Thrombolysis and Thrombectomy

Posterior circulation strokes (PCS) comprise a relatively small number of overall ischemic strokes; however, they carry a high level of morbidity and mortality. Clinicians must have a strong index of suspicion as presenting symptoms may be ambiguous and can occur in a smoldering fashion. Once recognized, acute intervention with thrombolytics or thrombectomy must be initiated immediately. The data are relatively sparse for systemic thrombolysis, local intra-arterial thrombolysis, and mechanical thrombectomy (MT) for PCS treatment compared to anterior circulation strokes (ACS), but if the vessel is not recanalized, outcomes are irrevocably poor. Multiple case series and reviews have demonstrated systemic and intra-arterial thrombolysis as promising recanalization methods for PCS. Furthermore, with the recent publications of the successful MT trials, MT has become the vogue option for treatment of PCS large-vessel occlusions (LVO). While current guidelines establish strict time criteria for treatment of ischemic strokes, there is some growing evidence that time should not limit treatment for PCS LVOs, given that the lack of treatment would result in a poor outcome. Optimizing triage and transport to appropriate centers, new-generation devices and neuroprotectants will be the next frontier in comprehensive acute PCS management.