BACKGROUND: The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. We compared clinical and technical outcomes with first-line stent retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion.

METHODS: This international case-control study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion presenting within 24 hours of time last seen well from January 2015 to August 2022. The primary outcome was the first-pass effect (FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3 on the first pass. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression.

RESULTS: There were 326 patients who met inclusion criteria, 56.1% male, median age 75 (interquartile range 65-82) years, and median National Institutes of Health Stroke Scale score 8 (5-12). Occlusion segments were PCA-P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First-line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. FPE was lower in patients treated with first-line CA or combined technique compared with SR (CA versus SR: adjusted odds ratio 0.45 [0.19-1.06]; P=0.07; combined versus SR: adjusted odds ratio 0.35 [0.016-0.80]; P=0.01). There were lower odds of functional independence (modified Rankin scale score 0-2) in the first-line CA versus SR alone group (adjusted odds ratio 0.52 [0.28-0.95]; P=0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0-2: 58% versus 43.4%; P=0.01; modified Rankin scale score 0-1: 36.6% versus 25.8%; P=0.05). Overall, symptomatic intracranial hemorrhage was present in 5.6% (18/326) and mortality in 10.9% (35/326) without difference between first-line technique.

CONCLUSION: In patients with isolated PCA occlusion, SR was associated with a higher rate of FPE compared with CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90 days was more likely with first-line SR compared with CA. FPE was associated with better 90-day clinical outcomes.