To compare the effectiveness and safety of EVT versus medical management (MM) in patients with acute PCA occlusion

Posterior 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.

A 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. Risk of bias was assessed with the Newcastle–Ottawa Scale. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models.

Nine 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).