title: Selecting endovascular treatment strategy according to the location of intracranial occlusion in acute stroke.
abstract: BACKGROUND
  Selection of endovascular approaches for acute stroke patients remains unclear. The efficacy of intra-arterial therapy (IAT) has been demonstrated in the past. However, in the last years, the use of mechanical thrombectomy by retrievers (RET) is increasing at the expense of IAT. We aimed to compare several clinical outcomes between patients treated with IAT or RET.
  
  
  METHODS
  In a 6-year period, acute stroke patients (<8 h) with confirmed internal carotid artery (ICA) occlusion or middle cerebral artery (MCA) occlusion undergoing endovascular therapy were prospectively included in our database. Patients who underwent intra-arterial tissue plasminogen activator (tPA) ± microguidewire mechanical clot disruption (IAT group) were compared with those who underwent thrombectomy with the Solitaire® or Trevo® retrievers (RET group). Recanalization (REC) was considered if at the end of the endovascular procedure thrombolysis in cerebral infarction score was 2a-3. Dramatic clinical improvement (DCI) was defined as a decrease of ≥10 NIHSSS points from baseline to discharge or 7 days.
  
  
  RESULTS
  One hundred and eighty patients were included, 100 (55.6%) patients in the IAT group and 80 patients (44.4%) in the RET group. There were no differences in baseline characteristics (age, gender, risk factors profile, previous treatment with i.v. tPA, baseline NIHSS, extracranial ICA angioplasty and time to REC). Rates of REC, DCI and symptomatic intracranial hemorrhage were also similar between groups. Among patients with ICA occlusions (41 IAT, 34 RET), REC was significantly higher with RET (83.9 vs. 61%; p = 0.04).There was a trend towards a higher DCI rate in the RET group (32.3%) compared with the IAT group (14.6%; p = 0.06). According to MCA occlusions, there were no major differences in the main outcome variables. The number needed to treat to achieve one additional DCI with RET compared with IAT was 12 for MCA occlusions, and only 5 for ICA occlusions.
  
  
  CONCLUSIONS
  Among acute stroke patients undergoing endovascular therapies, the benefits of RET over IAT are greater in ICA occlusions. Retrievers may be considered as the first therapeutic option in these patients.
authors.affiliation: Stroke Unit, Department of Neurology, Universitat Autònoma de Barcelona, Vall d'Hebrón University Hospital, Barcelona, Spain. jpagola @ vhebron.net
authors.forename: Jorge
authors.initials: J
authors.lastname: Pagola
authors.forename: Marta
authors.initials: M
authors.lastname: Rubiera
authors.forename: Alan
authors.initials: A
authors.lastname: Flores
authors.forename: David
authors.initials: D
authors.lastname: Rodríguez-Luna
authors.forename: Socorro
authors.initials: S
authors.lastname: Piñeiro
authors.forename: Mari A
authors.initials: MA
authors.lastname: Muchada
authors.forename: Manolo
authors.initials: M
authors.lastname: Quintana
authors.forename: Jose
authors.initials: J
authors.lastname: Alvarez-Sabin
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
authors.forename: Marc
authors.initials: M
authors.lastname: Ribo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D008297:Male; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D017131:Thrombectomy / Q000379:methods; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator