Endovascular therapy versus medical management in posterior cerebral artery stroke: neurological gains without functional superiority: a meta-analysis.

backgroundPosterior 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. We conducted this systematic review and meta-analysis to compare the effictiveness and safety of EVT versus medical management (MM) in patients with acute PCA occlusion.

methodsA 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. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models.

resultsNine 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).

conclusionsEVT for PCA was associated with short-term neurological improvement versus MM, with mortality and sICH remaining comparable. However, these benefits did not translate into superior long-term functional outcomes as measured by mRS. The unique clinical features of PCA stroke, particularly visual and cognitive impairments not adequately captured by global disability scales, may contribute to this discrepancy. High-quality randomized trials incorporating domain-specific outcomes are warranted to define the role of EVT in PCA occlusion.