Background Thrombectomy for acute ischemic stroke (AIS) management can be performed either via direct aspiration only or a combination of aspiration and stent retriever. However, it is unclear which approach is best suited for different clot types. Previous literature has conflicting evidence and vague justifications for each method, further complicated by subjective physician preference. Therefore, there is a need to investigate the role of clot density in the success of thrombectomy approaches to determine the best method for patient needs based on initial presentation and imaging data.

Methods A retrospective, single-center analysis of 693 total AIS patients at a high-volume comprehensive stroke center was conducted to determine if increasing clot size and density predicted a lower rate of success for first-pass aspiration mechanical thrombectomy. The study involved chart review for each patient, including demographic information such as age and gender, Hounsfield Unit (HU) information for proximal/medial/distal regions of the lesion as well as cumulative lesion HU, whether or not ADAPT was performed, if a rescue stentriever was employed, TICI recanalization scores, and mRS scores at 90 days to gauge outcomes. A TICI score of 2b-3 was considered to be a successful/full recanalization.

Results Statistical analysis showed that the mean HU for TICI score 0-2a was 5.17, and the mean HU for TICI score 2b-3 was 7.79. The average HU value was 6.57 for one pass, 8.11 for two passes, and 8.27 for three or more passes. For an mRS-90 score of 0-3, the average HU value was 4.94, and for an mRS-90 score of 4-6, the average HU value was 9.38.

Conclusion Clot density may help guide thrombectomy approach for stroke. In our study higher HU values correlated with better recanalization but required more passes. Higher HU values indicating greater clot density correlated with worse post-operative outcomes. Future studies may be required to confirm the findings and gather further evidence to optimize thrombectomy approaches for stroke management based on clot density

Disclosures K. Joshi: None. J. Gernstein: None. Y. Radaideh: None. M. Chen: None.