph.D., FAHA, director of neurology at the National Cerebral and Cardiovascular Center in Osaka, Japan.

When blood clots block a large artery supplying blood to the brain, a severe stroke with the potential for serious disability may occur. According to the American Heart Association/American Stroke Association, clot-caused (ischemic) strokes account for 87% of all strokes in the United States.

The genetic variant studied, called RNF213 p.R4810K, is present in 1 in 50 people of East Asian descent and in 80%-90% of people with the genetic disorder moyamoya disease. Moyamoya is a rare, progressive disorder caused by blocked arteries at the base of the brain that can result in a stroke or other neurological symptoms, such as motor or sensory impairment, headache or vertigo. Since moyamoya disease is diagnosed by conventional brain angiography or magnetic resonance angiography (MRA) and symptoms are varied and stroke-related, many people may not know they have moyamoya disease before they have a stroke. In addition to endovascular therapy, bypass surgery is also a treatment option to increase cerebral blood flow. Medically, antiplatelets are used to suppress clot formation in constricted or narrowed arteries.

The researchers analyzed the outcomes of 277 East Asian adults (46.2% women, median age of 76 years) who received endovascular therapy for an ischemic stroke at the National Cerebral and Cardiovascular Center in Osaka, Japan, between 2011 and 2021. All of the patients had an acute anterior-circulation large vessel occlusion, a stroke in which a clot blocks one of the large arteries responsible for supplying blood to the forebrain (the forebrain is the largest of three parts of the brain and includes the cerebrum, thalamus, hypothalamus, pituitary gland, limbic system, and the olfactory bulb; it is responsible for processing complex brain and physical activities, numerous sensory functions and voluntary motor activities).

Several types of endovascular procedures are available to restore blood flow to the artery, such as removing the blood clots through a stent retriever device or suction device, or opening the clogged vessel by inflating a balloon in the area and installing a stent to hold the blood vessel open. The type of procedure performed was determined by the medical team and was unrelated to whether the patient had the genetic variant.

Researchers compared 10 patients found to carry the RNF213 p.R4810K variant to 267 patients without the variant on several short-term outcome measures. The results were adjusted for the age of the patients.

While people with the genetic variant were just as likely as non-carriers to initially have success with reestablishing blood flow to at least half of the brain tissue that had been deprived of blood during the stroke, outcomes revealed:

• People with the genetic variant were far more likely (70%) than non-carriers (5.6%) to have the treated artery become re-blocked before the procedure was complete, called instant reocclusion.
• People with the genetic variant were far more likely (60%) than non-carriers (0.4%) to have the treated artery become re-blocked within two weeks of an initially successful endovascular procedure, called early reocclusion.

"We did not imagine this genotype would affect the outcome of endovascular therapy so substantially," Ihara said. "Information on the genotype will be useful for people who receive endovascular therapy (hopefully before the procedure) because individuals who are of East Asian descent and have the genetic variant need to be more strictly monitored than usual for reocclusion during and after endovascular treatment."

The number of people found to have the genetic variant was too small to determine which clot-removal devices or medicines may be better at preventing reocclusion. The researchers are initiating a larger, multi-center study to answer these questions, and to examine the long-term outcome of variant carriers following endovascular therapy. "It's important to note, however, that genotyping is currently only available in a research setting, for participants in a clinical trial such as ours," Ihara said.

Results from this study involving an East Asian population may not be generalized to other people with different genetic backgrounds. "However, additional genetic variants may affect the outcome of endovascular therapy in different ethnic populations, which needs further investigation," Ihara said.

In addition to stroke, the RNF213 p.R4810K gene has previously been associated with high blood pressure, pulmonary high blood pressure, heart attack and the narrowing of abdominal blood vessels.

Current State and Future for Emerging Stroke Therapies: Reflections and Reactions

 WOW, you consider the 88% failure rate of tPA to get fully recovered a success? And no one even mentions the full recovery rate of endovascular thrombectomy so I can only assume it is a complete failure in full recovery also. But you're using your fucking tyranny of low expectations to declare success.  I'd be fired in no time if the computer programs I installed only worked 12% of the time. In my opinion until we get an EXACT STROKE STRATEGY, almost all stroke research will be worthless. The endpoint for all stroke research should be 100% recovery, NOT this lazy shit of reperfusion.

Current State and Future for Emerging Stroke Therapies: Reflections and Reactions

 

Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke

This prediction doesn't do one damn bit of good unless you have EXACT PROTOCOLS  to prevent this edema from happening. 

Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke

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Frans Kauw*, Marie Louise E Bernsen, Jan W Dankbaar, ...

First Published May 12, 2022 Research Article Find in PubMed 

https://doi.org/10.1177/17474930221094693

Article information

 

Abstract

Background:

The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a potential predictor of malignant edema formation in patients with acute ischemic stroke.

Aims:

We aimed to evaluate the added value of the CSF/ICV ratio in a model to predict malignant edema formation in patients who underwent endovascular treatment.

Methods:

We included patients from the MR CLEAN Registry, a prospective national multicenter registry of patients who were treated with endovascular treatment between 2014 and 2017 because of acute ischemic stroke caused by large vessel occlusion. The CSF/ICV ratio was automatically measured on baseline thin-slice noncontrast CT. The primary outcome was the occurrence of malignant edema based on clinical and imaging features. The basic model included the following predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, occlusion of the internal carotid artery, collateral score, time between symptom onset and groin puncture, and unsuccessful reperfusion. The extended model included the basic model and the CSF/ICV ratio. The performance of the basic and the extended model was compared with the likelihood ratio test.

Results:

Malignant edema occurred in 40 (6%) of 683 patients. In the extended model, a lower CSF/ICV ratio was associated with the occurrence of malignant edema (odds ratio (OR) per percentage point, 1.2; 95% confidence interval (CI) 1.1–1.3, p < 0.001). Age lost predictive value for malignant edema in the extended model (OR 1.1; 95% CI 0.9–1.5, p = 0.372). The performance of the extended model was higher than that of the basic model (p < 0.001).

Conclusions:

Adding the CSF/ICV ratio improves a multimodal prediction model for the occurrence of malignant edema after endovascular treatment.

Keywords

Ischemic stroke, computed tomography, cerebrospinal fluid, thrombectomy, malignant edema

Introduction

The occurrence of malignant edema may require timely decompressive surgery to prevent poor clinical outcomes in patients with acute ischemic stroke.^1,2 Accurate prediction of malignant edema formation may help in making prompt treatment decisions. Important factors that have been associated with malignant edema include young age, high National Institutes of Health Stroke Scale (NIHSS), extensive early ischemic changes on noncontrast CT (NCCT), large perfusion deficits on CT perfusion, proximal thrombus location on CT angiography (CTA), and poor collateral filling in the affected area on CTA.³ The incorporation of these factors in multivariable models has led to reasonable discrimination between groups of patients with and without malignant edema, but predictive values for individual patients remain moderate.³

In a previous study, we found the ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) to be of added value in models predicting malignant edema in patients with acute ischemic stroke.⁴ Until now, this has not been validated in another cohort.

Recently, a prediction model for malignant edema after acute supratentorial ischemic stroke for which endovascular treatment (EVT) was performed has been developed based on the Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry.⁵ In this study, we tested the additional predictive value of the CSF/ICV ratio.

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An accurate prognostic prediction for aneurysmal subarachnoid hemorrhage dedicated to patients after endovascular treatment

 

You do realize you're predicting  high fatality and permanent disability rather than doing the correct research to prevent that from happening. I'd fire the lot of you for not solving stroke.

An accurate prognostic prediction for aneurysmal subarachnoid hemorrhage dedicated to patients after endovascular treatment

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Han Lu*, Gaici Xue*, Sisi Li*, ...

First Published June 1, 2022 Research Article 

https://doi.org/10.1177/17562864221099473

Article information

Abstract

Background:

Endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates. It remains unclear how the prognosis is determined by the complex interaction between clinical severity and aneurysm characteristics.

Objective:

This study aimed to design an accurate prognostic prediction model for aSAH patients after endovascular treatment and elucidate the interaction between clinical severity and aneurysm characteristics.

Methods:

We used a clinically homogeneous data set with 1029 aSAH patients who received endovascular treatment to develop prognostic models. Aneurysm characteristics were measured by variables, such as aneurysm size, neck size, and dome-to-neck ratio, while clinical severity on admission was measured by both comorbidities and neurological condition. In total, 18 clinical variables were used for prognostic prediction. Considering the imbalance between the favorable and the poor outcomes in this clinical population, both ensemble learning and deep reinforcement learning approaches were used for prediction.

Results:

The random forest (RF) model was selected as the best approach for the prognostic prediction for all patients and also for patients with good-grade aSAH. Using an independent test data set, the model made accurate predictions (AUC = 0.869 ± 0.036, sensitivity = 0.709 ± 0.087, specificity = 0.805 ± 0.034) with the clinical severity on admission as a leading contributor to the prediction. For patients with good-grade aSAH, the RF model performed the best (AUC = 0.805 ± 0.034, sensitivity = 0.620 ± 0.172, specificity = 0.696 ± 0.043) with aneurysm characteristics as leading contributors. The classic scoring systems failed in this patient group (AUC < 0.600; sensitivity = 0.000, specificity = 1.000).

Conclusion:

The proposed prognostic prediction model outperformed the classic scoring systems for patients with aSAH after endovascular treatment, especially when the classic scoring systems failed to make any informative prediction for patients with good-grade aSAH, who constitute the majority group (79%) of this clinical population.

Keywords

endovascular treatment, imbalanced data, machine learning, prognostic prediction, reinforcement learning

Introduction

Subarachnoid hemorrhage from ruptured intracranial aneurysms, a worldwide health burden, is characterized by its high fatality and permanent disability rates. Approximately one-third of all patients die owing to the severe brain injury with the initial weeks after aneurysmal subarachnoid hemorrhage (aSAH), and a large portion of survivors suffered from long-term disability or cognitive impairment.¹ Prognostic prediction model for patients after aSAH is critical not only to inform outcome expectations but also to identify modifiable contributors to a favorable prognosis. However, it remains unclear how the complex interaction between clinical severity and aneurysm characteristics jointly determines the prognosis after aSAH.

To date, a few clinical scoring systems can be used to inform the prognosis after aSAH, including the subarachnoid hemorrhage international trialists (SAHIT),² functional recovery expected after subarachnoid hemorrhage (FRESH),³ size of the aneurysm, age, Fisher grade, World Federation of Neurosurgical Societies after resuscitation (SAFIRE),⁴ and so on. However, these scoring systems were often built from clinically heterogeneous patient groups to maximize the overall sample size. For example, the patients in these studies were often treated with various methods, including surgical clipping, endovascular method, and even conservative treatment.^2–4 Among these different treatment approaches, the difference in prognosis had already been reported. A meta-analysis of the data from 11,568 patients showed that the coiling reduced the 1-year poor outcome rate (OR, 1.48) compared with clipping.⁵ Given the continuous surgical and material advances in the treatment of aSAH during the last two decades,⁶ the training data collected in the early 2000s for these scoring systems might make them less predictive in the latest clinical practice. Recently, the researches on the prognostic prediction models had begun to focus on the homogeneous groups of patients, especially the patients after aSAH treated with the endovascular approach only.^7–9 However, the sample sizes were often limited. To build an accurate and reliable prognostic prediction model, both large sample size and independent test data set are needed.

Another important limitation in literature is the lack of a prognostic prediction model for patients with good-grade aSAH on admission. As reviewed by a recent meta-analysis, five aSAH studies with a total of 2862 participants found that 2425 (84.7%) patients had the good-grade aSAH on admission, but among them 19.8% suffered poor outcomes.⁵ Therefore, an accurate prognostic model for this patient group could better inform the decision-making before the surgery. For example, when a poor outcome is predicted, alternative methods such as clipping may be considered. Furthermore, the identification of the key factors that contribute to this prognosis may provide novel opportunities toward better outcomes.

To address these limitations, we attempted to establish multivariate models for the prognostic prediction in patients after aSAH treated with the endovascular approach, both in the general patient population and in patients with good-grade aSAH on admission. We reviewed the data from the largest-to-date cohort of 1191 patients after aSAH who were treated with the endovascular approach at a single center between 2012 and 2018. Using the clinical information on admission, we proposed a few multivariate models and compared them with classic scoring systems to improve the prediction accuracy for 1-year prognoses of these patients and validated performances of these models using an independent test data set.

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Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

 If all it did was 'improve outcomes', you're discussing failure. WHAT THE FUCK ARE YOU DOING TO PREVENT THAT FAILURE?

Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Shuju Dong^†, Yanbo Li^†, Jian Guo, Yaxi Luo, Jinghuan Fang, Li Tang and Li He^*

• Department of Neurology, West China Hospital, Sichuan University, Chengdu, China

Aims: Whether endovascular treatment (EVT) can further improve the prognosis of patients with posterior circulation ischemic stroke (PCIS) is unclear. This meta-analysis aims to compare the efficacy and safety of PCIS patients treated with EVT plus standard medical treatment (SMT) and SMT alone.

Methods: We systematically searched for relevant randomized controlled trials (RCTs) and prospective cohort trials in MEDLINE, EMBASE, and the Cochrane Library up to February 2022. The primary outcome was favorable functional outcome of the modified Rankin Scale (mRS) with scores of 0–2 or 0–3; secondary outcomes included successful recanalization rate, intracranial hemorrhage (ICH), or symptomatic intracranial hemorrhage (sICH) after treatment and 90-day mortality.

Results: We identified six studies including 1, 385 PCIS patients (957 with EVT plus SMT; 428 with SMT alone). EVT plus SMT substantially improved 90-day functional outcomes compared with SMT alone [mRS score of 0–2: RR=1.95, 95% CI (1.52 – 2.51), P < 0.001; mRS score of 0–3: RR = 1.85, 95% CI (1.49 – 2.30), P < 0.001, respectively]. Moreover, compared with SMT, combined treatment significantly improved the rate of successful recanalization [RR = 5.03, 95% CI (3.96–6.40), P < 0.001] and reduced 90-day mortality [RR = 0.71, 95% CI (0.63–0.79), P < 0.001] despite a higher risk of ICH [RR = 6.13, 95% CI (2.50–15.02), P < 0.001] and sICH [RR = 10.47, 95% CI [2.79–39.32), P = 0.001].

Conclusion: Low-to-moderate evidence from RCTs and non-RCTs showed that increased ICH and sICH risk of EVT plus SMT did not translate to a higher risk of unfavorable outcomes compared with SMT and could even promote independence at 90 days in a real-world cohort.

Introduction

Posterior circulation ischemic stroke (PCIS) is caused by blood interruption of the vertebrobasilar arterial system and accounts for approximately 20–25% of all ischemic strokes (1). The most common mechanisms responsible for PCIS are embolism (40%), followed by atherosclerosis (32–35%), and other causes of PCIS include dissection, penetrating small-artery diseases, and other identified or unknown etiologies (2). PCIS represents only 1% of all strokes and 5% of large vessel occlusion (LVO) strokes (3, 4). Despite that, PCIS patients with LVO have an extremely poor prognosis, with a 90-day mortality rate of approximately 35–50%, and the majority of deaths (83%) occur in the hospital (5, 6). PCIS patients have higher mortality than anterior circulation stroke (ACS) patients despite successful revascularization (7, 8).

For PCIS patients, successful recanalization is an independent predictor of a good prognosis (9). Although intravenous thrombolysis (IVT) has been shown to be effective and safe, recanalization rates with IVT remain suboptimal in the setting of LVO (10, 11). Evidence in the ACS suggests that endovascular therapy (EVT) can improve recanalization rates or functional outcomes compared with IVT alone (12–14). And application to patients with PCIS patients appears to similarly improve prognosis in these patients (15–17). However, conclusions regarding the benefit of EVT compared with the conservative treatment in improving the clinical outcome of PCIS patients are still unconfirmed.

Several clinical studies (18–24) and subsequent meta-analyses (25) have shown that the benefits of EVT in patients with PCIS are comparable to those in patients with ACS. Similarly, evidence from several recent studies suggested that patients with PCIS treated with EVT may have higher recanalization rates and better outcomes compared to conservative treatment alone (26, 27). In contrast, other studies have shown that PCIS patients receiving EVT have poorer functional outcomes at 90 days, with a mortality rate of 41.9% (28–30).

Although several meta-analyses have attempted to confirm the additional benefit of EVT on basis of SMT in patients with acute BAO (15, 16, 26), the efficacy and safety of EVT in patients with PCIS remain uncertain due to design and methodological flaws (26, 31). Therefore, we aimed to include the latest research evidence to further evaluate the effectiveness and safety of EVT plus standard medical treatment (SMT) over SMT alone in patients with PCIS and to provide more reliable evidence for clinical decision making in PCIS (6, 24, 32, 33).

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