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Thrombectomy an option for primary distal posterior cerebral artery occlusion stroke

Journal
JAMA Neurology
Reuters Health - 23/02/2021 - Mechanical thrombectomy is a "reasonable, safe and technically feasible" option for isolated posterior circulation distal, medium vessel occlusion (DMVO) stroke, although it's rarely performed at comprehensive stroke centers, according to new research.

Isolated occlusions of the posterior cerebral artery (PCA) account for about 5% to 10% of all ischemic strokes, researchers note in JAMA Neurology.

"Given the latest advances in catheter technology and the development of smaller thrombectomy devices together with increasing neuroendovascular expertise, DMVO has been declared as a potential frontier in endovascular treatment (EVT) of acute ischemic stroke," write Dr. Lukas Meyer, with University Medical Center Hamburg-Eppendorf, in Germany, and colleagues. Yet clinical evidence of EVT for posterior circulation DMVO is lacking, they add.

Drawing on data from several centers, the team assessed the frequency, safety and clinical outcomes of mechanical thrombectomy versus standard medical treatment with or without intravenous thrombolysis (IVT) for primary distal occlusion of the P2 or P3 segment of the PCA.

After propensity-score matching, there were 92 patients in each group who were treated at stroke centers in Europe, the United States and Asia.

One hundred forty-three of 9,184 stroke thrombectomy patients (1.6%) were treated with mechanical thrombectomy for posterior circulation DMVO during the study period.

Mechanical thrombectomy showed "early clinical treatment benefits" on the National Institutes of Health Stroke Scale (NIHSS) compared with standard medical treatment alone, the researchers say.

At discharge, the mean NIHSS score decrease was -3.9 points in the thrombectomy group versus -2.4 points in the standard medical treatment group (P=0.06).

The mean difference in NIHSS score decrease was significantly higher in the thrombectomy group vs. those on standard medical treatment for the subgroup of patients with NIHSS score of 10 points or higher on admission (mean difference, -5.6; P=0.04) and in the subgroup of patients who were not eligible for IVT (mean difference, -3.0; P=0.005).

In line with prior studies, a successful "first-pass effect" associated with complete reperfusion was independently associated with early neurological improvement with mechanical thrombectomy.

"This finding emphasizes once more that technical success is associated with high treatment effects (compared with achieving complete reperfusion after multiple attempts) and that first-pass effect remains one of the most valuable therapy goals in endovascular stroke treatment, regardless of the occlusion site," the study team writes.

Thrombectomy also appeared to be safe - with no increased risk for intracerebral hemorrhage or in-hospital or 90-day mortality rates compared with medical therapy - and technically feasible in terms of successful recanalization.

The researchers emphasize that the retrospective nonrandomized design of the study does not allow general treatment recommendations.

A randomized controlled trial comparing mechanical thrombectomy with standard medical treatment is needed to "evaluate the use of thrombectomy for posterior circulation DMVO and to resolve clinical equipoise in acute therapeutic decision-making," they conclude.

The study had no specific funding. Dr. Meyer did not respond to a request for comment by press time.

SOURCE: https://bit.ly/3aJjnJq JAMA Neurology, online February 22, 2021.

By Reuters Staff



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