A subgroup analysis of the ASTER2 clinical trial has found that a first-line combined thrombectomy approach, which involves using contact aspiration and a stent retriever in tandem, may produce better reperfusion outcomes compared to use of a stent retriever alone in patients whose ischaemic stroke is caused by an internal carotid artery (ICA) terminus occlusion with or without an M1-middle cerebral artery (MCA) occlusion.
Writing in the journal Stroke, Arturo Consoli (Foch Hospital, Suresnes, France) and colleagues do note, however, that the same superiority was not observed in stroke patients with isolated M1-MCA occlusions.
For this analysis, researchers included patients enrolled in ASTER2—a randomised trial comparing the effects of combined versus stent retriever-only thrombectomy in large vessel occlusion (LVO) stroke patients. More specifically, they included patients with an ICA terminus occlusion with or without an M1-MCA occlusion, as well as those with an isolated M1-MCA occlusion.
Consoli and colleagues evaluated the effects of combination therapy against stent retriever-only thrombectomy as first-line approaches via angiographic and clinico-radiological outcomes. The former meant looking at the rate of first-pass effect, expanded treatment in cerebral infarction (eTICI) score ≥2b50, and eTICI ≥2c, at the end of the first-line strategy and at the end of the procedure. The latter consisted of 24-hour National Institutes of Health stroke scale (NIHSS) scores, European cooperative acute stroke study (ECASS-III) grades, and three-month modified Rankin scale (mRS) scores.
A total of 362 patients were included in the post-subgroup analysis—299 had an isolated M1-MCA occlusion, 150 of whom were treated with a first-line combined approach, and 63 had an ICA terminus±M1-MCA occlusion, with 30 undergoing a first-line combined approach.
Rates of eTICI ≥2b50 after the first-line technique were significantly higher with the combined approach (100%) compared to the stent retriever-only approach (75.8%) in patients with ICA terminus±M1-MCA occlusions (odds ratio [OR], 11.83; 95% confidence interval [CI], 2.32–60.12), Consoli and colleagues report. They add that the rate of eTICI ≥2c in the combined group (66.7%) was roughly double that of the stent-retriever group (33.3%; OR, 4.09; 95% CI, 1.39–11.94). However, the same trend was not present in patients with isolated M1-MCA occlusions.
Across the 63 patients with ICA terminus±M1-MCA occlusions included in the analysis, the authors also relay that they found a modified first-pass effect rate of 33% with the combined thrombectomy approach, compared to 21.2% with use of a stent retriever only. The need for rescue treatments was distinctly higher in the stent retriever-only group (42.4%) versus the combined-thrombectomy group (20%).
However, positive clinical outcomes were more even between the two—as per three-month rates of mRS scores of 0–2, which were 37.9% in the stent-retriever group and 40.6% in the combined group. Decreases in NIHSS scores at 24 hours were also similar across groups, at −0.2 points (95% CI, −3.5–3.2) in the former and –0.7 points (95% CI, –4.2–2.9) in the latter.
