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Mechanical thrombectomy for the treatment of primary and secondary anterior cerebral artery occlusions: insights from STAR
  1. Nisha Dabhi1,
  2. Jeyan Sathia Kumar1,
  3. Natasha Ironside1,
  4. Ryan T Kellogg1,
  5. Mohammad-Mahdi Sowlat2,
  6. Kazutaka Uchida3,
  7. Ilko Maier4,
  8. Sami Al Kasab2,
  9. Pascal Jabbour5,
  10. Joon-tae Kim6,
  11. Stacey Q Wolfe7,
  12. Ansaar Rai8,
  13. Robert M Starke9,10,
  14. Marios-Nikos Psychogios11,
  15. Edgar A Samaniego12,
  16. Adam S Arthur13,14,
  17. Shinichi Yoshimura3,
  18. Hugo Cuellar15,
  19. Brian M Howard16,17,
  20. Ali Alawieh16,
  21. Daniele G Romano18,
  22. Omar Tanweer19,
  23. Justin Mascitelli20,
  24. Isabel Fragata21,
  25. Adam J Polifka22,
  26. Joshua W Osbun23,
  27. Roberto Javier Crosa24,
  28. Charles Matouk25,
  29. Michael R Levitt26,
  30. Waleed Brinjikji27,
  31. Mark Moss28,
  32. Travis M Dumont29,
  33. Richard Williamson30,
  34. Pedro Navia31,
  35. Peter Kan32,
  36. Reade De Leacy33,
  37. Shakeel A Chowdhry34,
  38. Mohamad Ezzeldin35,36,
  39. Alejandro M Spiotta2,
  40. Min S Park37
  1. 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  2. 2Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  4. 4Department of Neurosurgery, University Medicine Goettingen, Goettingen, Germany
  5. 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  6. 6Department of Neurosurgery, Chonnam National University Hospital, Gwangju, Korea (the Republic of)
  7. 7Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  8. 8Department of Neurosurgery, West Virginia University Hospitals, Morgantown, West Virginia, USA
  9. 9Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  10. 10Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
  11. 11Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
  12. 12Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  13. 13Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
  14. 14Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  15. 15Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
  16. 16Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  17. 17Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  18. 18Department of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
  19. 19Department of Neurosurgery, NYU Langone Health, New York, New York, USA
  20. 20Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  21. 21Department of Neurosurgery, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  22. 22Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  23. 23Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  24. 24Department of Neurosurgery, Médica Uruguaya, Montevideo, Uruguay
  25. 25Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  26. 26Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington, USA
  27. 27Department of Neurosurgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
  28. 28Department of Neurosurgery, Washington Regional Medical Center, Fayetteville, Arkansas, USA
  29. 29Department of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  30. 30Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  31. 31Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
  32. 32Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  33. 33Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  34. 34Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA
  35. 35Department of Neurosurgery, University of Houston, Houston, Texas, USA
  36. 36Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA
  37. 37Department of Neurosurgery, Universitätsspital Basel, Basel, Switzerland
  1. Correspondence to Dr Min S Park, Department of Neurosurgery, Universitätsspital Basel, Basel 4031, Switzerland; MP2TQ{at}


Background The safety and efficacy of mechanical thrombectomy (MT) for the treatment of acute anterior cerebral artery (ACA) occlusions have not clearly been delineated. Outcomes may be impacted based on whether the occlusion is isolated to the ACA (primary ACA occlusion) or occurs in conjunction with other cerebral arteries (secondary).

Methods We performed a retrospective review of the multicenter Stroke Thrombectomy and Aneurysm (STAR) database. All patients with MT-treated primary or secondary ACA occlusions were included. Baseline characteristics, procedural outcomes, complications, and clinical outcomes were collected. Primary and secondary ACA occlusions were compared using the Mann–Whitney U test and Kruskal–Willis test for continuous variables and the χ2 test for categorical variables.

Results The study cohort comprised 238 patients with ACA occlusions (49.2% female, median (SD) age 65.6 (16.7) years). The overall rate of successful recanalization was 75%, 90-day good functional outcome was 23%, and 90-day mortality was 35%. There were 44 patients with a primary ACA occlusion and 194 patients with a secondary ACA occlusion. When adjusted for baseline variables, the rates of successful recanalization (68% vs 76%, P=0.27), 90-day good functional outcome (41% vs 19%, P=0.38), and mortality at 90 days (25% vs 38%, P=0.12) did not differ between primary and secondary ACA occlusion groups.

Conclusion Clinical and procedural outcomes are similar between MT-treated primary and secondary ACA occlusions for select patients. Our findings demonstrate the need for established criteria to determine ideal patient and ACA stroke characteristics amenable to MT treatment.

  • thrombectomy
  • stroke

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors Conception and design: ND, MSP, JSK, RTK, AMS. Acquisition, analysis, or interpretation of data: M-MS, KU. Drafting of the manuscript: ND, JSK, NI, MSP, RTK. Critical revision of the manuscript for important intellectual content: ND, JSK, NI, RTK, IM, SAK, PJ, J-TK, SQW, AR, RMS, M-NP, EAS, ASA, SY, HC, BMH, AA, DGR, OT, JM, IF, AJP, JWO, RJC, CM, MRL, WB, MM, TMD, RW, PN, PK, RDL, SAC, ME, AMS, MSP. Statistical analysis: M-MS, KU. Obtained funding: AMS. Administrative, technical, or material support: AMS. Supervision: MSP, AMS.

    Guarantor: MSP, AMS

  • Funding STAR receives financial support from Medtronic, Stryker Neurovascular, Penumbra, RapidAI, and Avail for maintenance of research database.

  • Competing interests KU receives lecture fees from Daiichi-Sankyo, Bristol-Myers Squibb, Stryker, and Medtronic. SY receives lecture fees from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. IM has speaker's honoraria from Pfizer and Bristol-Myers Squibb. SAK has a grant from Stryker for RESCUE-ICAS registry. RMS has research supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health, an unrestricted research grant from Medtronic and Balt, and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. M-NP has grants from the Swiss National Science Foundation (SNF), Bangerter-Rhyner Stiftung, Stryker Neurovascular, Phenox, Penumbra, and Rapid Medical, Sponsor-PI SPINNERS trial for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), research agreements with Siemens Healthineers, and has speaker fees from Stryker Neurovascular, Medtronic, Penumbra, Acandis, Phenox, Siemens Healthineers. EAS is a consultant for Medtronic, Microvention, Rapid Medical. ASA is a consultant for Arsenal, Balt, Johnson & Johnson, Medtronic, Microvention, Penumbra, Perfuze, Scientia, Siemens, Stryker; research support from Balt, Medtronic, Microvention, Penumbra and Siemens; shareholder Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros, Perfuze, Revbio, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI. SY has a lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. HC is a consultant for Medtronic, Penumbra and Microvention. DGR is a consultant for Penumbra, Balt, Microvention, Phenox. OT has consulting agreements with Viz.AI, Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention, Medtronic; educational/research grants: Q’apel, Steinberg Foundation. CM is a consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical; speaker for Penumbra and Silk Road Medical. MSP is a consultant for Medtronic. MRL has unrestricted educational grants from Medtronic and Stryker, consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative, equity interest in Proprio, Cerebrotech, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical, and makes up the editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery. RW is a consultant for Medtronic, Stryker, and Synaptive Medical. PN is a consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. PK has grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens, is a consultant for Imperative Care and Stryker Neurovascular, and has stock ownership in Vena Medical. RDL is a PI for Imperative Trial, has research grants from Siemens Healthineers and Kaneka Medical, is a consultant for Cerenovus, Stryker Neurovascular and Scientia Vascular, and has minor equity interest in Vastrax, Borvo Medical, Synchron, Endostream, Von Vascular. SAC is a consultant and proctor for Medtronic and Microvention. AMS has research support from Penumbra, Stryker, Medtronic, RapidAI, Avail, is a consultant for Penumbra, Stryker, Terumo, and RapidAI, and has equity in Avail.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.