Background The use of balloon guide catheters (BGCs) for proximal flow control is increasingly being adopted in stroke thrombectomy as series of nonrandomized studies have demonstrated improved outcomes with BGCs. However, the distinction in outcomes depending on the initial vessel affected is not clearly elucidated. Here, we aim to compare the radiographic and clinical outcomes between anterior circulation thrombectomy performed with and without BGC for non-tandem proximal (intracranial internal carotid artery and middle cerebral artery M1) and distal (M2 and above) vessel occlusion.

Methods We performed a multicenter retrospective study including all adult (≥ 18 years) patients treated for intracranial anterior circulation occlusion at our institutions. We extracted patient demographic data, clinical presentation, procedural details, and clinical and radiographic outcomes. Outcome measures such as first pass effect (FPE), modified FPE (mFPE), thrombolysis in cerebral infarction (TICI) score, discharge mortality, and favorable clinical outcomes (measured by modified Rankin Scale (mRS) of 0–2 at 90 day follow up) were compared between BGC and non-BGC group for both proximal and distal vessel occlusions. Secondarily, puncture to successful recanalization time was also compared.

Results Total of 188 patients (59.0% male; median age: 68 years) treated for non-tandem anterior circulation stroke were included in our analysis. 66.5% (64.8% proximal, 35.2% distal occlusion) of patients were treated with BGC and 35.1% (76.2% proximal, 23.8% distal occlusion) without. There were no significant differences in sex distribution (60.3% vs 58.4% male), median age (67 vs 69 years), presenting NIHSS score (14 vs 18), and intravenous thrombolysis administration prior to thrombectomy (30.4% vs 39.7%) between BGC and non-BGC group. Stent retriever plus local aspiration thrombectomy was performed in 58.4% of patients in BGC group and 47.6% without. In the subgroup with only proximal occlusion, no statistically significant differences were observed between BGC and non-BGC groups in FPE (35.8% vs 39.6% p=0.67), mFPE (53.1% vs 64.6% p=0.30), TICI≥2C (63.0% vs 52.1% p=0.23), discharge mortality (21.3% vs 10.4% p=0.12), favorable clinical outcomes (50.0% vs 44.4% p=0.58), embolization to new territory (1.2% vs 2.1%, p=0.71), and mean puncture to recanalization time (30.7 vs 20.2 minutes, p=.34). Similarly, in a separate group consisting only of distal vessel occlusion, no significant differences were noted in FPE (28.8% vs 30.0% p=0.90), mFPE (43.8% vs 46.7%, p=0.79), TICI≥2C (58.9% vs 46.7%, p=0.26), discharge mortality (19.1% vs 13.3%, p=0.49), favorable clinical outcomes (56.5% vs 48.0% p=0.46), embolization to new territory (1.4% vs 3.3% p=0.51), and mean puncture to recanalization time (30.8 vs 23.8 minutes, p=0.43). Similarly, no significant difference in outcome matrices were observed in a subgroup analysis involving patients treated with stent retriever and local aspiration for both proximal and distal occlusions.

Conclusion In contrast to previous studies, our preliminary analysis indicates there is no significant difference in clinical and radiographic outcomes between thrombectomy with and without BGC for non-tandem anterior circulation proximal and distal occlusions when assessed separately. Further analysis with larger patient cohort and propensity score matching based on patient characteristics and aspiration catheter bore size is planned.

Disclosures D. Gautam: None. J. Aubrey: None. M. Bounajem: None. M. Penckofer: None. M. Koneru: None. H. Shaikh: None. J. Khalife: None. T. Jovin: None. D. Tonetti: None. R. Grandhi: None.