Etiology of Large Vessel Occlusion Posterior Circulation Stroke: Results of the MR CLEAN Registry
Authors: Pirson F.A.V. (Anne) , Boodt Nikki , Brouwer Josje , Bruggeman Agnetha A.E. , Hinsenveld Wouter H. , Staals Julie , van Zwam Wim H. , van der Leij Christiaan , Brans Rutger J.B. , Majoie Charles B.L.M. , Dippel Diederik W.J. , van der Lugt Aad , Schonewille Wouter J. , van Oostenbrugge Robert J. , Dippel Diederik W.J. , van der Lugt Aad , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , van Oostenbrugge Robert J. , van Zwam Wim H. , Boiten Jelis , Albert Vos Jan , Jansen Ivo G.H. , Mulder Maxim J.H.L. , Goldhoorn Robert- Jan B. , Compagne Kars C.J. , Kappelhof Manon , Brouwer Josje , den Hartog Sanne J. , Hinsenveld Wouter H. , Dippel Diederik W.J. , Roozenbeek Bob , van der Lugt Aad , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , Emmer Bart J. , Coutinho Jonathan M. , Schonewille Wouter J. , Vos Jan Albert , Wermer Marieke J.H. , van Walderveen Marianne A.A. , van Es Adriaan C.G.M. , Staals Julie , van Oostenbrugge Robert J. , van Zwam Wim H. , Hofmeijer Jeannette , Martens Jasper M. , Lycklama à Nijeholt Geert J. , Boiten Jelis , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Bart van der Worp H. , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Vries J. , de Kort Paul L.M. , van Tuijl Julia , Peluso Jo P. , Fransen Puck , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eschgi Omid , Bokkers Reinoud P.H. , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Sturm Emiel J.C. , Brouwers Paul J.A.M. , Majoie Charles B.L.M. , van Zwam Wim H. , van der Lugt Aad , Lycklama à Nijeholt Geert J. , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , van den Berg René , Yoo Albert J. , Beenen Ludo F.M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Emmer Bart J. , Martens Jasper M. , Yo Lonneke S.F. , Albert Vos Jan , Bot Joost , van Doormaal Pieter-Jan , Meijer Anton , Ghariq Elyas , Bokkers Reinoud P.H. , van Proosdij Marc P. , Menno Krietemeijer G. , Peluso Jo P. , Boogaarts Hieronymus D. , Lo Rob , Gerrits Dick , Dinkelaar Wouter , Appelman Auke P.A. , Hammer Bas , Pegge Sjoert , van der Hoorn Anouk , Vinke Saman , Cornelissen Sandra , van der Leij Christiaan , Brans Rutger , Dippel Diederik W.J. , van der Lugt Aad , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , van Oostenbrugge Robert J. , van Zwam Wim H. , Lycklama à Nijeholt Geert J. , Boiten Jelis , Albert Vos Jan , Schonewille Wouter J. , Hofmeijer Jeannette , Martens Jasper M. , Bart van der Worp H. , Lo Rob H. , van Oostenbrugge Robert J. , Hofmeijer Jeannette , Zwenneke Flach H. , Lingsma Hester F. , Ghannouti Naziha el , Sterrenberg Martin , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , Simons Michelle , Vossers Marjolein , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , Messchendorp Gert , Nicolaij Nynke , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert Maureen , Verheesen Sabrina , Jeurrissen D. , Bos Erna , Drabbe Yvonne , Sandiman Michelle , Aaldering Nicoline , Zweedijk Berber , Vervoort Jocova , Ponjee Eva , Romviel Sharon , Kanselaar Karin , Barning Denn , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Berkhemer Olvert A. , Boers Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Treurniet Kilian M. , Tolhuisen Manon L. , Alves Heitor , Weterings Annick J. , Kirkels Eleonora L.F. , Voogd Eva J.H.F. , Schupp Lieve M. , Collette Sabine L. , Groot Adrien E.D. , LeCouffe Natalie E. , Konduri Praneeta R. , Prasetya Haryadi , Arrarte-Terreros Nerea , Ramos Lucas A. , Boodt Nikki , Pirson Anne F.A.V. , Bruggeman Agnetha A.E. 
Published: May 2022

Background:
In patients with large vessel occlusion stroke of the anterior circulation, underlying cause is a determinant of outcome. Whether this is the case for posterior circulation large vessel occlusion stroke has yet to be determined. We aimed to report on cause in patients with posterior circulation stroke treated with endovascular thrombectomy and to analyze the association with functional outcome.

Methods:
We used data of patients with posterior circulation stroke included in the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, a prospective multicenter observational study, between 2014 and 2018. Stroke cause was categorized into large artery atherosclerosis (LAA), cardioembolism, arterial dissection, embolic stroke of undetermined source (ESUS), other determined cause, or undetermined cause. For primary analysis on the association between cause and outcome, we used multivariable ordinal logistic regression analysis to estimate the adjusted common odds ratio for a shift towards a better functional outcome on the modified Rankin Scale at 90 days with LAA as a reference group. Secondary outcomes included favorable functional outcome (modified Rankin Scale score 0–3), National Institutes of Health Stroke Scale score at 24 to 48 hours, reperfusion on digital subtraction angiography, and stroke progression.

Results:
Of 264 patients with posterior circulation stroke, 84 (32%) had LAA, 48 (18%) cardioembolism, 31 (12%) dissection, and 14 (5%) ESUS. Patients with a dissection were younger (48 [interquartile range, 43–60] years) and had a lower National Institutes of Health Stroke Scale at baseline (12 [interquartile range, 6–31]) than patients with other cause. Functional outcome was better for patients with cardioembolism and ESUS compared to LAA (modified Rankin Scale adjusted common odds ratio, 2.4 [95% CI, 1.1–5.2], respectively adjusted common odds ratio, 3.1 [95% CI, 1.0–9.3]). Patients with a dissection had a lower chance of successful reperfusion compared with LAA (adjusted odds ratio, 0.20 [95% CI, 0.06–0.70]).

Conclusions:
Unlike the anterior circulation, most frequent cause in our posterior large vessel occlusion stroke cohort is LAA followed by cardioembolism, dissection, and ESUS. Patients with cardioembolism and ESUS have a better prognosis for functional outcome after endovascular thrombectomy than patients with LAA.