Abstract 2314: Selecting Endovascular Treatment Strategy According to the Location of Intracranial Occlusion in Acute Stroke

Abstract

Background Intra-arterial thrombolysis (IAT), with or without mechanical clot disruption, used to be the first line endovascular treatment strategy in acute stroke. However, the use of costly retrievers (RET) is progressively taking over despite the lack of comparative studies. Methods Acute stroke patients with confirmed ICA or MCA occlusion who underwent endovascular therapy were prospectively included in our database. Before retrievers were available patients were treated with IA-tPA up to 20mg plus guidewire mechanical clot disruption: IAT group. After retrievers were available in our Center patients were primarily treated with a Merci®, Solitaire® or Trevo® according to availability and physician preferences. Recanalization (REC) was considered when TIMI score was ≥2a on final angiogram. The primary outcome, dramatic clinical improvement (DCI), was defined as a ≥10 points decrease in NIHSS score from baseline to discharge or 7 days. Symptomatic intracranial hemorrhage (SICH), long-term outcome (mRS≤2) and mortality were also analyzed. Results Of the 136 included patients (76 MCA, 57 ICA), 92 (67%) received IAT and 45 (33%) RET (8 Merci, 20 Solitaire, 13 Trevo, 4 Multiple). There were no differences in baseline clinical characteristics including stroke severity, groin-to-REC and onset-to-REC times (table).There were no significant differences in REC rate (IAT 74.4% Vs RET 78%; p=0.082), rate of DCI (35.4% Vs 48.5%; p=0.21), SICH (7% vs 8%, p=0.84), clinical long-term outcome (27% vs 35%, p=0.45) or mortality (32% vs 28%, p=0.72). Among patients with TICA occlusions (28 IAT, 15 RET), DCI rate was significantly higher in the RET group compared to the IAT group (IAT 33% Vs RET 67%; p=0.031). The number needed to treat (NNT) to achieve one additional DCI patient with RET compared to IAT was 20 for MCA occlusions, and only 3 for TICA occlusions. Conclusion In major anterior circulation stroke patients, IAT and RET showed similar results in terms of safety and efficacy. The IAT approach should not be prematurely discarded. However, in patients with TICA occlusions, Retrievers may be considered as the first therapeutic option.