Do you recommend endovascular therapy in patients with isolated posterior cerebral artery stroke?

The general approach to acute ischemic stroke - (1) assess your patient for clinical suitability for EVT and then (2) look at your imaging - still applies to ischemic stroke due to PCA occlusion. For example, if the deficit is only a quadrantanopia in an elderly patient who already does not drive, then no, I would not offer EVT; I would consider medical treatment, including thrombolysis, only. If the deficit is more severe - hemianopia, some degree of hemiparesis - and the patient needs full visual fields for employment, etc., and we are early in the time from onset (<4.5 h), I would consider EVT. The lessons from ESCAPE-MeVO, DISTALS, DISCOUNT, and ORIENTAL-MeVO trials are that: all patients with MeVO do not benefit from EVT; some patients...

There is limited data on EVT for PCA occlusions. The two studies I am familiar with are the TOPMOST study and the PLATO study, both of which are retrospective. The data from these studies suggest that EVT may improve recovery, including visual outcomes, compared to medical management. However, these benefits are offset by an increased risk of intracranial hemorrhage & mortality.

In clinical practice, I assess PCA occlusions on a case-by-case basis, when patients present within a 24-hour window and imaging indicates salvageable tissue. My decision to intervene is generally based on the level of consciousness, visual impairment, and associated motor deficits. There is no specific NIHSS threshold for these cases but I typically intervene when t...