Endovascular recanalization for acute posterior cerebral artery occlusion: a pre-specified secondary analysis of the ATTENTION, BAOCHE, and PLATO studies.

BACKGROUND

Acute posterior cerebral artery (PCA) occlusion causes disabling deficits, but evidence for endovascular therapy (EVT) is lacking. This gap exists between established efficacy of thrombectomy in anterior and posterior circulations.

OBJECTIVE

To evaluate evidence for PCA thrombectomy via a pre-specified synthesis of the ATTENTION, BAOCHE, and PLATO studies.

METHODS

Three evidence layers were integrated: (1) indirect supportive evidence from two RCTs on basilar artery occlusion (ATTENTION/BAOCHE) for posterior circulation EVT; (2) the targeted observational PLATO study for isolated PCA occlusion; and (3) connecting subgroup data. Efficacy and safety estimates (adjusted Risk Ratio [aRR] /adjusted Odds Ratio [aOR], 95% CI) were compared across studies.

RESULTS

ATTENTION (aRR 2.06, 1.46-2.91) and BAOCHE (aRR 1.81, 1.26-2.60) indirectly support the feasibility of the principle, enrolling relevant basilar tip occlusions (33% in ATTENTION, 12% in BAOCHE). PLATO provides direct target data, suggesting potential benefit for PCA occlusion (functional recovery aOR 1.13, 0.85-1.50); complete vision recovery (70% vs. 43%, p = 0.002) with a higher mortality signal (RR 2.15, 1.32-3.50). Evidence assessment scores high for principle feasibility in RCTs (9/10) and target-specificity in PLATO (9/10), identifying a critical gap in dedicated PCA RCT evidence.

CONCLUSION

Endovascular therapy for acute PCA occlusion is physiologically plausible, shows promising direct signals, but lacks randomized confirmation. This synthesis suggests that EVT may be considered in severe cases but underscores the urgent need for a dedicated PCA thrombectomy RCT.