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

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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.

Article Information

Correspondence Aman B. Patel, Massachusetts General Hospital, Department of Neurosurgery, 15 Parkman St., Wang 745, Boston, MA 02114. email: abpatel@mgh.harvard.edu.

INCLUDE WHEN CITING Published online April 14, 2017; DOI: 10.3171/2016.11.JNS161563.

Drs. Stapleton and Leslie-Mazwi contributed equally to this work.

Disclosures Dr. Hirsch is a consultant for Medtronic and CareFusion and a member of the data and safety monitoring board of Codman NV. Dr. Patel is consultant for Medtronic-Covidien and Penumbra. Dr. Yoo is a consultant for Neuravi and receives non–study-related clinical or research support from Penumbra.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A 46-year-old male patient presented with an NIHSS score of 12 and right MCA syndrome. CTA showed a right ICA terminus occlusion. A: MRI demonstrated acute infarction of the right anterior temporal lobe, insula, and basal ganglia as assessed by DWI. B: Initial diagnostic cerebral angiography confirmed the right ICA terminus occlusion. C: A single ADAPT attempt resulted in recanalization of the right ICA terminus, but persistent partial occlusion of the distal right M1 MCA (arrow). D: A second ADAPT attempt resulted in TICI 3 recanalization of the right anterior circulation. Figure is available in color online only.

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    A 59-year-old female patient presented with an NIHSS score of 20 and left MCA syndrome. CTA showed a proximal left M1 MCA occlusion. A: MRI demonstrated acute infarction of the left insula as assessed by DWI. B: Initial diagnostic cerebral angiography confirmed the proximal left M1 MCA occlusion. C and D: A single ADAPT attempt resulted in recanalization of the left M1 MCA but persistent occlusion of the left M2 MCA superior division (arrow). E and F: A 4 mm × 20–mm Solitaire FR stentriever was then employed for mechanical thrombectomy, resulting in TICI 2b recanalization of the left anterior circulation. Figure is available in color online only.

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