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Peer-reviewedCC BY 4.0Frontiers in Neurology

Cause-specific mortality after endovascular treatment for anterior vs. posterior circulation large vessel occlusion: a multicenter cohort study

  • Miao Li1,2
  • Yue Wan3
  • Yi Mo4
  • Jingwei Li5
  • Xiaoli Zhang2,6
  • Xiongjun He7
  • Hanlin Chen1,2
  • Mingxuan Huang1,2
  • Jinghan Guo1,2
  • Feng Gao1,2
  • Dapeng Mo1,2
  • Ning Ma1,2
3 more authors
  • Zhongrong Miao1,2
  • Anxin Wang2,6
  • Yiming Deng1,2
7 affiliations
  1. 1Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
  2. 2China National Clinical Research Center for Neurological Diseases
  3. 3Department of Neurology, The Third People’s Hospital of Hubei Province
  4. 4Department of Neurosurgery, The First People’s Hospital of Changzhou
  5. 5Department of Neurology of Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University
  6. 6Department of Epidemiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
  7. 7Department of Neurology, Shenzhen Hospital, Southern Medical University
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Abstract

Background: Acute ischemic stroke due to large vessel occlusion (AIS-LVO) carries substantial mortality despite endovascular treatment (EVT). Whether causes of death differ between anterior (AVO) and posterior (PVO) circulation occlusions is poorly characterized. We compared cause-specific 90-day mortality between patients with AVO and PVO treated with EVT.

Methods: In this multicenter retrospective cohort, consecutive patients with AIS-LVO who underwent EVT at 111 hospitals in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Workflow Improvement of acute ischemic stroke]) were included, and adjudicated causes of death were grouped into prespecified categories. Cause-specific mortality was assessed in the complete analytic cohort using the Fine-Gray subdistribution hazard model, with survivors censored at 90 days and deaths from other causes treated as competing events. Cumulative incidence functions were estimated with the Aalen-Johansen estimator.

Results: Among 1,671 eligible patients (1,300 AVO, 371 PVO), 228 deaths (13.6%) occurred within 90 days. All-cause mortality was higher in PVO than AVO (19.4% vs. 12.0%). Cerebral edema-related death was significantly more frequent in PVO than AVO (90-day cumulative incidence 9.16% vs. 4.15%; adjusted subdistribution hazard ratio [sHR] 0.47, 95% CI 0.30–0.73, p = 0.001; Gray’s test p < 0.001). Fatal hemorrhagic transformation was numerically more frequent in AVO but did not reach statistical significance in the complete cohort (3.77% vs. 1.89%; adjusted sHR 1.76, 95% CI 0.78–3.98, p = 0.17; Gray’s test p = 0.076), consistent across all sensitivity analyses. Pneumonia-related (adjusted sHR 0.34, 95% CI 0.17–0.68, p = 0.003) and recurrent stroke-related (adjusted sHR 0.29, 95% CI 0.10–0.86, p = 0.026) deaths were also more frequent in PVO; the pneumonia association remained significant after Bonferroni correction, whereas the recurrent stroke association did not.

Conclusion: Fatal complications after EVT differ by occlusion territory. Posterior circulation occlusion is independently associated with a higher risk of death from cerebral edema, pneumonia, and recurrent stroke, although the recurrent stroke association did not survive Bonferroni correction. Hemorrhagic transformation accounted for a larger share of anterior circulation deaths, but this did not correspond to a statistically significant increase in risk in the complete cohort.

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Cite

BibTeXRIS
BibTeX
@article{li2026causespecific,
  title = {{Cause-specific mortality after endovascular treatment for anterior vs. posterior circulation large vessel occlusion: a multicenter cohort study}},
  author = {Miao Li and Yue Wan and Yi Mo and Jingwei Li and Xiaoli Zhang and Xiongjun He and Hanlin Chen and Mingxuan Huang and Jinghan Guo and Feng Gao and Dapeng Mo and Ning Ma and Zhongrong Miao and Anxin Wang and Yiming Deng},
  journal = {Frontiers in Neurology},
  year = {2026},
  month = oct,
  doi = {10.3389/fneur.2026.1948536},
  url = {https://www.frontiersin.org/articles/10.3389/fneur.2026.1948536/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Cause-specific mortality after endovascular treatment for anterior vs. posterior circulation large vessel occlusion: a multicenter cohort study
AU  - Miao Li
AU  - Yue Wan
AU  - Yi Mo
AU  - Jingwei Li
AU  - Xiaoli Zhang
AU  - Xiongjun He
AU  - Hanlin Chen
AU  - Mingxuan Huang
AU  - Jinghan Guo
AU  - Feng Gao
AU  - Dapeng Mo
AU  - Ning Ma
AU  - Zhongrong Miao
AU  - Anxin Wang
AU  - Yiming Deng
PY  - 2026
DA  - 2026/10/26
JO  - Frontiers in Neurology
DO  - 10.3389/fneur.2026.1948536
UR  - https://www.frontiersin.org/articles/10.3389/fneur.2026.1948536/full
AB  - Background: Acute ischemic stroke due to large vessel occlusion (AIS-LVO) carries substantial mortality despite endovascular treatment (EVT). Whether causes of death differ between anterior (AVO) and posterior (PVO) circulation occlusions is poorly characterized. We compared cause-specific 90-day mortality between patients with AVO and PVO treated with EVT.  Methods: In this multicenter retrospective cohort, consecutive patients with AIS-LVO who underwent EVT at 111 hospitals in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Workflow Improvement of acute ischemic stroke]) were included, and adjudicated causes of death were grouped into prespecified categories. Cause-specific mortality was assessed in the complete analytic cohort using the Fine-Gray subdistribution hazard model, with survivors censored at 90 days and deaths from other causes treated as competing events. Cumulative incidence functions were estimated with the Aalen-Johansen estimator.  Results: Among 1,671 eligible patients (1,300 AVO, 371 PVO), 228 deaths (13.6%) occurred within 90 days. All-cause mortality was higher in PVO than AVO (19.4% vs. 12.0%). Cerebral edema-related death was significantly more frequent in PVO than AVO (90-day cumulative incidence 9.16% vs. 4.15%; adjusted subdistribution hazard ratio [sHR] 0.47, 95% CI 0.30–0.73, p = 0.001; Gray’s test p < 0.001). Fatal hemorrhagic transformation was numerically more frequent in AVO but did not reach statistical significance in the complete cohort (3.77% vs. 1.89%; adjusted sHR 1.76, 95% CI 0.78–3.98, p = 0.17; Gray’s test p = 0.076), consistent across all sensitivity analyses. Pneumonia-related (adjusted sHR 0.34, 95% CI 0.17–0.68, p = 0.003) and recurrent stroke-related (adjusted sHR 0.29, 95% CI 0.10–0.86, p = 0.026) deaths were also more frequent in PVO; the pneumonia association remained significant after Bonferroni correction, whereas the recurrent stroke association did not.  Conclusion: Fatal complications after EVT differ by occlusion territory. Posterior circulation occlusion is independently associated with a higher risk of death from cerebral edema, pneumonia, and recurrent stroke, although the recurrent stroke association did not survive Bonferroni correction. Hemorrhagic transformation accounted for a larger share of anterior circulation deaths, but this did not correspond to a statistically significant increase in risk in the complete cohort.
SN  - 1664-2295
ER  -