A direct aspiration first-pass technique vs stentriever thrombectomy in emergent large vessel intracranial occlusions

Christopher J. Stapleton Departments of Neurosurgery and
Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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Thabele M. Leslie-Mazwi Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
Neurology and

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Collin M. Torok Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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Reza Hakimelahi Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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Joshua A. Hirsch Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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Albert J. Yoo Texas Stroke Institute, Plano, Texas

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James D. Rabinov Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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Aman B. Patel Departments of Neurosurgery and
Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and

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OBJECTIVE

Endovascular thrombectomy in patients with acute ischemic stroke caused by occlusion of the proximal anterior circulation arteries is superior to standard medical therapy. Stentriever thrombectomy with or without aspiration assistance was the predominant technique used in the 5 randomized controlled trials that demonstrated the superiority of endovascular thrombectomy. Other studies have highlighted the efficacy of a direct aspiration first-pass technique (ADAPT).

METHODS

To compare the angiographic and clinical outcomes of ADAPT versus stentriever thrombectomy in patients with emergent large vessel occlusions (ELVO) of the anterior intracranial circulation, the records of 134 patients who were treated between June 2012 and October 2015 were reviewed.

RESULTS

Within this cohort, 117 patients were eligible for evaluation. ADAPT was used in 47 patients, 20 (42.5%) of whom required rescue stentriever thrombectomy, and primary stentriever thrombectomy was performed in 70 patients. Patients in the ADAPT group were slightly younger than those in the stentriever group (63.5 vs 69.4 years; p = 0.04); however, there were no differences in the other baseline clinical or radiographic factors. Procedural time (54.0 vs 77.1 minutes; p < 0.01) and time to a Thrombolysis in Cerebral Infarction (TICI) scale score of 2b/3 recanalization (294.3 vs 346.7 minutes; p < 0.01) were significantly lower in patients undergoing ADAPT versus stentriever thrombectomy. The rates of TICI 2b/3 recanalization were similar between the ADAPT and stentriever groups (82.9% vs 71.4%; p = 0.19). There were no differences in the rates of symptomatic intracranial hemorrhage or procedural complications. The rates of good functional outcome (modified Rankin Scale Score 0–2) at 90 days were similar between the ADAPT and stentriever groups (48.9% vs 41.4%; p = 0.45), even when accounting for the subset of patients in the ADAPT group who required rescue stentriever thrombectomy.

CONCLUSIONS

The present study demonstrates that ADAPT and primary stentriever thrombectomy for acute ischemic stroke due to ELVO are equivalent with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. Given the reduced procedural time and time to TICI 2b/3 recanalization with similar functional outcomes, an initial attempt at recanalization with ADAPT may be warranted prior to stentriever thrombectomy.

ABBREVIATIONS

ADAPT = a direct aspiration first-pass technique; ASPECTS = Alberta Stroke Program Early CT Score; CASPER = combined aspiration and stentriever; CTA = CT angiography; DWI = diffusion-weighted imaging; ELVO = emergent large vessel occlusion; ICA = internal carotid artery; MCA = middle cerebral artery; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; sICH = symptomatic intracranial hemorrhage; TICI = Thrombolysis in Cerebral Infarction; tPA = tissue plasminogen activator.
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