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Original research
More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke
  1. Romain Bourcier1,
  2. Suzana Saleme2,
  3. Julien Labreuche3,
  4. Mikael Mazighi4,
  5. Robert Fahed4,
  6. Raphael Blanc4,
  7. Benjamin Gory5,
  8. Maeva Kyheng3,
  9. Gaultier Marnat6,
  10. Serge Bracard5,
  11. Hubert Desal1,
  12. Arturo Consoli7,
  13. Michel Piotin4,
  14. Bertrand Lapergue8
  15. on behalf of the ASTER Trial Investigators
    1. 1 Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
    2. 2 Department of Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
    3. 3 Universite Lille, CHU Lille, EA 2694-Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
    4. 4 Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
    5. 5 Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
    6. 6 Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
    7. 7 Hopital Foch, Suresnes, France
    8. 8 Department of Stroke Centre and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
    1. Correspondence to Dr. Romain Bourcier, Department of Neuroradiology, University Hospital of Nantes, Nantes 44000, France; romain.bourcier2{at}


    Introduction Despite successful recanalization with mechanical thrombectomy (MT) for acute anterior ischemic stroke (AAIS), the number of passes may impact clinical outcome.

    We analyzed the impact of more than three MT passes (>3) in a trial that evaluated contact aspiration (CA) versus stent retriever (SR) as the first-line technique in AAIS.

    Methods We included patients with mTICI 2b/3 recanalization after MT for isolated intracranial occlusions. The primary outcome was the percentage of patients with a 90-day modified Rankin Scale (mRS)≤2. Secondary outcomes included overall distribution of 90-day mRS, parenchymal hematoma on 24 hours' brain imaging (PH), and 90-day mortality.

    Results Among the 281 patients included and even after adjustment on time to recanalization, significantly more patients with >3 passes had PH than patients with ≤3 passes in multivariate analysis (adjusted OR, 3.62; 95% CI, 1.55 to 8.44). When the analyses were stratified according to CA vs. SR, patients with >3 passes had a stronger risk of PH than patients with ≤3 passes, only in the SR first-line-treated group (adjusted OR, 9.24; 95% CI, 2.65 to 32.13) and not in the CA first-line-treated group (adjusted RR, 1.73; 95% CI, 0.57 to 5.19). A negative association of borderline significance (P=0.07) between >3 passes and favorable outcome was observed only in SR first-line-treated patients (adjusted OR, 0.33; 95% CI, 0.09 to 1.11).

    Conclusions After three passes of SR and unlike for three passes of CA, there is an increased risk of PH and a trend toward a worse clinical outcome.

    • device
    • thrombectomy
    • technique
    • stroke
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    • Contributors RB conceived the study and wrote the manuscript. SS, MM, RF, RB, BG, MK, GM, SB, HD, AC, MP, and BL have collected data and critically reviewed the manuscript. JL and MK performed the statistical analysis.

    • Funding The ASTER trial research was sponsored by Fondation Ophtalmologique Adolphe de Rothschild. An unrestricted research grant was provided by Penumbra, Alameda, California.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval (Identifier NCT02523261), was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice. The study protocol and the consent form were approved by the Comité de Protection des Personnes Ile de France VI (ID 2015-A00830 -49). In the present study, we conducted a post-hoc analysis of the data from the ASTER trial.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data are available upon request from the corresponding author.

    • Collaborators The ASTER trial investigators are: Piotin M, Blanc R, Redjem H, Ciccio G, Smajda S, Mazighi M, Fahed R, Desilles JP, Lapergue B, Rodesch G, Consoli A, Coskun O, Di Maria F, Bourdain F, Decroix JP, Wang A, Tchikviladze M, Evrard S, Turjman F, Gory B, Labeyrie PE, Riva R, Mounayer C, Saleme S, Costalat V, Bonafé A, Eker O, Gascou G, Dargazanli C, Bracard S, Tonnelet R, Derelle AL, Anxionnat R, Desal H, Bourcier R, Daumas-Duport B, Berge J, Barreau X, Margnat G, Djemmane L, Labreuche J, Duhamel A.

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