The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions

Castro-Afonso, Luís Henrique de; Nakiri, Guilherme Seizem; Monsignore, Lucas Moretti; Cougo-Pinto, Pedro Telles; Dias, Francisco Antunes; Aléssio-Alves, Frederico; Pontes-Neto, Octávio Marques; Abud, Daniel Giansante

doi:10.1590/0004-282X20170059

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ARTICLES • Arq. Neuro-Psiquiatr. 75 (7) • July 2017 • https://doi.org/10.1590/0004-282X20170059 copy

The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions

Técnica de aspiração primária no tratamento do acidente vascular cerebral isquêmico por oclusões de grandes vasos

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Mechanical thrombectomy using stent retrievers is the standard treatment for acute ischemic stroke that results from large vessel occlusions. The direct aspiration first pass technique (ADAPT) has been proposed as an efficient, fast, and cost-effective thrombectomy strategy. The aim of this study was to assess the safety and efficacy of ADAPT.

Methods

Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale.

Results

Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%.

Conclusions

The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.

stroke; stents; catheters

Patient	Gender / Age	NIHSS at admission / 24 hours after treatment	Aspects	Symptomatic intracranial hemorrhage	Artery site occluded	IV rTPA / Intubation	Recanalization time (minutes)	Procedure time (minutes)	Device passes(n) / Carotid stenting	mTICI	Baseline mRS / 3-months mRS
1	M / 74	12/ago	10	N	Basilar artery	N / N	-	120	5 / N	0 / 3	0 / 2
2	F / 65	30/abr	10	N	Basilar artery	Y / Y	810	50	2 / N	3	0 / 2
3	M / 60	19/abr	10	N	Basilar artery	N / N	355	35	1 / N	3	0 / 2
4	M / 62	24 / 20	10	N	Distal LICA	N / N	480	60	3 / N	3	0 / 3
5	F / 76	26 / 26	9	N	Tandem proximal and distal RICA	Y / Y	-	120	7 / Y	0	0 / 6
6	M / 61	22/jul	10	N	Proximal left M1	N / N	255	15	1 / N	3	1/2
7	M / 34	20 / 18	9	N	Distal LICA	N / N	350	60	2 / N	3	0 / 2
8	M / 66	28 / 30	10	N	Basilar artery	Y / Y	480	45	2 / N	2b	0 / 5
9	F / 73	30 / 30	6	N	Basilar artery	Y / Y	475	30	2 / N	3	0 / 5
10	M / 52	14/dez	10	N	Tandem proximal RICA + right M1	N / N	450	80	1 / Y	3	2/2
11	M / 62	12/dez	8	N	Tandem proximal and distal RICA	N / N	600	60	3 / Y	2b	2/2
12	F / 68	06/jun	6	N	Basilar artery	N / N	450	40	1 / N	3	2/2
13	F / 79	30 / 30	7	N	Distal LICA	Y / Y	320	45	3 / N	2b	0 / 6
14	M / 68	25/dez	10	N	Distal LICA	Y / N	375	50	3 / N	3	0 / 2
15	F / 92	25 / 23	7	N	Proximal left M1	N / Y	-	100	8 / N	2a / 2a	3/5

Variable	Patients (n = 15)
Age (mean, range, SD)	66.1 (34–92, 13)
Age > 80 years (n, %)	1 (6.6)
Male sex (n, %)	9 (60)
Previous chronic conditions (n, %)
High blood pressure	13 (86.7)
Alcoholism	4 (26.6)
Smoking	6 (40)
Hyperlipidemia	7 (46.7)
Diabetes mellitus	2 (13.3)
Atrial fibrillation	2 (13.3)
Baseline mRS (mean, median, range, SD)	0.7, 0 (0–3, 1)
NIHSS at admission (mean, range, SD)	21.2 (6–30, 7.4)
ASPECTS (mean, median, SD)	9, 10 (6–10, 1.4)
10	9 (60)
9	2 (13.3)
8	1 (6.7)
7	2 (13.3)
6	1 (6.7)

Variable	Patients (n= 15)
Site of vessel occlusion (n, %)
Tandem carotid artery	3 (20)
Distal carotid artery	4 (26.6)
Middle cerebral artery M1	2 (13.3)
Basilar artery	6 (40)
General anesthesia (n, %)	6 (40)
Device passes (median, mean, range, SD)	2, 2.6 (1–7, 1.6)
Recanalization mTICI = 2b-3 (n, %)	12 (80)
Recanalization mTICI = 3 (n, %)	9 (60)
Received intravenous r-tPA (n, %)	7 (46.7)
Use of adjunctive stentriever (n, %)	2 (13.3)
Embolization (n, %)	1 (6.6)
Procedure time (minutes, mean, range, SD)	60.6 (15–120, 31.3)
Time from symptoms onset to recanalization (min) (mean, range, SD)	475.3 (255–810, 167)
Time from symptoms onset to recanalization > 6 h (n, %)	9 (60)
Unknown time of symptoms onset (n, %)	2 (13.3)
Any intracranial hemorrhage (n, %)	0 (0.0)
Symptomatic intracranial hemorrhage (n, %)	0 (0.0)
NIHSS at 24 hours (mean, range, SD)	16.1 (4–30, 9.7)
mRS at 3 months (mean, median, range, SD)	3.2, 2 (2–6, 1.6)
mRS ≤ 2 at 3 months (n, %)	9 (60)
mRS = 6 (Mortality, n, %)	2 (13.3)

Author - Year	N	Mean NIHSS baseline	mTICI 2b-3	mTICI 3	Mean procedure time (min) / Use of stentriever (%)	Thrombus fragmentation n (%)	Mean recanalization time (min)	sICH	mRS ≤ 2	Mortality n (%)

			n (%)	n (%)				n (%)	3 months n (%)
Turk et al. 2014 ⁴	100	17.2	95 (95)	51 (51)	37 / NR	10	544	0 (0)	40 (40)	20 (20)
John et al. 2015 ⁵	15	13	11 (73)	5 (33)	46 / 33	NR	NR	0 (0)	4 (33)	2 (13.3)
Stampfl et al. 2015 ⁶	115	16.8	100 (86.9)	NR	73 / NR	5.2	267	7 (6.1)	NR	16 (13.9)
Jankowitz et al. 2015 ⁷	112	17	96 (86)	34 (31)	70 / 28.5	3.5	337	7 (6.2)	52 (46)	35 (31)
Comai et al. 2015 ⁸	16	22	14 (87.5)	8 (50)	47 / 31.2	12.5	NR	1 (6.2)	9 (56)	4 (25)
Delgado Almandoz et al. 2015 ⁹	45	19.2	40 (89)	NR	50 / 0	4	274	1 (2)	25 (56)	8 (18)
Romano et al. 2016 ¹⁰	152	19	115 (75.6)	NR	57.8 / 36.8	1.9	284.8	12 (7.8)	77 (50.6)	12 (7.8)
Kowoll et al. 2016 ¹¹	54	15	50 (93)	35 (65)	41 / 44.4	6	220	2 (4)	25 (46)	6 (11)
Vargas et al. 2016 ¹²	191	15.4	180 (94.2)	85 (44.5)	37.3 / 22.5	0	468.3	13 (6.8)	98 (54.1)	27 (14.1)
Authors 2016	15	21.2	12 (80)	9 (60)	60.6 / 13.3	6.6	475.3	0 (0)	9 (60)	2 (13.3)
Total	815	17.5	87.5	27.8	52 / 26.2	5.5	358.8	4,3	37,7	13,2

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[1] Correspondence: Daniel Giansante Abud; Divisão de Neurorradiologia Intervencionista, Faculdade de Medicina de Ribeirão Preto da USP; Avenida Bandeirantes, 3900; 4048-090 Ribeirão Preto SP, Brasil; E-mail: dgabud@fmrp.usp.br