This systematic review and meta-analysis aimed to compare the efficacy and safety of EVT with or without IVT (EVT±IVT) versus IVT alone in patients with isolated PCA occlusion.

Posterior cerebral artery (PCA) occlusions account for 5–10% of ischemic strokes and are associated with visual, cognitive, and neuropsychological impairments. While intravenous thrombolysis (IVT) remains standard for eligible patients, the role of endovascular thrombectomy (EVT) in PCA strokes is uncertain.

A comprehensive search of PubMed, Scopus, and Web of Science was conducted from inception to July 2025. The study protocol was registered in PROSPERO with the registration number CRD420251133104. Eligible studies included randomized controlled trials and observational cohorts evaluating EVT±IVT versus IVT in PCA stroke. Outcomes of interest were 90-day modified Rankin Scale (mRS) scores (0–1 and 0–2), mortality, and symptomatic intracranial hemorrhage (sICH). Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model.

Five high-quality cohort studies comprising 2,101 patients were included. EVT±IVT did not significantly improve functional independence defined by mRS 0–1 compared with IVT (RR = 1.10; 95% CI: 0.95–1.27; p = 0.19). In contrast, IVT was associated with better odds of achieving mRS 0–2 (RR = 0.77; 95% CI: 0.61–0.98; p = 0.03). EVT±IVT was linked to a higher risk of sICH (RR = 2.35; 95% CI: 1.11–5.01; p = 0.03) and increased mortality (RR = 1.50; 95% CI: 1.03–2.18; p = 0.03).

In patients with isolated PCA occlusions, IVT alone was associated with better functional outcomes and lower risks of sICH and mortality compared with EVT±IVT. These findings support IVT as the preferred reperfusion therapy in eligible PCA strokes, while EVT should be reserved for carefully selected patients with proximal occlusions or disabling deficits.