First-line use of contact aspiration not superior to stent retriever for acute ischemic stroke

1. In patients presenting with acute ischemic stroke, first-line use of contact aspiration was not found to result in an increased successful revascularization rate compared to first line use of a stent retriever.

2. The degree of disability post-procedure and the procedure-related serious adverse events did not differ significantly.

Evidence Rating Level: 1 (Excellent)

Study Rundown: For patients with acute ischemic stroke, recent studies demonstrated the superiority of mechanical thrombectomy over standard medical management alone. Thus, increasing studies have looked at different methods of thrombectomy. Contact aspiration has gained popularity because it is thought to result in quicker revascularization at a lower cost, but others argue it may delay revascularization if the more thorough stent retriever technique is ultimately necessary. The purpose of this study was to evaluate whether first-line contact aspiration resulted in an increased successful revascularization rate compared to first line use of a stent retriever. In 381 patients with acute ischemic stroke who were randomized to first line contact aspiration or first line stent retriever in 8 stroke centers in France from 2015-2016, 85.4% in the contact aspiration group were successfully revascularized vs. 83.1% in the stent retriever group. This was not statistically significant. There were also no significant differences in adverse events.

Overall, this study suggests that first line contact aspiration did not result in an increased successful revascularization rate compared with first line stent retriever use. However, this study had a superiority design in order to detect a 15% difference, and so was not powered to detect a smaller but possibly important difference between groups. Finally, the centers where these procedures took place were all highly experienced and so the results may not be generalizable to all centers.

Click to read the study, published in JAMA

Relevant Reading: Endovascular thrombectomy after large-vessel ischemic stroke: a meta-analysis of individual patient data from five randomized trials

In-Depth [randomized controlled trial]: This study included 381 patients who presented with acute ischemic stroke and large vessel occlusion in the anterior circulation within 6 hours of symptom onset. Patients were randomized to first line contact aspiration or first line stent retriever immediately prior to mechanical thrombectomy at 8 comprehensive stroke centers in France from 2015-2016. Mean time from symptom onset to arterial puncture was 227 minutes (interquartile range 180-280 minutes). The primary outcome was the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infraction score of 2b or 3. A total of 85.4% in the contact aspiration group were successfully revascularized vs. 83.1% in the stent retriever group (OR 1.2 [CI95% 0.68-2.1], p = 0.53; difference 2.4% [CI95% -5.4% to 9.7%]). Secondary outcomes were degree of disability as assessed by the modified Rankin scale score at 90 days, change in National Institutes of Health Stroke Scale score at 24 hours, all-cause mortality at 90-days, and procedure-related serious adverse events. No secondary outcomes were statistically significant between groups.

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