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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Neuroimaging Predictors of Futile Recanalization in Posterior Circulation Stroke: A Systematic Review and
Sana Mozaffari1, Faryar Koolinia1, Negin Safari Dehnavi1
1From the Medical School (S. Mozaffari, F.K., H.M., S. Mohammadzadeh), Sina Trauma and Surgery Research Center (N.S.D.), Students' Scientific Research Center (I.K.), Tehran University of Medical Sciences, Tehran, Iran; Medical School (Y.M.), Shiraz University of Medical Sciences, Shiraz, Iran; Department of Neuroradiology (D.A.L.), Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neuroradiology (H.A.S.), MD Anderson Cancer Center, Houston, TX, USA; Department of Neurology and Rehabilitation Medicine (Y.N.A.), Department of Radiology (A.S.), University of Cincinnati, OH, USA; Division of Interventional Neuroradiology (S. Majmundar), Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Neurointerventional & Neuroanalytics Collaboration (NAN-C) (A.A.D.), School of Medicine, Toronto Metropolitan University, Toronto, ON; Institute of Therapeutic Neuroradiology (A. A.D.), Nuffield Department of Surgical Sciences, Faculty of Clinical Medicine, University of Oxford, Oxford, UK; Department of Interventional Neuroradiology (A.G.), Erasme University Hospital, Brussels, Belgium; Department of Neurosurgery (R.X.), Biomedical Engineering (H.L.), Division of Neuroradiology (H.L., V.S.Y.), Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA; F.M. Kirby Research Center for Functional Brain Imaging (H.L.), Kennedy Krieger Research Institute, Baltimore, MD, USA; Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA, USA; Department of Neurology (D.L.), Neurovascular Imaging Research Core and UCLA Stroke Center, University of California at Los Angeles, CA, USA; Department of Radiology and Biomedical Imaging (K.N.), University of California, San Francisco, San Francisco, CA, USA; Department of Interventional Neuroradiology (J.J.H.), Stanford Medical Center, Palo Alto, CA, USA; Department of Radiology (T.D.F.), Neuroendovascular Program, University Medical Center Münster, Germany; Mallinckrodt Institute of Radiology (A.R.C.), Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA; Department of Neurology (E.A.F.), Harvard University, Boston, MA, USA; Division of Neurointerventional Surgery (F.H.), The Neuroscience Institute, The Queen's Medical Center, Honolulu, HI, USA and Stony Brook University Renaissance School of Medicine (V.S.V.), New York, New York, USA.
Purpose:
This systematic review and meta-analysis aimed to synthesize evidence on baseline and procedural neuroimaging markers associated with futile recanalization in posterior circulation stroke.
Data Sources:
A systematic search was conducted across PubMed, Scopus, Web of Science, and Embase from inception through April 2025.
Study Selection:
Studies evaluating neuroimaging predictors of futile recanalization in patients with posterior circulation stroke who achieved successful recanalization (mTICI ≥2b) after endovascular treatment were included.
Data Analysis:
Risk of bias was assessed using PROBAST. Random-effects meta-analysis was performed for imaging parameters reported in two or more studies. Heterogeneity was assessed using I2 statistics, and leave-one-out sensitivity analyses were conducted.
Data Synthesis:
Twelve studies comprising 3,521 patients met the inclusion criteria. Meta-analysis of five studies demonstrated that higher PC-ASPECTS scores were significantly associated with reduced odds of futile recanalization (pooled OR = 0.72, 95% CI: 0.60-0.86; I2 = 74.8%). The BATMAN collateral score showed a non-significant general direction toward lower futile recanalization with higher scores (OR = 0.81; 95% CI: 0.57-1.14; I2 = 51.8%). Additional imaging predictors identified across studies included PMT score, PC-CS, PComA patency, CBF <35% volume, and cerebral circulation time. Perfusion metrics such as hypoperfusion intensity ratio and core volume did not independently predict futile recanalization.
Limitations:
The current study has several limitations. A small number of included studies (mostly retrospective with limited sample sizes), high heterogeneity (I2 = 74.8% for PC-ASPECTS), varying definitions of functional outcome, differing covariates in multivariable models with possible residual confounding, and wide variation in study size/design. Furthermore, we were unable to perform reliable formal subgroup analyses, and publication-bias assessments due to only five eligible studies for PC-ASPECTS and two for BATMAN, necessitating reliance on qualitative assessment and leave-one-out sensitivity analyses while leaving publication bias and small-study effects unexcluded.
Conclusion:
PC-ASPECTS is a robust imaging predictor of futile recanalization in posterior circulation stroke. Location-based and collateral-based imaging parameters demonstrate greater prognostic value than volumetric thresholds in this territory. Integration of multiple imaging parameters into composite scores may enhance predictive accuracy and guide patient selection.

