Revascularization Strategies for Posterior Circulation Ischemic Stroke: Insights from a Comprehensive Analysis

A new network meta-analysis pooled outcomes for intravenous thrombolysis (IVT), endovascular therapy (EVT), and combined EVT+IVT in posterior-circulation ischemic stroke, finding combined therapy ranked highest for functional recovery while raising a clear trade‑off with hemorrhagic risk.

Posterior‑circulation strokes present anatomic and diagnostic challenges that complicate revascularization compared with anterior‑circulation disease. Practice has historically varied between EVT, IVT, or both; this meta‑analysis narrows that uncertainty and frames the clinician’s decision as weighing 90‑day mRS benefit against symptomatic intracranial hemorrhage (sICH) risk.

Efficacy results show EVT+IVT had the highest ranking for 90‑day functional independence (mRS 0–2; SUCRA 0.83; ProBest 0.69) versus EVT (SUCRA 0.36) and IVT (SUCRA 0.30), based on a network meta‑analysis of X trials (Y patients) reporting 90‑day mRS. Moderate between‑study heterogeneity was noted, which tempers certainty around the rank estimates.

Safety ranking favored IVT alone for lower symptomatic intracranial hemorrhage (sICH SUCRA 0.83) compared with EVT (SUCRA 0.44) and EVT+IVT (SUCRA 0.22).