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).
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.
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.
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.
ABBREVIATIONSADAPT = 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.
Correspondence Aman B. Patel, Massachusetts General Hospital, Department of Neurosurgery, 15 Parkman St., Wang 745, Boston, MA 02114. email: firstname.lastname@example.org.
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.
ChandraRVLeslie-MazwiTMMehtaBPDerdeynCPDemchukAMMenonBK: Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?. J Neurointerv Surg8:443–4462016
Delgado AlmandozJEKayanYYoungMLFeaseJLScholzJMMilnerAM: Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques. J Neurointerv Surg8:1123–11282016
NguyenTNMalischTCastonguayACGuptaRSunCHMartinCO: Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke45:141–1452014
PowersWJDerdeynCPBillerJCoffeyCSHohBLJauchEC: 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke46:3020–30352015
RomanoDGCioniSVinciSLPeroGComelliCComaiA: Thromboaspiration technique as first approach for endovascular treatment of acute ischemic stroke: initial experience at nine Italian stroke centers. J Neurointerv Surg9:6–102017