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J Neurointerv Surg. 2019 Apr 11. pii: neurintsurg-2018-014624. doi: 10.1136/neurintsurg-2018-014624. [Epub ahead of print]

'Real-world' comparison of first-line direct aspiration and stent retriever mechanical thrombectomy for the treatment of acute ischemic stroke in the anterior circulation: a multicenter international retrospective study.

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Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA.
The Mount Sinai Health System, New York, USA.
Department of Neurosurgery, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA.
Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.
Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.
SUNY SB, New York, USA.
Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA.
Britton Woodward, Knoxville, Tennessee, USA.
Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA.
Department of Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA.
Department of Interventional Neuroradiology, Abbott Northwestern Hospital, Minnesota, USA.
Royal University Hospital, University of Saskatchewan, Department of Neurosurgery, Saskatoon, Saskatchewan, Canada.
Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
UT Dept Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA.
Department of Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA.
Department of Neurology and Radiology, UCSF, San Francisco, California, USA.
Baptist Cardiac and Vascular Institute, Miami, Florida, USA.



Thrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to 'real-world' practice.


To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting.


Data from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores.


Adequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever.


Our data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.


direct aspiration; ischemic stroke; mechanical thrombectomy; revascularization; stent-retriever

Conflict of interest statement

Competing interests: AHS: financial interest/investor/stock options/ownership: Imperative Care, Q’Apel Medical, Inc; consultant/advisory board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Inc, Stryker. JE: consultant: Stryker Neurovascular, Medtronic. AT: consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW0: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: consultant: Stryker, Cerenovus, Microvention. BB: consultant: Penumbra, Medtronic, Stryker; shareholder: Penumbra. RH: grant/research support: Medtronic, Stryker, Microvention; consultant: Medtronic, Stryker, Cerenovous, Microvention, Balt. JEDA: consultant: Penumbra, Medtronic, Microvention. ASA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. AA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. MK: consultant: Penumbra, Medtronic. LP: consultant: Medtronic. DF: consultant/speakers bureau: Penumbra; Stryker; research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; stock ownership: Penumbra. IL: consultant: Medtronic, Stryker, Cerenovus. RDL: consultant: Cerenovus, Penumbra, Q’Apel Medical Inc, Imperative Care, Mivi Neuroscience; research support: Medtronic, Asahi Intec. JM: consultant: Cerebrotech, Rebound Therapeutics, TSP Inc, Lazarus Effect, Medina, Pulsar Vascular; investor: Blockade, Medina, Lazarus Effect, TSP Inc; research support: Penumbra

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