Thrombectomy In Anterior Circulation Research Articles

How Low Do We Go? NIHSS in Anterior Circulation Thrombectomy Decision‐Making

How Low Do We Go? NIHSS in Anterior Circulation Thrombectomy Decision‐Making

Abstract TMP96: Clear Thrombectomy Score: An Index to Estimate Probability of Good Functional Outcome Following Endovascular Treatment in the Late Window for Anterior Circulation Occlusion

Background: Endovascular thrombectomy (EVT) has established efficacy across a wide range of patient age, radiological findings, and clinical features. However, EVT may be less effective in extreme scenarios (e.g., large established infarction in later treatment windows), where there are currently limited data. Methods: A heterogeneous, multinational observational cohort (CLEAR registry) of consecutive adult patients ≥18 years old who underwent EVT for acute occlusion (2014-2022) of the internal carotid or proximal middle cerebral (M1 or M2) arteries was queried (n=64 sites). A high-fidelity model for predicting good functional outcome at 90 days (return to pre-stroke modified Rankin Scale [mRS] or mRS 0-2 after EVT) was developed using a binary, multivariable logit model with adaptive double lasso adjustment, which was validated using 5-fold cross validation and 1000 bootstrap sampling for confidence intervals. Results: At the time of the analysis, we evaluated 2953 patients from the registry treated with EVT, of which 1855 (63%) had complete covariate data for inclusion. The median National Institutes of Health Stroke Scale (NIHSS) score was 15 (IQR 9-20), with 14.0% having a pre-stroke mRS >2, 8.3% having a NIHSS <6, and 17.8% having an Alberta Stroke Program Early Computed Tomography Scale (ASPECTS) score ≤6. A good functional outcome occurred in 813 (43.8%) patients. Independent predictors of the primary outcome, with points allocated toward the final score, included younger age, higher ASPECTS, lower NIHSS, and time from last known well to arterial puncture. The areas under the curve for derivation and validation cohorts were 0.72 (95% CI 0.70-0.75) and 0.74 (95% CI 0.71-0.80), respectively. Discussion: The CLEAR thrombectomy score provides a simple, validated means of predicting good functional outcome following late-window, anterior circulation thrombectomy using routinely acquired clinical and imaging data. External validation is warranted.

Retraction: Anterior Circulation Thrombectomy in Patients With Low National Institutes of Health Stroke Scale Score: Analysis of the National Inpatient Sample

The following article, published online on August 23, 2023 in Stroke: Vascular and Interventional Neurology , has been retracted by mutual agreement between the authors and the journal Editors. The retraction has been issued at the authors’ request. Patel et al Anterior Circulation Thrombectomy in Patients With Low National Institutes of Health Stroke Scale Score: Analysis of the National Inpatient Sample. Stroke: Vascular and Interventional Neurology . 2023, e000998. https://www.ahajournals.org/doi/10.1161/SVIN.123.000998 After publication, an error was discovered that pertains to the misclassification of two variables in the National Inpatient Sample. Specifically, the variables for endovascular therapy and intravenous thrombolysis were mistakenly switched. Given that this error significantly alters the original results and conclusions, the authors have requested to retract the article. The authors regret these errors and appreciate the opportunity to correct the published record. All parts of the article that were affected by the error have been corrected and republished online: https://www.ahajournals.org/doi/10.1161/SVIN.123.001283

Retracted: Anterior Circulation Thrombectomy in Patients With Low National Institutes of Health Stroke Scale Score: Analysis of the National Inpatient Sample

Background Prior studies have shown benefit for endovascular therapy (EVT) in patients with large‐vessel occlusion and severe deficits, as captured by the National Institutes of Health Stroke Scale. However the benefit of EVT in patients with National Institutes of Health Stroke Scale score <6 is unclear. Methods We queried the National Inpatient Sample (2018–2020) for patients with a large‐vessel occlusion of the internal carotid or middle cerebral artery with a National Institutes of Health Stroke Scale score <6, and compared outcomes between patients treated with EVT versus best medical management, using propensity score matching. The primary outcome was routine discharge (home or self‐care). Secondary outcomes were in‐hospital mortality, intracerebral hemorrhage, and length of stay. Primary and secondary outcomes were evaluated using multivariable regression adjusted for baseline characteristics, stroke severity, and treatment with thrombolysis. Results Of the 212 515 patients with an internal carotid artery/middle cerebral artery stroke, 49 115 met the inclusion criteria for our study. A total of 8035 patients were treated with EVT, and 41 080 were treated with best medical management. Patients treated with EVT had increased odds of routine discharge (adjusted odds ratio [OR], 1.78 [95% CI, 1.57–2.01]; P <0.001), shorter length of hospital stays (adjusted β, −0.41 [95% CI, −0.63 to −0.19]; P <0.001), and similar rates of death (adjusted OR, 0.70 [95% CI, 0.39–1.24]; P = 0.22), compared with patients treated with best medical management. These relationships persisted in the propensity‐matched cohort. Conclusions Patients treated with EVT compared with best medical management had greater odds of routine discharge, reduced length of stay, and no differences in intracerebral hemorrhage or early mortality. Our findings suggest potential real‐world benefit for EVT in patients with low National Institutes of Health Stroke Scale scores.

The effect of procedural end-tidal CO2 on infarct expansion during anterior circulation thrombectomy.

Carbon dioxide is a potent cerebral vasodilator that may influence outcomes after ischemic stroke. The objective of this study was to investigate the effect of intraprocedural mean end-tidal CO2 (ETCO2) levels on core infarct expansion and neurologic outcome following thrombectomy for anterior circulation ischemic stroke. A retrospective review was conducted of consecutive patients from March 2020 to June 2021 who underwent mechanical thrombectomy for acute anterior circulation ischemic stroke under general anesthesia and achieved successful recanalization (Thrombolysis in Cerebral Infarction [TICI] ≥ 2b). Only patients with CT perfusion, procedural ETCO2, and postoperative MRI data were included. Segmentation software was used for multi-parametric image analysis. Normocarbia defined as mean ETCO2 of 35 mmHg was used to dichotomize subjects. Univariate and multivariate statistics were applied. Fifty-eight patients met criteria for analysis. Of these, 44 had TICI 3 recanalization, 9 had TICI 2c, and 5 had TICI 2b. Within this combined recanalization group, patients with mean ETCO2 > 35 had significantly higher rates of functional independence at 90 days. Although patients tended to salvage more penumbra and experience smaller final infarcts when ETCO2 exceeded 35 mmHg, this did not reach statistical significance. Stroke patients who underwent successful thrombectomy with general anesthesia achieved higher rates of functional independence when procedural ETCO2 exceeded 35 mmHg. Further studies to confirm this effect and investigate optimal ETCO2 parameters should be considered.

Posterior Circulation Approach for Anterior Circulation Thrombectomy in a Patient with Dysgenetic Internal Carotid Artery.

Dysgenesis of the internal carotid artery is a rare congenital variation that is mostly asymptomatic. The key to the imaging diagnosis is the identification of a narrow bony carotid canal. Dysgenetic carotid is a hindrance for endovascular access for ipsilateral intracranial anterior circulation, timely identification and differentiation from collapsed ICA secondary to intracranial occlusion can help guide timely access to mechanical thrombectomy via embryonic collateral routes which are usually prominent in those individuals. We describe a patient with hyperacute ischemic stroke with middle cerebral artery occlusion with the similar anatomic variation of ipsilateral internal carotid artery treated with mechanical thrombectomy using posterior circulation access from vertebral artery bridging to anterior circulation across posterior communicating artery after timely recognition of the anomaly.

Abstract TP76: Quantitative Comparison of Multidetector CT and Cone-Beam CT Perfusion Maps in Large Vessel Occlusion Stroke Patients Undergoing Mechanical Thrombectomy

Cerebral perfusion evaluation using CT or MR perfusion is the gold standard modality to select large vessel occlusion (LVO) stroke patients presenting >6 hours from symptom onset. The availability of cone beam C-arm CT perfusion (CBCTP) in angiography suites could reduce time to endovascular revascularization. We aimed to evaluate the reliability of using CBCTP when compared to multidetector CT perfusion (MDCTP). In this prospective, single-arm, interventional study, 14 LVO anterior circulation thrombectomy patients underwent both a 128 slice MDCTP in the ED and a CBCTP <30 minutes apart prior to groin puncture. CBCTP was acquired using a prototype acquisition mode enabling 10 consecutive C-Arm rotations with nearly continuous data acquisition. A total of 60 cc of contrast layered with 60 cc of saline were injected covering arterial inflow, parenchymal phase and venous outflow. Image data was reconstructed into CBF, CBV, MTT and TTP maps. Three types of measurements were used to compare modalities. In measurement 1, 6 circular regions of interest (ROI) (400mm 2 ) were placed in the anterior arterial territory. In measurement 2, circular ROIs were placed in the ASPECTS regions (cortical 300mm 2 , subcortical 200mm 2 ). In measurement 3, a ROI was drawn around the entire affected area. All ROIs were placed in the basal ganglia and supraganglionic level of both brain sides. Rates (unaffected/affected area) between MDCTP and CBCTP were compared for all sequences. The intraclass correlation coefficient (ICC) was calculated using a single rater, consistency, two-way random-effects model. Measurement 1 found a moderate degree of agreement between MDCTP and CBCTP in CBF, CBV, MTT and TTP rates with ICCs of 0.58 (CI 0.42 - 0.69), 0.65 (CI 0.53 - 0.74), 0.77 (CI 0.68 - 0.83) and 0.52 (CI 0.35 - 0.65). In measurement 2, moderate agreement was found in CBF, CBV and MTT rates; with ICCs of 0.51 (CI 0.32 - 0.65), 0.57 (CI 0.4 - 0.69) and 0.62 (CI 0.47 - 0.73). The results of measurement 3 found an excellent (ICC=0.95, CI 0.88 - 0.98), good (ICC=0.83, CI 0.62 - 0.9) and moderate (ICC=0.7, CI 0.34 - 0.87), degree of agreement in the CBV, MTT and CBF rates, respectively. These results demonstrate promising accuracy of CBCTP in the evaluating ischemic tissue in patient presenting with LVO acute stroke.

Common carotid artery puncture in anterior circulation thrombectomy in patients with unfavorable vascular anatomy: A case-control study.

The objective of this study was to compare clinical outcomes in patients who with unfavorable vascular anatomy underwent mechanical thrombectomy (MT) by common carotid artery access versus transfemoral approach.A retrospective review was performed in our hospital database to identify patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion (LVO) between August 2015 and November 2018. Transcarotid and transfemoral cohorts were compared. Patient characteristics, procedural techniques, clinical outcomes were recorded.A total of 52 patients were included, 16 (31%) underwent MT via transcarotid access. There were no significant differences in patient characteristics, intravenously recombinant tissue plasminogen activator therapy, clot location, or carotid tortuosity and presence of aortic arch type. There were significant differences in clinical outcomes between the 2 cohorts, including mean access-to-reperfusion time (84 vs 44 minutes; P = .000), poor clinical outcome (modified Rankin scale >2) at 90 days follow-up (37.5% vs 63.9%; P = .034). But there were no significant differences in successful revascularization rates (thrombolysis in cerebral infarction score ≥2b 87.5% vs 80.6%; P = .541), post-thrombectomy symptomatic intracranial hemorrhage (12.5% vs 13.9%; P = .892), and mortality (12.5% vs 22.2%; P = .412) were similar between transcarotid and transfemoral cohorts.Our results demonstrate that transcarotid access for MT of anterior circulation LVO in patients with unfavorable vascular anatomy may be considerable. Transcarotid access may be better than transfemoral access in well-selected unfavorable vascular anatomy patients undergoing MT.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates.

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates. We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups. In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005). Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Abstract TP470: The Value of Perfusion Ct as a Prognostic Factor After Mechanical Thrombectomy in Anterior Circulation

Introduction: Mechanical thrombectomy is recommended as first line treatment for large vessel occlusion(LVO) patients. Mechanical thrombectomy is performed based on the ASPECT score to achieve recanalization of the blood vessels at a faster rate. However, in patients with ASPECT score of 6 or more, the infarction volume on the diffusion MRI can occur throughout the MCA territory, resulting in hemorrhage after the thrombectomy and low cost effectiveness. Therefore, we conducted a study to determine whether recanalization was faster and whether perfusion CT could be used as a predictor of prognosis. Method and Material: We retrospectively studied patients who had recanalization therapy with LVO of anterior circulation at our hospital from 2011 to 2015. The cerebrovascular accident(CVA) protocol was activated when LVO was suspected, and non-enhance CT, perfusion CT, and CT angiography were performed. The CVA CT scan takes a 7 minutes. In these patients, 10 areas such as ASPECT score were designated and scores were given to the lowered areas of CBF, MTT, and CBV compared with the contralateral side, and scoring was performed at 10 points. EMR and imaging study of patients with ASPECT score of 7 or more were confirmed. We checked NIHSS at admission, mRS at discharge, and mRS at 90 days after discharge. Results: In total, 94 patients met the inclusion criteria of this study. After recanalization, TICI G 2b and 3 were achieved 80 patients (85.10%). Of the total patients, 71 patients (75.53%) had a CBV score of 4points or less and 23 patients (24.47%) had a score of 5points or more. In patients with CBV 4 points or less, good outcome(mRS 0 ~ 2) was 34 patients (47.88%). In patients with CBV 5 points or more, good outcome(mRS 0 ~ 2) was 6 patients(26.08%). The mortality rate was 7.04%(5patients) in patient with CBV 4points or less, but there were 30.43%(7patients) in patients with CBV 5points or more. Conclusion: Mechanical thrombectomy showed better prognosis in LVO patients with CBV score of 4 points or less. But there is showed higher mortality rate in patients with CBV score of 5 points or more. Perfusion CT can be helpful in predicting the prognosis of the patient.

Unfavorable Vascular Anatomy Is Associated with Increased Revascularization Time and Worse Outcome in Anterior Circulation Thrombectomy

Reperfusion time influences patient outcome in mechanical thrombectomy for large vessel occlusion. We analyzed anatomic features that could be used to make preoperative and intraoperative decisions to minimize revascularization time. We reviewed a prospectively maintained database for patients with stroke evaluated from February 2015 to July 2016. Patients received a score based on bovine arch, aortic arch, and internal carotid artery dolichoarteriopathy (B.A.D. score), which we correlated with procedural times and outcomes. Univariate analysis was performed to identify predictors of procedural times, revascularization, complications, and outcome. Relevant variables were assessed via multivariate regression. We identified 61 patients (31 men) who underwent transfemoral thrombectomy. Mean puncture to reperfusion time was 46 minutes. Age >75 years (odds ratio [OR]= 3.98; 95% confidence interval [CI], 1.17-13.54; P= 0.027) and high B.A.D. score (OR= 2.55; 95% CI, 1.17-5.57; P= 0.019) were significant predictors of puncture to reperfusion time >40 minutes. Mean puncture to first-pass time was 24 ± 14.2 minutes. Age >65 years (OR= 4.68; 95% CI, 1.07-20.55; P=0.041) and high B.A.D. score (OR= 2.84; 95% CI, 1.18-6.85; P= 0.020) were independently predictive of time to first pass >20 minutes. Lower scores predicted higher Thrombolysis In Cerebral Infarction score (OR= 0.07; 95% CI, 0.01-0.81; P=0.033). Higher scores predicted hemorrhagic transformation (OR= 4.8; 95% CI, 1.19-12.29; P= 0.024) and modified Rankin Scale score >4 (OR= 3.0; 95% CI, 1.15-7.92; P= 0.025) after thrombectomy. Bovine variation, aortic arch type, and internal carotid artery dolichoarteriopathy are associated with increased revascularization time and poor outcomes in thrombectomy. We developed the B.A.D. score to predict reperfusion time and outcomes, demonstrating need for preoperative anatomic evaluation to guide treatment.

Abstract TP42: Equivalent Favorable Outcomes Possible After Thrombectomy for Posterior Circulation Large Vessel Occlusion Compared to Anterior Circulation: The MUSC Experience

Introduction: In acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVO) have been associated with poorer outcomes compared to anterior circulation LVO. Using a strategy for determining candidacy relying on CT perfusion rather than time parameters, the outcomes of anterior vs. posterior circulation thrombectomy for LVO were compared at a high volume center employing a direct aspiration first pass technique (ADAPT). Methods: We retrospectively studied a database of AIS cases that underwent ADAPT thrombectomy for large vessel occlusions. Cases were grouped by anatomical location of thrombectomy (posterior vs. anterior circulation), and analysis was performed on both entire sample size and on matched subsets within each group. Results: A total of 436 AIS patients (50.2% women, mean age 67.3 years) underwent ADAPT thrombectomy for LVO during the study period of which 13% of had posterior circulation thrombectomy. Patients with posterior circulation thrombectomy did not show a significant difference in pre-procedural variables including age, baseline NIHSS and onset to groin time compared to anterior circulation (p&gt;0.05). There were also no differences in procedural variables between the two groups. Patients in the posterior group were found to have a similar likelihood of good outcome (mRS 0—2) at 90 days compared to the anterior group (42.9% vs. 43.2% respectively) and a small but not significant increase in mortality at 90 days. Multivariate logistic regression analysis shows that the anatomical location (anterior vs. posterior) is not an independent predictor of good outcome or mortality after thrombectomy. Prominent predictors of outcome/mortality include age, female gender, procedure time, and baseline NIHSS. Conclusion: Our findings suggest that posterior circulation thrombectomy for LVO has a similar outcome and a similar rate of post-procedural complications compared to anterior circulation thrombectomy indicating comparable safety and efficacy profiles.

Increased middle cerebral artery mean blood flow velocity index after stroke thrombectomy indicates increased risk for intracranial hemorrhage

Background and purposeCerebral hyperperfusion has been related to the risk of intracranial hemorrhage (ICH) in stroke patients after vessel recanalization therapy. We hypothesized that after successful mechanical thrombectomy for acute...

Equivalent favorable outcomes possible after thrombectomy for posterior circulation large vessel occlusion compared with the anterior circulation: the MUSC experience

IntroductionIn acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVOs) have been associated with poorer outcomes compared with anterior circulation LVOs. The outcomes of anterior versus posterior circulation thrombectomy...

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience.

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.

Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study.

Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. One hundred seventy patients with a median age of 64 years (range, 25-88 years) were treated. They presented after a median of 98 minutes (range, 52-160 minutes) with a median NIHSS score of 15 (range, 12-19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥ 2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.

032 Time to reperfusion does not predict clinical outcomes in anterior circulation stroke patients undergoing thrombectomy within 8 h of symptoms onset: pooled analysis of the Merci and Multimerci trials

Background and Purpose: The Merci and Multi-Merci trials evaluated the safety and efficacy of endovascular thrombectomy with the Merci Retriever in the treatment of proximal intracranial arterial occlusions performed within...

Peripheral neuropathy due to nitrofurantoin.

<h3>BACKGROUND AND PURPOSE:</h3> Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates. <h3>MATERIALS AND METHODS:</h3> We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever–first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b–3) and the number of passes were compared between the 2 groups. <h3>RESULTS:</h3> In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (<i>P</i> &lt; .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, <i>P</i> &lt; .001) and required fewer passes (mean, 2.4 versus 3.1; <i>P</i> &lt; .05). A higher proportion of patients had a TICI score of 2b–3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, <i>P</i> &lt; .005). <h3>CONCLUSIONS:</h3> Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.