Different learning curves between stent retrieval and a direct aspiration first-pass technique for acute ischemic stroke

J Neurosurg. 2018 Dec 1;129(6):1456-1463. doi: 10.3171/2017.6.JNS17872.


OBJECTIVEThe clinical outcomes of a direct aspiration first-pass technique (ADAPT) and stent retriever (SR) have been reported to be similar in several observational studies. In this study, procedural and clinical outcomes with ADAPT and SR for the treatment of acute ischemic stroke with large artery occlusion were compared in different time periods.METHODSIn each specific time period, SR and ADAPT were used as the first-line treatment approach for acute ischemic stroke patients with large artery occlusion at the authors' institution. Baseline characteristics, procedural variables, and functional outcome at 90 days were compared between patients treated with SR and those treated with ADAPT. These 2 groups were divided into 3 sequential subgroups to assess the learning curve effects of the endovascular team and individual operators on the procedural variables of each treatment strategy.RESULTSOverall, 89 patients were treated. In the SR group, the recanalization rate was higher (84% vs 65%; p = 0.01) and the procedure time was shorter than in the ADAPT group (median 42 minutes vs 76 minutes, p = 0.04). On the subgroup analysis of the learning curve, the SR group showed more rapid improvement in procedure time than the ADAPT group (p = 0.01 for the team; p < 0.01 for individual operators).CONCLUSIONSIn this initial experience, a higher recanalization rate and shorter procedure time were achieved with SR than with ADAPT. A high recanalization rate with SR was possible with relatively less clinical experience, whereas procedure time dramatically decreased with experience. These observed effects on the learning curve might be useful when choosing the method for initial endovascular treatment of acute ischemic stroke at relatively small stroke centers.

Keywords: ADAPT; ADAPT = a direct aspiration first-pass technique; ICA = internal carotid artery; IQR = interquartile range; NIHSS = National Institutes of Health Stroke Scale; SICH = symptomatic intracerebral hemorrhage; SR = stent retriever; acute ischemic stroke; learning curve; mRS = modified Rankin Scale; mTICI = modified Thrombolysis in Cerebral Infarction; stent retriever; vascular disorders.

MeSH terms

  • Brain Ischemia / surgery*
  • Clinical Competence
  • Endovascular Procedures / education*
  • Humans
  • Learning Curve
  • Stents*
  • Stroke / surgery*
  • Treatment Outcome