Purpose: Acute intracranial internal carotid artery (ICA) occlusion has high clot burden and poor outcomes. No consensus exists on optimal first-line mechanical thrombectomy (MT) using direct aspiration first pass technique (ADAPT), stent retriever (SR) alone, or combined thrombectomy (non-ADAPT). We compared outcomes between ADAPT and non-ADAPT strategies for ICA occlusion. Materials and Methods: Data were collected from a comprehensive stroke center between January 2019 and August 2024. Patients with intracranial ICA occlusions were divided into ADAPT and non-ADAPT groups. Demographic, clinical, angiographic, and clinical outcomes (National Institute of Health Stroke Scale [NIHSS] score at 24 hours and modified Rankin Scale [mRS] score at 3 months) were compared. Good functional outcome was defined as a mRS score of 0–2. Results: Of 85 patients (mean age, 75 years; 47% females), 60 (70.6%) received ADAPT and 25 (29.4%) non-ADAPT (18 with aspiration and SR combined and 7 with SR alone). ADAPT achieved successful recanalization with shorter procedure time (median, 32 minutes vs. 60 minutes, P=0.001), higher modified Treatment In Cerebral Ischemia (mTICI) recanalization rates (final mTICI 2c-3, 75% vs. 52%; P=0.038; mTICI 2b-3, 98.3% vs. 88%; P=0.074), and better outcomes at 3 months (mRS ≤2, 47% vs. 22%; P=0.039). Multivariate analysis showed NIHSS at discharge as the only significant predictor of good functional outcome at 3 months (odds ratio [OR] 0.68, P<0.001), while ADAPT exhibited a trend toward significance (OR 5.10, P=0.075). Conclusion ADAPT exceeded other strategies for intracranial ICA occlusion as first-line technique, achieving faster recanalization and potentially impacting long-term functional outcome.

Background: and Purpose Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2–5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT. Methods: This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke. Results: Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0–3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18–4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07–4.41; P=0.04). Conclusion In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.