Is a picture-perfect thrombectomy necessary in acute ischemic stroke?

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

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Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5

Stroke ◽

10.1161/strokeaha.118.023465 ◽

2019 ◽

Vol 50 (4) ◽

pp. 880-888 ◽

Cited By ~ 25

Author(s):

Johannes Kaesmacher ◽

Panagiotis Chaloulos-Iakovidis ◽

Leonidas Panos ◽

Pasquale Mordasini ◽

Patrik Michel ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Favorable Outcome ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptomatic Intracerebral Hemorrhage

Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov . Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Abstract WP53: Safety and Efficacy of Mechanical Thrombectomy in Acute Stroke Patients on New Oral Anticoagulants

Stroke ◽

10.1161/str.51.suppl_1.wp53 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Nurose Karim ◽

Alicia C Castonguay ◽

Hisham Salahuddin ◽

Julie Shawver ◽

Syed Zaidi ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Oral Anticoagulants ◽

National Institutes Of Health ◽

New Oral Anticoagulants ◽

Limited Data ◽

Stroke Patients ◽

Safety And Efficacy ◽

Nihss Score ◽

Symptomatic Intracerebral Hemorrhage ◽

Symptomatic Intracranial Hemorrhage

Background: Limited data exists on the benefits of mechanical thrombectomy (MT) in acute ischemic stroke patients on new oral anticoagulants (NOAC). The aim of our study is to examine the safety and efficacy of MT in NOAC patients at our center. Methods: A retrospective review of our prospective MT database was performed for this study. Baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) score, revascularization rate, symptomatic intracranial hemorrhage rate (sICH), and 90-day mortality and favorable outcomes were compared in MT patients on NOAC (MT-NOAC) versus those who were not on NOAC (MT). Results: From July 2012 to December 2018, 553 AIS patients underwent treatment with MT, with 36 patients on NOAC (6.5%). Median age was similar (73 versus 74), with 52.8% and 52.0% (p=0.8) female in the MT-NOAC and MT groups, respectively. Median baseline NIHSS score (17 IQR10-21 versus 17 IQR 12-21, p=0.75) and ASPECTS (9 IQR 8-9, p=0.80) were similar between the groups. Atrial fibrillation was more prevalent in the MT-NOAC group (80.6% versus 37.7%, p=<0.0001). No difference was seen in occlusion site between the group, with M1 occlusions the most common site (44.4% versus 43.3%, p=0.9). Median onset to revascularization times did not differ between the cohorts (146 minutes versus 206, p=0.61). Successful revascularization (mTICI≥2b) was 87.5% and 81.8% in the MT NOAC and MT groups, respectively. Rates of symptomatic intracerebral hemorrhage per ECASS III criteria were similar between the two groups (5.5% versus 4.6%, p=0.68). No difference was seen in 90-day favorable outcomes (mRS 0-2) (48.3% versus 41.1%, p=0.44) or mortality (27.6% versus 27.1%, 0.95). Conclusion: MT in patients on NOAC appears to be safe and efficacious. As our study is limited by sample size, larger prospective studies are needed to understand the safety and efficacy of MT in AIS patients on NOAC.

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Catch Plus thrombectomy device in acute stroke: initial evaluation

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012760 ◽

2016 ◽

Vol 9 (12) ◽

pp. 1214-1218 ◽

Cited By ~ 3

Author(s):

Ahmet Peker ◽

Ethem Murat Arsava ◽

Mehmet Akif Topçuoğlu ◽

Anıl Arat

Keyword(s):

Mechanical Thrombectomy ◽

National Institutes Of Health ◽

Initial Experience ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Nihss Score ◽

Thrombectomy Device ◽

Baseline Characteristics ◽

Mean Time

ObjectiveTo report our initial experience with the Catch Plus thrombectomy device (CPD) in patients with acute ischemic stroke (AIS).Materials and methodsWe retrospectively evaluated the procedural variables as well as the clinical and angiographic outcomes of patients with acute occlusion of a major intracranial artery in the anterior circulation who were treated with CPD at our center. Baseline characteristics (gender, age, comorbidities, cardiovascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and vessel occlusion sites) of these patients were recorded. Thrombolysis in Cerebral Infarction (TICI) score, incidence of symptomatic and asymptomatic bleeding, and 90 day modified Rankin Scale (mRS) scores were evaluated as indicators of outcome.Results38 patients with a mean age of 67.5 years were treated with CPD. Mean time from symptom onset to procedure initiation was 226.7 min. Recanalization (TICI 2b–3) was achieved in 27 patients (71.1%). The median NIHSS score on admission was 20. Rates of symptomatic and asymptomatic intracerebral hemorrhage were 7.9% and 13.2%, respectively. The 90 day clinical follow-up data were available for 37 patients. The 90 day mortality rate was 18.9%, and the 90 day clinically acceptable functional outcome (mRS score ≤2) rate was 43.2% (mRS score 0–3, 54.1%). Very distal thrombectomy involving the cortical arteries was performed on four patients without complications.ConclusionsOur initial experience suggests that mechanical thrombectomy with the CPD improves 90 day outcomes of patients with AIS by facilitating effective recanalization.

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Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Neurology ◽

10.1212/wnl.0000000000012827 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012827

Author(s):

Adam de Havenon ◽

Alicia Castonguay ◽

Raul Nogueira ◽

Thanh N. Nguyen ◽

Joey English ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Primary Outcome ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die. 

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Abstract P549: Total Small Vessel Disease Burden Not Associated With Functional Independence After Endovascular Treatment in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p549 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Lina Zheng ◽

Xinyi Leng ◽

Ximing Nie ◽

Hongyi Yan ◽

Thomas W Leung ◽

...

Keyword(s):

Endovascular Treatment ◽

Primary Outcome ◽

Small Vessel Disease ◽

Functional Independence ◽

Small Vessel ◽

Perivascular Spaces ◽

Stroke Patients ◽

Vessel Occlusion ◽

Vessel Disease ◽

Secondary Outcomes

Background: Individual small vessel disease (SVD) markers had been associated with outcomes of endovascular treatment (EVT) in acute stroke patients. We aimed to investigate the associations between total SVD burden and outcomes in such patients. Methods: In a nation-wide multicenter registration study, we enrolled stroke patients with anterior circulation large vessel occlusion (LVO) receiving EVT, who had undergone 3T MRI. Presence of lacunes, white matter hyperintensities, cerebral microbleeds and perivascular spaces in both hemispheres were assessed in MRI and each marker was assigned a score of 0 or 1 by presence. A total SVD burden score (0-4) was calculated by summing up the individual scores, which was dichotomized as none-to-mild (score 0-2) and moderate-to-severe (score 3-4). The primary outcome was 90-day functional independence, defined as modified Rankin Scale (mRS) of 0-2. Secondary outcomes included change in NIHSS from baseline to 7 days, early neurological deterioration (END), symptomatic intracranial hemorrhage and 90-day mortality. We investigated the associations of dichotomized total SVD burden score with the outcomes using binary logistic regression analyses. Results: Of the 202 patients (65.38% male; mean age 65.54 ± 11.93 years) enrolled, 176 patients had none-to-mild and 26 had moderate-to-severe total SVD burden. Those with moderate-to-severe SVD were older (mean age 69.8 versus 64.7; P=0.043) and more of them had a prior stroke (42.31% versus 23.3%; P=0.039), compared with otherwise. Dichotomized total SVD burden was not significantly associated with the primary outcome, 90-day functional independence (moderate-to-severe versus none-to-mild SVD burden: 53.85% versus 47.13%; OR 0.76, 95% CI 0.33-1.75; P=0.523). Although moderate-to-severe total SVD burden was associated with a higher rate of END (15.38% versus 3.43%; OR 5.12; 95% CI 1.34-19.58; P=0.017), no significant association was detected between the total SVD burden and other secondary outcomes. Conclusions: The total SVD burden as assessed in MRI was not significantly associated with the chance of obtaining functional independence at 90 days in LVO-stroke patients receiving EVT. A higher total SVD burden may not be an exclusion criteria for clinical decision for EVT.

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Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation

Stroke ◽

10.1161/strokeaha.117.018113 ◽

2017 ◽

Vol 48 (12) ◽

pp. 3274-3281 ◽

Cited By ~ 38

Author(s):

Cyril Dargazanli ◽

Caroline Arquizan ◽

Benjamin Gory ◽

Arturo Consoli ◽

Julien Labreuche ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Mild Stroke

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Safety and Angiographic Efficacy of Intra-Arterial Fibrinolytics as Adjunct to Mechanical Thrombectomy: Results from the INFINITY Registry

Journal of Stroke ◽

10.5853/jos.2020.01788 ◽

2021 ◽

Vol 23 (1) ◽

pp. 91-102

Author(s):

Johannes Kaesmacher ◽

Nuran Abdullayev ◽

Basel Maamari ◽

Tomas Dobrocky ◽

Jan Vynckier ◽

...

Keyword(s):

Primary Outcome ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stroke Study ◽

Increased Risk ◽

Tissue Plasminogen ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose Data on safety and efficacy of intra-arterial (IA) fibrinolytics as adjunct to mechanical thrombectomy (MT) are sparse.Methods INtra-arterial FIbriNolytics In ThrombectomY (INFINITY) is a retrospective multi-center observational registry of consecutive patients with anterior circulation large-vessel occlusion ischemic stroke treated with MT and adjunctive administration of IA fibrinolytics (alteplase [tissue plasminogen activator, tPA] or urokinase [UK]) at 10 European centers. Primary outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the European Cooperative Acute Stroke Study II definition. Secondary outcomes were mortality and modified Rankin Scale (mRS) scores at 3 months.Results Of 5,612 patients screened, 311 (median age, 74 years; 44.1% female) received additional IA after or during MT (194 MT+IA tPA, 117 MT+IA UK). IA fibrinolytics were mostly administered for rescue of thrombolysis in cerebral infarction (TICI) 0-2b after MT (80.4%, 250/311). sICH occurred in 27 of 308 patients (8.8%), with an increased risk in patients with initial TICI0/1 (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1 to 5.0 per TICI grade decrease) or in those with intracranial internal carotid artery occlusions (aOR, 3.7; 95% CI, 1.2 to 12.5). In patients with attempted rescue of TICI0-2b and available angiographic follow-up, 116 of 228 patients (50.9%) showed any angiographic reperfusion improvement after IA fibrinolytics, which was associated with mRS ≤2 (aOR, 3.1; 95% CI, 1.4 to 6.9).Conclusions Administration of IA fibrinolytics as adjunct to MT is performed rarely, but can improve reperfusion, which is associated with better outcomes. Despite a selection bias, an increased risk of sICH seems possible, which underlines the importance of careful patient selection.

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Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Cerebrovascular Diseases ◽

10.1159/000468995 ◽

2017 ◽

Vol 43 (5-6) ◽

pp. 305-312 ◽

Cited By ~ 22

Author(s):

Cyril Dargazanli ◽

Arturo Consoli ◽

Benjamin Gory ◽

Raphaël Blanc ◽

Julien Labreuche ◽

...

Keyword(s):

Ischaemic Stroke ◽

Favourable Outcome ◽

National Institutes Of Health ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Excellent Outcome ◽

Mild Stroke ◽

The Impact

Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

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First-line use of contact aspiration for thrombectomy versus a stent retriever for recanalization in acute cerebral infarction: The randomized ASTER study protocol

International Journal of Stroke ◽

10.1177/1747493017711948 ◽

2017 ◽

Vol 13 (1) ◽

pp. 87-95 ◽

Cited By ~ 14

Author(s):

Bertrand Lapergue ◽

Julien Labreuche ◽

Raphael Blanc ◽

Xavier Barreau ◽

Jérome Berge ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Infarction ◽

Primary Outcome ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Treatment Technique ◽

Large Vessel Occlusion ◽

First Line ◽

Anterior Circulation ◽

Vessel Occlusion

Rationale Mechanical thrombectomy with a stent retriever is now the standard of care in anterior circulation ischemic stroke caused by large vessel occlusion. New techniques for mechanical thrombectomy, such as contact aspiration, appear promising to increase reperfusion status and improve clinical outcome. Aim We aim at ascertaining whether contact aspiration is more efficient than the stent retriever as a first-line endovascular procedure. Sample size estimates With a two-sided test (alpha = 5%, power = 90%) and an anticipated rate of spontaneous recanalization and catheterization failures of 15%, we estimate that a sample size of 380 patients will be necessary to detect an absolute difference of 15% in primary outcome (superiority design). Methods and design The ASTER trial is a prospective, randomized, multicenter, controlled, open-label, blinded end-point clinical trial. Patients admitted with suspected ischemic anterior circulation stroke secondary to large vessel occlusion, with onset of symptoms <6 h, will be randomly assigned to contact aspiration or stent retriever in a 1:1 ratio; stratified by center and prior IV thrombolysis. If the assigned treatment technique is not successful after three attempts, another technique will be applied, at the operator’s discretion. Study outcomes The primary outcome will be successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b–3) at the end of the endovascular procedures. Secondary outcome will include successful recanalization after the assigned first-line treatment technique alone, procedural times, the need for a rescue technique, complications and modified Rankin Scale at three months. Discussion No previous head to head randomized trials have directly compared contact aspiration versus stent retriever reperfusion techniques. This prospective trial aims to provide further evidence of benefit of contact aspiration versus stent retriever techniques among patients with ischemic stroke.

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