Direct Aspiration versus Stent Retriever Thrombectomy for Acute Stroke: A Systematic Review and Meta-Analysis in 9127 Patients

Christopher T Primiani; Angel Chinea Vicente; Michael T Brannick; Aquilla S Turk; J Mocco; Elad I Levy; Adnan H Siddiqui; Maxim Mokin

doi:10.1016/j.jstrokecerebrovasdis.2019.01.034

Direct Aspiration versus Stent Retriever Thrombectomy for Acute Stroke: A Systematic Review and Meta-Analysis in 9127 Patients

J Stroke Cerebrovasc Dis. 2019 May;28(5):1329-1337. doi: 10.1016/j.jstrokecerebrovasdis.2019.01.034. Epub 2019 Feb 14.

Authors

Christopher T Primiani¹, Angel Chinea Vicente¹, Michael T Brannick², Aquilla S Turk³, J Mocco⁴, Elad I Levy⁵, Adnan H Siddiqui⁵, Maxim Mokin⁶

Affiliations

¹ Department of Neurosurgery, University of South Florida, Tampa, Florida.
² Department of Psychology, University of South Florida, Tampa, Florida.
³ Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina.
⁴ Department of Neurosurgery, Mount Sinai Health System, New York, New York.
⁵ Department of Neurosurgery, University at Buffalo, Buffalo, New York.
⁶ Department of Neurosurgery, University of South Florida, Tampa, Florida. Electronic address: mokin@health.usf.edu.

PMID: 30772159
DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.034

Abstract

Background: The two most common approaches to thrombectomy of emergent large vessel occlusion (direct aspiration and primary stent retriever thrombectomy) have been extensively studied; however, the detailed benefit and risk comparison is largely unknown.

Objective: To conduct a systematic review and meta-analysis to compare radiographic and clinical outcomes between the use of primary stent retrievers and direct aspiration in management of acute ischemic stroke.

Methods: PubMed database was searched for studies between September 1, 2012 and December 31, 2017 with acute ischemic stroke patients.

Results: We identified 64 studies with 6875 patients in the primary stent retriever group and 25 studies with 2252 patients in the aspiration group. Primary aspiration alone, without the need of rescue stent retriever devices within the aspiration cohort, was performed in 65% of 2252 patients. There was no difference in the distribution of emergent large vessel occlusion based on occlusion site, age, baseline National Institutes of Health Stroke Scale, or the use of intravenous tPA (P = .19, .051, .23, and .093, respectively). Successful recanalization rates, defined as thrombolysis in cerebral Infarction 2b/3, were significantly higher in the aspiration group than the primary stent retriever group (89% versus 80%, P < .0001). No significant difference in good clinical outcome, defined as modified Rankin scale 0-2 (aspiration 52% versus stent 48%, P = .13), symptomatic intracerebral hemorrhage (aspiration 5.6% versus stent 7.2%, P = .07), and mortality at 3 months (aspiration 15% versus stent 19%, P = .10).

Conclusions: Both aspiration-first (including the subsequent use of stent retriever) and primary stent retriever thrombectomy approaches are equally effective in achieving good clinical outcomes. Our study suggests that direct aspiration with or without subsequent use of stent retriever is a safe and effective alternative to primary stent retriever in acute ischemic stroke.

Keywords: ADAPT; Stent; aspiration; endovascular; stroke; thrombectomy.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Aged
Disability Evaluation
Endovascular Procedures* / adverse effects
Endovascular Procedures* / instrumentation
Endovascular Procedures* / mortality
Female
Humans
Male
Middle Aged
Recovery of Function
Risk Factors
Stroke / diagnosis
Stroke / mortality
Stroke / physiopathology
Stroke / therapy*
Suction
Thrombectomy / adverse effects
Thrombectomy / instrumentation
Thrombectomy / methods*
Thrombectomy / mortality
Time Factors
Treatment Outcome