Clinical outcomes of intra-arterial thrombectomy versus medical therapy for isolated posterior cerebral artery occlusion

Introduction

Ischemic stroke accounted for 5.2% of global deaths in 2015. Moreover, after recovering from an ischemic stroke, a patient may continue to experience long-term sequelae such as neuronal damage-related disability, contributing to a substantial socioeconomic burden. Medical expenditure for stroke was approximately Korean Won (KRW) 1.68 trillion in South Korea in 2015, and long-term health care and annual rehabilitation cost is approximately £25.6 billion in the United Kingdom (1,2).

Based on the major vessels, ischemic stroke can be classified into (I) anterior circulation stroke, which occurs in the internal carotid artery (ICA), middle cerebral artery (MCA), or anterior cerebral artery (ACA), and (II) posterior circulation stroke, affecting the posterior cerebral artery (PCA), basilar artery, or vertebral artery. Anterior circulation stroke commonly present with symptoms such as hemiplegia, aphasia, and dysarthria, whereas posterior circulation strokes commonly present with visual disturbances. However, these symptoms are mild and are easily overlooked.

Conventional medications and intra-arterial thrombectomy (IAT) are the primary treatment options for ischemic stroke (3,4). Aggressive IAT is associated with a good prognosis for anterior circulation strokes, such as those of the ICA and MCA (3,4). However, limited evidence exists regarding the efficacy of IAT for isolated PCA occlusions. In addition, IAT is often not considered because the symptoms of isolated PCA occlusion are not severe. However, isolated PCA occlusion is often exacerbated by hemorrhagic transformation that is caused by disruption of the blood-brain barrier and reperfusion injury which causes damage to peripheral blood cells. Therefore, understanding the necessity and efficacy of aggressive IAT performed within the golden hour of isolated PCA occlusion treatment is important (5).

Accordingly, we aimed to evaluate the differences between conventional medication therapy and IAT in patients with isolated PCA occlusion. Additionally, we aimed to identify the factors affecting patient prognosis. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1015/rc).

Methods

Patient selection

This study retrospectively included patients with PCA proximal segment (P1) occlusion and cerebral infarction in the P1 segment who were admitted to a regional hub university medical center between March 2012 and August 2022. Patients with lesions in areas other than the PCA territory (n=18) or those whose occlusion and infarction sites did not match (n=6) were excluded. In addition, patients with occlusion of the PCA P2 segment or more distal branches (n=2) were excluded. Finally, 102 participants were included in the final analysis (Figure 1). The patient groups who received IAT in this study are as follows. In the case of clear onset, the mismatch is prominent on computed tomography (CT) perfusion image within 12 hours of onset time, and there is no hypodense lesion on non-contrast CT, and in the case of wake-up stroke, among the patients who visited within 24 hours of last normal time, the mismatch is prominent on CT perfusion image and there is no hypodense lesion on non-contrast CT. Patients who did not receive this did not receive IAT. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Jeonbuk National University Hospital (No. 2023-10-006) and individual consent for this retrospective analysis was waived.

Figure 1 Study flowchart. PCA, posterior cerebral artery.

Definition

PCA occlusion was defined as non-visualization of the proximal segment of the PCA on brain CT angiography performed at the time of hospitalization due to occlusion. A complaint of visual symptoms was defined as a defect in the visual field, such as hemianopsia, at the time of admission. Stroke classification was based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria (6). In addition, stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), which reflects patient outcomes at admission and discharge (7). The modified Rankin Scale (mRS) was used to evaluate the prognosis of patients with cerebral infarction at admission, discharge, and 3 and 12 months after discharge (8,9). An mRS score of 0–2 points was considered a good outcome, whereas an mRS score ≥3 was considered a poor outcome (8,9).

Hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, ischemic heart disease, patent foramen ovale, previous stroke, smoking, and alcohol consumption have been identified as risk factors of stroke. Hypertension was defined as a condition in which a patient was diagnosed with hypertension before hospitalization or when systolic and diastolic blood pressures measured at a hospital were ≥140 and ≥90 mmHg, respectively (10). Diabetes mellitus was defined as a condition in which a patient was diagnosed with diabetes mellitus prior to hospitalization, fasting blood glucose for more than 8 h was ≥126 mg/dL, or random plasma glucose level was ≥200 mg/dL, with hyperglycemia symptoms (11). Dyslipidemia was defined as a condition in which the total cholesterol level was ≥200 mg/dL or a low-density lipoprotein (LDL) level of ≥130 mg/dL in a fasting blood test. A patient was defined as having a cardiac disease (e.g., atrial fibrillation, ischemic heart disease, patent foramen ovale, or congestive heart failure) when diagnosed by a cardiologist before or after hospitalization. Previous ischemic stroke was defined as a condition in which a patient was diagnosed with or treated for ischemic stroke due to PCA P1 occlusion before hospitalization. Smoking status was defined as smoking five or more cigarettes per day, whereas those who had quit smoking for 1 year or more were classified as non-smokers. Alcohol consumption was defined as consumption of 20 mg or more alcohol per day for more than 3 months. The thrombolysis group included patients hospitalized for PCA P1 occlusion, who received intravenous thrombolysis (IVT) or underwent IAT during hospitalization.

Imaging analysis

In the present study, P1 segment was defined from basilar artery to posterior communicating artery. Patients who underwent IAT were confirmed through CT angiography, and if CT angiography was unavailable, it was confirmed through magnetic resonance angiography (MRA). White matter hyperintensity (WMH) was defined as a hyperintense lesion on magnetic resonance imaging (MRI) T2-weighted imaging and fluid-attenuated inversion recovery (FLAIR) imaging (12). The severity of the WMH was graded according to the Fazekas scale (13). Microbleeds were defined as hemosiderin deposition ˂10 mm observed as a hypointense lesion on MRI T2-weighted imaging (12) and were categorized as absent [0], mild [1–2], moderate [3–10], or severe [>10], according to the number of observed microbleeds (14). The maximum Alberta Stroke Program Early CT (ASPECT) score (10 points) was used as a quantitative indicator of early ischemic changes on CT (15).

Statistical analysis

First, the demographics and laboratory findings were compared between patients with isolated PCA occlusion who underwent IAT and those who did not. In addition, we compared patients with PCA infarction and visual symptoms with those without visual symptoms. Pearson’s Chi-squared test or Fisher’s exact test was used to analyze categorical variables, and the t-test was used to analyze continuous variables. Second, multivariate analysis was performed to identify independent factors associated with poor outcomes (mRS score >2) in patients with isolated PCA occlusion and acute infarction. To avoid variable selection caused by spurious correlations, only variables showing a potential association (P<0.1) in univariate analysis were included in the multivariate logistic regression model as potential factors associated with good outcomes in patients with isolated PCA occlusion and acute infarction. Statistical significance was set at P<0.05 (two-tailed). All statistical analyses were performed using SPSS 21.0 (IBM Corp., Armonk, NY, USA).

Results

In the present study, 102 patients hospitalized for isolated PCA P1 occlusion were categorized into two groups: (I) a control group (n=72), comprising patients who did not undergo IAT, and (II) a patient group (n=30), including patients who underwent IAT (Figure 2). A comparison between the two groups was summarized in Table 1.

Figure 2 Representative neuroimaging with PCA occlusion: (A-C) images underwent IAT, and (D-F) images did not receive IAT. (A) Digital subtraction angiography showing right PCA occlusion prior to IAT. (B) Successful recanalization of the right PCA following IAT. (C) Diffusion-weighted DWI revealing acute infarction in right PCA territory. (D) Magnetic resonance angiography demonstrating left PCA occlusion. (E) Perfusion-weighted imaging (Tmax map) indicating delayed perfusion in the left PCA territory. (F) DWI showing established infarction in the left PCA distribution. DWI, magnetic resonance imaging; IAT, intra-arterial thrombectomy; PCA, posterior cerebral artery.

In the control group, 29 patients (40.3%) were female, and the mean age was 74.5 years. In the patient group, 16 patients (53.3%) were female, and the mean age was 75.3 years. No significant age differences were observed between the two groups. Patients who underwent IAT were more likely to have undetermined etiologies with two or more causes. Regarding stroke severity, NIHSS scores on admission were significantly higher in the patient group than in the control group (P<0.001). In comparing stroke risk factors, the proportion of patients with atrial fibrillation was higher in the patient group than in the control group (20.8% vs. 50.0%; P=0.003). In addition, the rate of procedure-related complications such as hemorrhagic transformation was very low in the patient group (4.7%).

Furthermore, study participants comprising 102 patients hospitalized for isolated PCA P1 occlusion were categorized into those with and those without visual symptoms (Table 2). The group with visual symptoms was younger (76.86±12.82 vs. 70.78±12.51 years; P=0.023), had higher ASPECT scores (9.22±1.44 vs. 9.75±0.73; P=0.018), and had a higher proportion of patients with no microbleeds (36.7% vs. 60.0%; P=0.013) than did the group without visual symptoms. Among patients who presented to the hospital beyond the time window for IVT administration, patients without visual symptoms were more likely to undergo IAT (27.3% vs. 8.3%; P=0.024). Moreover, stroke severity, as indicated by NIHSS scores at admission, was significantly higher in the group without visual symptoms (6.70±5.14 vs. 4.14±3.09; P=0.002).

In addition, based on prognosis, we classified patients with isolated PCA P1 occlusion into two groups, good outcome (mRS score, 0–2) and poor outcome (mRS score, 3–6), using the patients’ mRS scores at 3 months after symptom onset (Table 3). The good outcome and poor outcome groups did not show a significant difference in the proportion of patients undergoing thrombolysis (43.2% vs. 38.9%; P=0.667); however, the mean ASPECT score was significantly higher in the good outcome group (9.77±0.65 vs. 9.08±1.56; P=0.005). The poor outcome group had a significantly higher proportion of patients with severe WMHs (grade 3), as measured using the Fazekas scale (28.9% vs. 52.9%; P=0.032); in addition, the NIHSS score, indicative of stroke severity at admission, of the poor outcome group was significantly higher than that of the good outcome group (3.52±2.71 vs. 7.50±5.23; P<0.001). Although the difference was not significant, the proportion of patients with early neurological deterioration (END) in the poor outcome group was approximately 9.3%, whereas none of the patients in the good outcome group had END. In addition, the proportion of previous strokes, a stroke risk factor, was significantly higher in the poor outcome group than in the good outcome group (20.5% vs. 44.4%; P=0.012), and albumin levels in the poor outcome group were significantly lower at admission (4.28±0.38 vs. 3.91±0.51 g/dL; P<0.001).

Multivariate analysis was conducted to identify factors associated with good outcomes (mRS score, 0–2) in patients with stroke with isolated PCA P1 occlusion (Table 4). The results showed that a higher albumin level at admission was significantly associated with a good outcome in patients with stroke with isolated PCA P1 occlusion [adjusted odds ratio (OR), 7.754; 95% confidence interval (CI): 1.626–36.977; P=0.010], as was a lower NIHSS score at admission (adjusted OR, 1.408; 95% CI: 1.156–1.714; P=0.001).

Discussion

The treatment of ischemic stroke caused by large artery occlusion in the acute stage affects a patient’s long-term quality of life after recovery (16). Therefore, several studies have evaluated aggressive IAT during the acute stages of ischemic stroke. However, most of these studies have focused on isolated PCA occlusion of the anterior circulation, such as the ICA and MCA, and only few studies have examined the outcomes of IAT in patients with isolated PCA occlusion of the posterior circulation (17,18). Additionally, P1 supplies critical structures in the midbrain and diencephalon, especially the arterial inflow to the thalamus and subthalamus comes mainly from small perforating branches, there is a high possibility of hemiplegia and dysfunction in the event of P1 occlusion (19). Therefore, we evaluated the necessity and effectiveness of aggressive IAT within the golden hour for patients with isolated PCA occlusion.

The PCA supplies blood mainly to the occipital lobe; therefore, PCA occlusion usually causes visual symptoms. However, because the PCA also supplies blood to the internal capsule, posterior limb, and thalamus, isolated PCA occlusion may result in motor or sensory symptoms involving the corticospinal and spinothalamic tracts. In the NIHSS (7), which indicates stroke severity, visual symptoms account for only three points (approximately 7% of the total score of 42 points). The high NIHSS scores of patients presenting with isolated PCA occlusion at admission indicated that they had other symptoms, such as motor and sensory symptoms, in addition to visual symptoms. These findings suggest that these patients had large penumbral areas. In patients with isolated PCA occlusion, a high NIHSS score at admission may indicate a high risk of developing ischemia over a large area, and thus IAT may be considered, as suggested by the finding of this study. Furthermore, in the present study, the mRS scores of the control and patient groups differed at discharge; however, the prognoses at 3 and 12 months were not significantly different. Therefore, IAT should be considered.

Moreover, the group without visual symptoms had a higher NIHSS score than those with visual symptoms (Table 2; 6.70±5.14 vs. 4.14±3.09; P=0.002). The results showed that isolated PCA occlusion affected not only the occipital area, causing visual symptoms, but also other PCA branch arteries, resulting in other symptoms (20,21). Therefore, a higher NIHSS score in patients presenting with an isolated PCA occlusion may indicate the presence of lesions in relatively large areas and poor blood supply via the collateral artery.

The ASPECT score is typically used to assess ischemic changes in the MCA (15). When calculating the ASPECT score, the M3 region was the border zone of the PCA. Therefore, PCA occlusion may have a greater effect on the ASPECT scores of patients with more prominent PCA flow. The posterior circulation ASPECT score is related to the overall posterior circulation, including the basilar and vertebral arteries, and applying it specifically to isolated PCA occlusions may be challenging. In the present study, patients who showed good outcomes (mRS score, 0–2) after stroke had high ASPECT scores, suggesting that the ASPECT score may be helpful in predicting the prognosis of patients with isolated PCA occlusions (Table 3). In addition, the patient group with a poor prognosis for isolated PCA occlusion (poor outcome) had a higher Fazekas scale score, suggesting that white matter intensity was severe in the poor outcome group. These results agree with those of Bonkhoff et al. (22), who reported that the total white matter burden was associated with adverse outcomes in patients with stroke.

The results of this study revealed that a higher serum albumin level at admission was highly associated with a good prognosis at 3 months (adjusted OR, 7.754; 95% CI: 1.626–36.977; P=0.001), and a lower NIHSS score at admission was associated with a better prognosis (adjusted OR, 1.408; 95% CI: 1.156–1.714; P=0.001) (Table 4). Albumin, which constitutes the largest proportion of serum proteins, regulates osmotic pressure, and transports various endogenous molecules. Furthermore, albumin levels are affected by patients’ nutritional status and chronic inflammation. Paar et al. showed that albumin exerts anticoagulant effects by inhibiting platelet function (23). Therefore, decreased albumin levels may increase the risk of ischemic stroke associated with thrombosis and emboli. Li et al. confirmed that the risk of stroke (ischemia and hemorrhage) increases with decreasing albumin levels (24). The results of the present study showed that patients with isolated PCA occlusion and mRS score of 0–2 had significantly higher serum albumin levels (adjusted OR, 7.754; 95% CI: 1.626–36.977; P=0.010). This result implies that albumin plays a role in the prognosis of patients with stroke, in addition to increasing the risk of stroke due to albumin, as reported in previous studies.

Furthermore, in the patient group, the proportion of patients with mRS score of 0–2 was 23.3% at discharge and 43.3% at 3 months (Figure 3). In contrast, in the control group, the proportion of patients with an mRS score of 0–2 was 34.7% at discharge and 45.0% at 3 months (Figure 3). Although the patient group had a higher NIHSS score at admission, with the mRS score decreasing at discharge, the prognosis of patients in the patient group at 3 months was not significantly different from that of patients in the control group. Moreover, the patient group rarely had procedure-related complications such as the development of hemorrhagic transformation. Therefore, aggressive IAT is necessary for patients with isolated PCA occlusion.

Figure 3 This figure is divided into two parts according to thrombectomy use; the modified Rankin Scale scores measured at discharge and 3 months after discharge are schematized for each score.

This study had few limitations. First, because this was a retrospective study, we could not control for confounding variables that could affect the prognosis of isolated PCA occlusions. Second, the data were collected at a tertiary medical center with many patients with severe diseases, which may have induced selection bias. However, because thrombolytic treatment is rarely performed by primary care institutions and most patients with stroke symptoms visit tertiary medical centers, similar results would have been obtained if patients from primary and secondary medical centers were included in the analysis. Third, we evaluated only the total NIHSS score, an index of stroke severity, and were unable to analyze the detailed NIHSS score for each patient. Moreover, as the NIHSS and mRS scores were presented as the sum of the scores for each item, the effect of the evaluator’s subjective intervention could not be excluded, which is a limitation of this study. Visual symptoms were recorded based on patient complaints. In addition, no NIHSS cut-off score is available for IAT. Fourth, theoretically, comparing the isolated medication treatment group with the isolated IAT group is necessary to understand the effect of IAT on patient prognosis. However, IAT is rarely performed without adjunctive medical therapy; therefore, it was not possible to compare an isolated medication treatment group with an isolated IAT group. Moreover, as long-term medication is necessary to prevent recurrence in patients with ischemic stroke, a comparison of the two groups will be difficult in future studies. Finally, patient prognosis was evaluated via outpatient follow-up after discharge; however, only 80 patients had their mRS measured at 12 months, which was 22 fewer than the 102 patients included in the study. Because the mRS score at 3 months was used to evaluate prognosis, we believe that this limitation did not affect the results.

Conclusions

A high serum albumin level and low NIHSS score in a patient with isolated PCA occlusion at admission favorably affected prognosis at 3 months. Patients’ nutritional status and degree of neurological symptoms at admission affected their prognosis. Although no significant differences were observed, IAT was performed more often because patients with high NIHSS scores at admission were more likely to have a large area of PCA territorial infarction with visual or other symptoms. In addition, patients who underwent IAT showed a significant difference in the mRS scores at discharge; however, their mRS scores were not significantly different from those of patients who did not undergo IAT. Moreover, IAT may be associated with procedure-related complications, such as hemorrhagic transformation. Based on these results, we believe that a more aggressive implementation of IAT in patients with high NIHSS scores at admission may not adversely affect the prognosis.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1015/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1015/dss

Funding: This paper was supported by Fund of Biomedical Research Institute, Jeonbuk National University Hospital and Yuyu Pharmaceutical Co., Ltd.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1015/coif). H.G.K. reports that this study was supported by the Fund of Biomedical Research Institute, Jeonbuk National University Hospital, and Yuyu Pharmaceutical Co., Ltd. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Jeonbuk National University Hospital (No. 2023-10-006) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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