Citations 2
First-pass aspiration versus stent retriever thrombectomy: machine learning study of treatment effect heterogeneity
Chen, Huanwen , Isidor, Julio , Schirmer, Clemens, Ernst, Marielle , Rai, Ansaar, Jabbour, Pascal , Abecassis, Isaac Josh , Grossberg, Jonathan A , Alawieh, Ali, Khanna, Omaditya, Starke, Robert M, Psychogios, Marios-Nikos, Siddiqui, Fazeel, Samaniego, E, Goyal, Nitin, Ezzeldin, Mohamad , Dye, Justin, Alcedo, Rodolfo, Cerejo, Russell , Luther, Evan, Romano, Daniele G, Tanweer, Omar, Mascitelli, Justin, Cuellar, Hugo H, Chalouhi, Nohra , Limaye, Kaustubh, Kellogg, Ryan, Brinjikji, Waleed, Chowdhry, Shakeel , Spiotta, Alejandro M , Kan, Peter , Jabbour, Pascal , Abecassis, Isaac Josh , Grossberg, Jonathan A , Navia, Pedro , Ezzeldin, Mohamad , Alaraj, Ali , Yoshimura, Shinichi , Fiorella, David , Fragata, Isabel , Mokin, Maxim , Matouk, Charles , Chowdhry, Shakeel A , Altschul, David J , Ogilvy, Christopher S , Levitt, Michael R , Grandhi, Ramesh , Spiotta, Alejandro M , Kan, Peter , Kim, Jae‐Joong , Rai, Ansaar , Jabbour, Pascal , Navía, Pedro , Starke, Robert M. , Psychogios, Marios‐Nikos , Goyal, Nitin , Dye, Justin , Alaraj, Ali , Yoshimura, Shinichi , Almallouhi, Eyad , Fiorella, David , Romano, Daniele Giuseppe , Tanweer, Omar , Fragata, Isabel , Mascitelli, Justin R , Limaye, Kaustubh , Matouk, Charles , Kellogg, Ryan Thomson , Brinjikji, Waleed , Altschul, David , Ogilvy, Christopher S. , Levitt, Michael R. , Grandhi, Ramesh
Journal of NeuroInterventional Surgery | July 24, 2026 | Volume: No volume available | Issue: No issue available | Pages: jnis-2026-025615
Background Randomized trials have shown equivocal outcomes between a direct aspiration as first-pass technique (ADAPT) and stent retriever (SR) stroke thrombectomy, yet whether specific patient subgroups benefit differentially from one technique over the other remains unknown. Methods In this retrospective multicenter cohort study, patients with large vessel occlusion were included, and those who underwent ADAPT versus SR first-pass thrombectomy (either as standalone or combined with aspiration) were compared. The primary outcome was a composite of first-pass effect (FPE, modified Thrombolysis In Cerebral Infarction (mTICI) 2c or better with one attempt) with no symptomatic intracranial hemorrhage (sICH). A causal forest model was used to estimate the conditional average treatment effect (CATE) for each patient, with larger CATEs indicating that ADAPT is expected to be more advantageous. Patients were stratified by CATEs, and outcomes were compared between treatment groups. Results Among 6700 included patients, ADAPT (n=3695, 55%) was associated with a higher rate of FPE with no sICH (39.9% vs 26.9%; adjusted OR (aOR) 2.07, 95% CI 1.77 to 2.41, P<0.001). The causal forest identified significant treatment effect heterogeneity (interaction P<0.001), where ADAPT was more advantageous in more recent years and among patients with M1 occlusions presenting in earlier time windows. Low-CATE patients showed no statistically significant difference between techniques (aOR 0.91, 95% CI 0.57 to 1.45, P=0.70), while medium- and high-CATE patients demonstrated progressively larger ADAPT advantages (aOR 2.06, 95% CI 1.67 to 2.55, and aOR 2.99, 95% CI 2.24 to 3.98, respectively, both P<0.001). Conclusions ADAPT may be superior to SR for a majority of patients, particularly in recent years, and among patients with M1 occlusions presenting in earlier time windows.
Minor stroke, major stakes: impact of procedure duration on thrombectomy outcomes in minor stroke
Kasem, Rahim Abo, Baba, Bachar El, Ma, Tianwen, Zelmanovich, Rebecca, Pabaney, Aqueel, Khelo, Roy Raheb, Giraudo, Francesca, Chandler, Katherine, Elawady, Sameh Samir, Chalhoub, Reda, Levitt, Michael R., Mascitelli, Justin, Cawley, Charles Michael, Akbik, Feras, Chisango, Zvipo, Wolfe, Stacey Quintero, Kim, Joon-Tae, Jabbour, Pascal, Yoshimura, Shinichi, Maier, Ilko, Ogilvy, Christopher S., Ezzeldin, Mohamad, Psychogios, Marios-Nikos, Siddiqui, Fazeel, Navia, Pedro, Goyal, Nitin, Arthur, Adam S., Romano, Daniele G., Fragata, Isabel, Daglioglu, Ergun, Altschul, David, Park, Min S., Crosa, Roberto, Brinjikji, Waleed, Moss, Mark, Dye, Justin, Alaraj, Ali, Kan, Peter, Limaye, Kaustubh, Mokin, Maxim, Starke, Robert M., Spiotta, Alejandro M., Grossberg, Jonathan A , Alawieh, Ali M., Kasem, Rahim Abo , Baba, Bachar El , Ma, Tianwen , Zelmanovich, Rebecca , Pabaney, Aqueel, Khelo, Roy Raheb , Giraudo, Francesca, Chacón-Aponte, Ariana Alejandra , Chandler, Katherine , Elawady, Sameh Samir , Howard, Brian M , Levitt, Michael R. , Grandhi, Ramesh , Mascitelli, Justin R , Cawley, Charles Michael, Akbik, Feras , Chisango, Zvipo Mutsa , Wolfe, Stacey Q , Kim, Joon‐Tae , Jabbour, Pascal , Maier, Ilko , Ogilvy, Christopher S. , Ezzeldin, Mohamad , Psychogios, Marios‐Nikos , Navía, Pedro , Goyal, Nitin , Arthur, Adam S., Romano, Daniele Giuseppe , Fragata, Isabel , Dağlıoğlu, Ergün , Altschul, David , Crosa, Roberto , Brinjikji, Waleed , Moss, Mark, Dye, Justin , Alaraj, Ali , Limaye, Kaustubh , Mokin, Maxim , Starke, Robert M. , Spiotta, Alejandro M , Alawieh, Ali
Journal of Neurosurgery | July 15, 2026 | Volume: No volume available | Issue: No issue available | Pages: 1-12
OBJECTIVE Endovascular thrombectomy (EVT) for acute large-vessel occlusion stroke is well established, yet its role in patients presenting with minor stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score < 6) remains unclear. Prior studies have not accounted for intraprocedural factors that may influence outcomes in this subgroup. METHODS The authors analyzed 5693 patients from the STAR (Stroke and Thrombectomy and Aneurysm Registry), including 398 with low NIHSS scores, to evaluate the association between procedure time (PT) and outcomes. Among patients with low NIHSS scores, propensity score matching was used to compare outcomes between those with PT ≤ 35 versus > 35 minutes, a cutoff defined using receiver operating characteristic curve analysis. The authors performed a meta-analysis of studies reporting best medical management (BMM) outcomes in patients with low NIHSS scores. To compare these with EVT-treated patients, a matched BMM comparator cohort using stratification on pooled baseline characteristics was constructed. Outcomes included 90-day functional independence (modified Rankin Scale [mRS] scores 0–2), intracranial hemorrhage, and mortality. RESULTS PT had a stronger negative effect on outcomes in patients with low NIHSS scores compared with those with high scores, with a steeper decline in functional independence per minute of PT (slope: –0.45% vs –0.21%; p = 0.03 for interaction). Among patients with low scores, PT ≤ 35 minutes was associated with higher 90-day functional independence compared with the propensity score–matching cohort with PT > 35 minutes (82.6% vs 59.0%, p < 0.001). When benchmarked against BMM (75.2% mRS scores 0–2), patients undergoing EVT within 35 minutes had superior outcomes (85.1%, p = 0.047). In contrast, EVT with PT > 35 minutes resulted in worse outcomes than BMM (mRS scores 0–2: 59.8%, p = 0.008). The number needed to treat for PT ≤ 35 minutes was 10, whereas PT > 35 minutes yielded a number needed to harm of 6. CONCLUSIONS PT critically modulates the benefit of EVT in minor stroke. While efficient EVT yields better outcomes than BMM, prolonged procedures are associated with harm. These findings may explain prior inconsistent evidence on EVT in patients with low NIHSS scores and underscore the need to individualize procedural thresholds in this population.