Endovascular Therapy Versus Best Medical Treatment in Posterior Cerebral Artery Stroke: A Systematic Review and Meta‐Analysis

INTRODUCTION: Posterior cerebral artery (PCA) stroke, while comprising a smaller proportion of ischemic strokes, often results in significant neurological deficits and poses distinctive therapeutic challenges. This study aims to systematically review and meta-analyze the efficacy and safety of EVT compared with best medical management (BMM) in patients with PCA stroke. METHODS: Electronic searches of PubMed, Embase, and Scopus up to July 2025 identified studies comparing EVT and BMM for PCA stroke. Eligible studies included patients with PCA stroke, compared EVT with BMM, and reported at least one outcome of interest. Statistical analyses employed random or fixed-effects models as appropriate; results are presented as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI). RESULTS: A total of 12 studies were included, encompassing 39,525 patients (2,540 EVT; 37,075 BMM). EVT was associated with significantly increased odds of early neurological improvement (ENI) (OR 2.11, 95% CI 1.81-2.45), and greater reduction in NIHSS at 24 h (MD -1.30, 95% CI -1.89 to -0.71). There was no significant difference in visual field normalization and no difference in excellent functional outcome. EVT was associated with lower odds of achieving functional independence (mRS 0-2 at 90 days: OR 0.75, 95% CI 0.67-0.85), and significantly increased risks of symptomatic intracranial hemorrhage (OR 2.32, 95% CI 1.66-3.23) and mortality at 90 days (OR 1.86, 95% CI 1.47-2.35). CONCLUSION: In PCA stroke, endovascular thrombectomy (EVT) confers early neurological recovery but does not improve long-term functional independence and is associated with higher risks of symptomatic hemorrhage and mortality compared with BMM. While EVT may benefit selected patients, these results underscore the need for individualized treatment decisions and prospective randomized trials focused on PCA stroke.