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

Feasibility, efficacy, and safety of mechanical thrombectomy via sheathless transradial access as a first-line strategy: A case series

OBJECTIVE

Although mechanical thrombectomy (MT) is primarily performed via transfemoral access (TFA), transradial access (TRA) is a potential alternative in older patients or those with tortuous vessels. However, the small radial artery diameter restricts the use of large-bore balloon guides and aspiration catheters, a limitation that may be overcome using the sheathless technique. Thus, we aimed to explore the feasibility, efficacy, and safety of sheathless TRA-MT as a first-line treatment approach for acute ischemic stroke.

METHODS

This single-center retrospective case series included patients who underwent TRA-MT as first-line treatment between September 2020 and June 2023. Per our MT protocol, TRA was not the first-line approach in cases of left anterior circulation lesions with a type 3 aortic arch. We evaluated treatment effectiveness based on the successful recanalization rate, puncture-to-recanalization time, and modified first-pass effect; access route effectiveness based on the puncture-to-first-pass time and switch-to-TFA rate; and procedure safety based on procedure-related and severe puncture site complications.

RESULTS

Sheathless 8-F guide catheters were used in 68 % and large-bore aspiration catheters in 70 % of the procedures. Successful recanalization was achieved in 98 % of the patients, with a modified first-pass effect in 54 % of them. The median puncture-to-first-pass and puncture-to-recanalization times were 20.5 and 33 min, respectively. The rate of procedure-related complications was low (4 %), with no severe puncture site complications.

CONCLUSION

Sheathless TRA-MT enabled the use of large-bore guide and aspiration catheters, providing a swift approach to the target and satisfactory outcomes, and might be an effective first-line treatment for acute ischemic stroke.

Efficacy and safety of SOFIA aspiration catheter for mechanical thrombectomy via ADAPT and Solumbra echniques in acute ischemic stroke: A systematic review and meta-analysis

INTRODUCTION

SOFIA catheter is a relatively new and recently FDA-approved aspiration catheter. This systematic review aims to investigate the safety and efficacy of SOFIA catheter for treatment of acute ischemic stroke (AIS) via ADAPT and Solumbra techniques.

METHODS

Search of all studies evaluating the SOFIA catheter for mechanical thrombectomy (MT) for treatment of AIS via ADAPT and Solumbra techniques from inception through 2020 on Pubmed, PMC, and Embase was performed. We analyzed the angiographic and clinical outcomes of both techniques with SOFIA catheter using the random-effects model.

RESULTS

From 18 studies, 1836 patients were included with 1365 receiving MT using ADAPT and 471 with solumbra technique. The mean age was 69.8 years and 51.1% of the patients were women. The rate of rescue therapy was 30%. The outcomes rates of ADAPT group were as follows; mFPE (59.3%), FPE (34.4%) final TICI 2b/3 (89.3%), procedural complications (8%), embolization to new territory (ENT) (2.3%), symptomatic ICH (5.4%), mean NIHSS (8.97), 90-day-mRS 0-2 (48.8%), and mortality (15.3%). The outcomes rates of Solumbra group were as follows; mFPE (60.5%), FPE (46.7%), final TICI 2b/3 (93%), procedural complications (6.4%), ENT (2%), symptomatic ICH (6%), mean NIHSS (7.59), mRS 0-2 (53.8%), and mortality (10.8%). ICA and posterior circulation strokes, and tandem lesions had worse outcomes (P < .005). MCA strokes were associated with better outcomes (P = .005). ASPECT scores' association with the clinical outcomes was found statistically significant.

CONCLUSION

SOFIA catheter is effective and safe to treat acute ischemic stroke regardless of applied MT technique.

Standardized approach to direct first pass aspiration technique for endovascular thrombectomy: Description and initial experience with CANADAPT

BACKGROUND

Endovascular thrombectomy (EVT) is standard of care for acute ischemic stroke. Stent assisted EVT with aspiration (SOLUMBRA) technique has remained a mainstay approach. There is growing evidence that A Direct Aspiration First Pass Technique (ADAPT) is a safe, efficient and effective approach for EVT, offering several advantages. This study describes and reports initial institutional experience in the use of a standardized scientific based aspiration only technique: CANADAPT.

METHODS

Single center prospective cohort study was performed on consecutive patients treated for large/medium vessel ischemic stroke with CANADAPT. Intravenous thrombolytics were administered according to routine practice, independent of the decision to proceed with EVT. A sequential stepwise aspiration only technique was then applied, CANADAPT, consisting of three maneuvers, A, B and C. The reperfusion success rate, number of passes, use of rescue technique, complication rate and procedural cost were determined.

RESULTS

Twenty-two patients were included in this case series representing M1 (17, 77%), M1/2 (2, 9%), carotid-T (2, 9%) and basilar (1, 5%) occlusions. First pass recanalization was achieved in 11 (50%) of patients. A further four patients had successful reperfusion with a second pass of CANADAPT (total 68% success rate). Only one patient had successful reperfusion with the aspiration catheter at the clot interface (CANADAPT A). All others required some withdrawal of the aspiration catheter for reperfusion (CANADAPT B and C). Seven patients had SOLUMBRA rescue. Of these, five patients (22% of total patients) had further successful reperfusion. Overall median procedural time was 23 min for first recanalization and 30 min for final recanalization. The cost per procedure was $6630 ± 1069 for CANADAPT, and $13,530 ± 2706 for SOLUMBRA techniques.

CONCLUSIONS

CANADAPT represents a standardized scientific-based approach to aspiration only thrombectomy intervention. This initial study demonstrates the safety, efficiency and efficacy of this technique for use in EVT.

Coronary balloon-assisted navigation of aspiration catheter for stroke thrombectomy

In recent years, A Direct Aspiration First Pass Technique (ADAPT) has emerged as an effective and safe method of thrombectomy. Large trials have shown noninferiority of ADAPT compared to primary stent retriever approach, while new studies emphasize on its shorter procedural time with potentially fewer complications and costs.1,2. Failure of the A Direct Aspiration First Pass Technique (ADAPT) is often due to the inability to successfully navigate the aspiration catheter to the thrombus site. As a solution, several techniques have been considered such as the use of stiffer microcatheters or a wedge device.3 In Video 1, we present our technique of navigating aspiration catheters with the assistance of coronary balloons. This technique has been very successful in our experience of about 30 cases in the past 6 months. Thanks to its safety and efficacy, this technique has dramatically changed our technical management of acute ischemic stroke. It can increase the ADAPT success rate while potentially reducing procedural costs.

Standardised aspiration first approach reduces materials used and cost of thrombectomy procedure in anterior circulation large vessel occlusion stoke

PURPOSE

The aim of this study is to compare the volume of equipment and equipment costs in a cohort of consecutive patients with anterior circulation large vessel occlusion treated with a standardised aspiration first approach to those treated with a stent retriever first approach.

METHODS

The equipment used in each case was recorded from a prospectively maintained equipment log. We then compared the volume of equipment used in each group. The cost of this equipment was calculated for each group based on local prices. Estimated equipment costs were then compared.

RESULTS

Our patient cohort consisted of 127 consecutive patients who were treated with a non-standardised stent retriever first technique (group A), 127 consecutive patients who underwent a new standardised aspiration first technique (group B), and 126 consecutive patients reflecting more recent practise where an aspiration first approach has been an established practise in our department (group C).Standardised aspiration first approach results in reduced equipment usage in thrombectomy procedures. The total equipment cost per case in the stent retriever first group (group A) was significantly higher at €4726.4 ($4818.3) versus €3093.1 ($3153.2) in the aspiration first group (group B), a reduction of 34.6% and €2798.5 ($2852.9) in the current practise group (group C), a reduction of 40.8%. There was no statistically significant difference in cost between groups B and C (p  =  0.57).

CONCLUSION

The standardised aspiration first technique utilised a reduced volume of equipment and confers a 40.8% reduced cost per procedure compared to a stent retriever first approach.

Detection, Diagnosis and Treatment of Acute Ischemic Stroke: Current and Future Perspectives

Stroke is one of the leading causes of disability worldwide. Early diagnosis and treatment of stroke are important for better clinical outcome. Rapid and accurate diagnosis of stroke subtypes is critical. This review discusses the advantages and disadvantages of the current diagnostic and assessment techniques used in clinical practice, particularly for diagnosing acute ischemic stroke. Alternative techniques for rapid detection of stroke utilizing blood based biomarkers and novel portable devices employing imaging methods such as volumetric impedance phase-shift spectroscopy, microwave tomography and Doppler ultrasound are also discussed. Current therapeutic approaches for treating acute ischemic stroke using thrombolytic drugs and endovascular thrombectomy are discussed, with a focus on devices and approaches recently developed to treat large cranial vessel occlusions.

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.

Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients

Background:

The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients.

Methods:

We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird.

Results:

Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05).

Conclusion:

Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.

A clinical perspective on endovascular stroke treatment biomechanics

Acute ischemic stroke (AIS) is caused by blockage of an arterial blood vessel in the brain by a thrombus, which interrupts oxygen supply to the brain parenchyma. The goal of endovascular stroke treatment (mechanical thrombectomy) is to restore blood flow as quickly and completely as possible. There are numerous factors that influence endovascular treatment success. They can be broadly grouped into a) factors related to blood vessels, b) factors related to the thrombus, c) factors related to endovascular treatment technique and tools and d) operator-related factors. While blood vessel and tgthro thrombus-related factors are mostly non-modifiable in the acute setting, operator and technique-related factors can be modified, and extensive research is currently being done to investigate the complex interplay of all these variables, and to optimize the modifiable factors to the maximum possible extent. In this review, we will describe these factors and how they interact with each other in detail, and outline some of their practical implications. We will conclude with a short summary and outlook on future directions for optimizing endovascular treatment success.

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles

BACKGROUND AND PURPOSE

Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter.

MATERIALS AND METHODS

A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location.

RESULTS

We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA.

CONCLUSION

The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods

Stroke remains one of the leading causes of death and disability in Europe. The European Stroke Action Plan (ESAP) defines four main targets for the years 2018 to 2030. The COVID-19 pandemic forced the use of innovative technologies and created pressure to improve internet networks. Moreover, 5G internet network will be helpful for the transfer and collecting of extremely big databases. Nowadays, the speed of internet connection is a limiting factor for robotic systems, which can be controlled and commanded potentially from various places in the world. Innovative technologies can be implemented for acute stroke patient management soon. Artificial intelligence (AI) and robotics are used increasingly often without the exception of medicine. Their implementation can be achieved in every level of stroke care. In this article, all steps of stroke health care processes are discussed in terms of how to improve them (including prehospital diagnosis, consultation, transfer of the patient, diagnosis, techniques of the treatment as well as rehabilitation and usage of AI). New ethical problems have also been discovered. Everything must be aligned to the concept of “time is brain”.

MRS SOFIA: a multicenter retrospective study for use of Sofia for revascularization of acute ischemic stroke

BACKGROUND

Over the past several years there has been increased interest in the use of the Sofia aspiration system (MicroVention, Tustin, California) as a primary aspiration catheter.

OBJECTIVE

To perform a multicenter retrospective study examining the efficacy of the Sofia aspiration catheter as a standalone aspiration treatment for large vessel occlusion.

METHODS

Consecutive cases in which the Sofia catheter was used for aspiration thrombectomy for large vessel occlusion were included. Exclusion criteria were the following: (1) Sofia not used for first pass, and (2) a stent retriever used as an adjunct on the first pass. The primary outcome of the study was first pass recanalization (Thrombolysis in Cerebral Infarction (TICI) 2c/3). Secondary outcomes included first pass TICI 2b/3, crossover to other thrombectomy devices, number of passes, time from puncture to recanalization, and complications.

RESULTS

323 patients were included. First pass TICI 2c/3 was achieved in 49.8% of cases (161/323). First pass TICI 2b/3 was achieved in 69.7% (225/323) of cases. 74.8% had TICI 2b/3 with the Sofia alone. Crossover to other thrombectomy devices occurred in 29.1% of cases (94/323). The median number of passes was 1 (IQR=1-3). Median time from puncture to recanalization was 26 min (IQR=17-45). Procedure related complications occurred in 3.1% (10/323) of cases.

CONCLUSION

Our study highlights the potential advantage of the Sofia aspiration catheter for primary aspiration thrombectomy in acute ischemic stroke. High rates of first pass recanalization with low crossover rates to other thrombectomy devices were achieved. Median procedure time was low, as were procedural complications.

A direct aspiration first-pass technique (ADAPT) versus stent retriever for acute ischemic stroke (AIS): a systematic review and meta-analysis

BACKGROUND AND PURPOSE

There is an ongoing debate about whether a direct aspiration first-pass technique (ADAPT) or stent retriever should be used as the first-pass mechanical thrombectomy device for patients with acute ischemic stroke (AIS). This meta-analysis aimed to compare the safety and efficacy of ADAPT versus stent retriever in patients with AIS.

METHODS

Structured searches on the PubMed, Embase, and Cochrane Library databases were conducted through July 2020. The primary outcomes of this study were: successful and complete recanalization; excellent and favorable outcomes; all-cause mortality at 90 days; and symptomatic intracerebral hemorrhage (sICH). The secondary outcomes of this study were: successful recanalization by primary chosen device; additional therapy; occurrence of emboli in a new territory; hemorrhagic complication; hemorrhagic infarction; parenchymatous hematoma; and subarachnoid hemorrhage. The odds ratios (ORs) with 95% confidence intervals (CIs) of the primary and secondary outcomes were calculated using a random-effects model. I² statistics were used to assess the heterogeneity for each outcome among the included studies.

RESULTS

Finally, 20 studies with a total of 6311 patients were included in our meta-analysis. There were no significant differences between the ADAPT group and the stent retriever group of the primary and secondary outcomes except additional therapy. Our pooled results indicated that patients in the ADAPT group needed more additional therapy than those in the stent retriever group (OR 2.24, 95% CI 1.41-3.57).

CONCLUSION

In conclusion, our meta-analysis showed similar clinical outcomes of ADAPT and stent retriever. However, patients in the ADAPT group had higher additional therapy rates than those in the stent retriever group. Due to several inevitable limitations of this meta-analysis, more large-scale randomized controlled trials are required to further investigate this topic.

Preclinical evaluation of Millipede 088 intracranial aspiration catheter in cadaver and in vitro thrombectomy models

Background

Larger bore aspiration catheters are expected to significantly improve the speed and completeness of acute stroke revascularization.

Objective

To evaluate the navigability and clot retrieval performance of a novel 8Fr aspiration catheter, Millipede 088 (Perfuze Ltd), using fresh-frozen cadavers and an in vitro thrombectomy model, respectively.

Methods

Cadaveric study: Transfemoral catheterization of the intracranial arteries was performed in six cadavers, allowing evaluation of navigation to 12 middle cerebral arteries (MCAs) and six basilar arteries. Commercially available 6Fr aspiration catheters (SOFIA Plus, Microvention) were used as controls. In vitro study: Three human blood clot phenotypes were created; red blood cell-rich, mixed, and fibrin/platelets-rich. Two clot sizes, resulting in occlusion of the internal carotid artery (ICA) and MCA-M1 were investigated. Endpoints were first-pass effect (FPE), first-pass complete ingestion, and second-pass recanalization.

Results

Cadaveric study: Both the Millipede 088 and SOFIA Plus devices reached the distal MCA-M1 and the basilar artery in 10/12 and 2/2 of the navigation attempts, respectively. In the two instances of unsuccessful navigation, neither device was able to cross the ophthalmic artery. In vitro study: In 10 mm long M1 occlusions, Millipede 088 achieved 100% FPE versus 40% for 6Fr devices (p>0.001). In 20 mm long ICA occlusions, Millipede 088 achieved 100% removal success within two passes in each clot phenotype compared with an average of 27% for 6Fr devices (p>0.001).

Conclusions

Navigation of the Millipede 088 catheter to the MCA-M1 and basilar artery is feasible in a cadaver model. Millipede 088 demonstrates superiority over 6Fr aspiration catheters for three representative clot phenotypes at the most common sites of occlusion in an in vitro vasculature model.

Strategies to reduce the impact of demand for concurrent endovascular thrombectomy

BACKGROUND

The rise in demand for endovascular thrombectomy (EVT) has increased the possibility that multiple patients with acute ischemic stroke may present concurrently and exceed local capacity to provide timely treatment. In this work, we quantitatively compared the efficacy of various strategies to mitigate demand in excess of capacity (DEC).

METHODS

Strategies evaluated included a backup neurointerventional team for 3 hours, 8 hours, or 24 hours per day; a separate pre-intervention imaging team; and a 30% decrease in procedure duration. For each strategy, empirical distributions were used to probabilistically generate arrival time and case duration for 16 000 independent trials repeated across a range of annual case volumes. DEC was calculated from time series representing the number of concurrent cases at each minute of the year for each trial at each case volume.

RESULTS

All strategies decreased DEC compared with baseline. At a representative volume of 250 cases per year, availability of a backup team for 3 hours, 8 hours, and 24 hours per day reduced DEC by 27.0%, 60.3%, and 97.2%, respectively, compared with baseline. Similarly, availability of a pre-intervention imaging team and a 30% decrease in procedure duration reduced DEC by 26.6% and 17.7%, respectively, compared with baseline.

CONCLUSIONS

A backup neurointerventional team, even if available only part time, was an effective strategy for decreasing DEC for EVT. Understanding the actual quantitative benefit of each strategy can facilitate rational cost-benefit analyses underlying the development of efficient and sustainable models of care.

Comparison of Aspiration versus Stent Retriever Thrombectomy as the Preferred Strategy for Patients with Acute Terminal Internal Carotid Artery Occlusion: A Propensity Score Matching Analysis

BACKGROUND AND PURPOSE

There is no consensus on endovascular treatment for terminal ICA. The purpose of this study was to evaluate the comparative safety and efficacy of preferred aspiration thrombectomy and stent retriever thrombectomy for revascularization in patients with isolated terminal ICA occlusion.

MATERIALS AND METHODS

We conducted a retrospective analysis of patients with terminal ICA occlusion treated with aspiration thrombectomy or stent retriever thrombectomy in our center, from September 2013 to November 2018. To minimize the case bias, propensity score matching was performed. The primary outcomes were successful reperfusion defined by expanded TICI grades 2b-3 at the end of all endovascular procedures and puncture-to-reperfusion time.

RESULTS

A total of 109 consecutive patients with terminal ICA occlusion were divided into the aspiration thrombectomy group (40 patients) and the stent retriever thrombectomy group (69 patients), and 30 patients were included in each group after propensity score matching. The proportion of complete reperfusion was significantly higher in the aspiration thrombectomy group (OR 4.75 [95% CI, 1.10-1.38]; P = .002). The median puncture-to-reperfusion time in the aspiration thrombectomy group was shorter than that in the stent retriever thrombectomy group (38  versus 69 minutes; P = .001). Fewer intracerebral hemorrhage events were recorded in the aspiration thrombectomy group (OR 0.29 [95% CI, 0.09-0.90]; P = .028). No significant differences were observed for good outcomes (OR 1.92 [95% CI, 0.86-4.25]) and mortality (OR 0.84 [95% CI, 0.29-2.44]) at 90 days.

CONCLUSIONS

For the treatment of terminal ICA occlusion, aspiration thrombectomy was technically superior to stent retriever thrombectomy in the absence of a balloon guide catheter in achieving successful reperfusion with shorter puncture-to-reperfusion time and procedure-related adverse events.

Effect of direct angioplasty therapy on acute middle cerebral artery occlusion with good leptomeningeal collateral

OBJECTIVE

The objective of this study was to investigate and discuss the effect of direct angioplasty therapy on acute middle cerebral artery occlusion (MCAO) patients with good leptomeningeal collateral circulation in 4.5 h.

PATIENTS AND METHODS

We retrospectively reviewed our acute ischemic stroke database from January 2017 to January 2019, then selected consecutive patients with evidence of the proximal M1 segments of MCAO and good leptomeningeal collateral who have received angioplasty or mechanical thrombectomy (MT). The baseline characteristics and outcome of patients was statistical analysis, included age, gender and risk factors, baseline national institutes of health stroke scale (NIHSS) scores, preoperative alberta stroke programme early CT (ASPECT) score, time from door to needle, time of door to puncture, endovascular procedure time, 7d NIHSS score and the modified treatment in cerebral infarction (m-TICI) 2b or 3, symptomatic hemorrhage, average hospital stays, modified rankin scale (mRS) score 0-2 at 3-month and mortality. All the thrombi were analyzed by histopathology. All statistical analysis was done with t-test for continuous data and χ2 test for binary data.

RESULTS

A total of 93 patients were included (direct angioplasty = 41 (44.1 %), MT = 52 (55.9 %)). There was no significant difference in baseline data between the two groups. The difference in the time of door to recanalization, the time of puncture to recanalization, symptomatic hemorrhage, and average hospital stays were significantly different between groups (P < 0.05). The other agents were not significantly different between groups (P > 0.05 each). Histopathological analysis showed all thrombi contained different amounts of platelets, fibrinogen, white blood cell, and red blood cell.

CONCLUSION

Direct angioplasty therapy on acute MCAO with good leptomeningeal collateral may help to shorten the time of surgery, reduce symptomatic hemorrhage, and hospital stay.