Efficacy and safety of mechanical thrombectomy in distal medium middle cerebral artery occlusion ischemic stroke patients on low-dose aspirin

Hamza Adel Salim; Vivek Yedavalli; Fathi Milhem; Basel Musmar; Nimer Adeeb; Motaz Daraghma; Kareem El Naamani; Nils Henninger; Sri Hari Sundararajan; Anna Luisa Kühn; Jane Khalife; Sherief Ghozy; Luca Scarcia; Benjamin Yq Tan; Robert W Regenhardt; Jeremy J Heit; Nicole M Cancelliere; Joshua D Bernstock; Aymeric Rouchaud; Jens Fiehler; Sunil Sheth; Ajit S Puri; Christian Dyzmann; Marco Colasurdo; Leonardo Renieri; João Pedro Filipe; Pablo Harker; Răzvan Alexandru Radu; Mohamad Abdalkader; Piers Klein; Thomas R Marotta; Julian Spears; Takahiro Ota; Ashkan Mowla; Pascal Jabbour; Arundhati Biswas; Frédéric Clarençon; James E Siegler; Thanh N Nguyen; Ricardo Varela; Amanda Baker; Muhammed Amir Essibayi; David Altschul; Nestor R Gonzalez; Markus A Möhlenbruch; Vincent Costalat; Benjamin Gory; Christian Paul Stracke; Constantin Hecker; Hamza Shaikh; Christoph J Griessenauer; David S Liebeskind; Alessandro Pedicelli; Andrea M Alexandre; Illario Tancredi; Tobias D Faizy; Erwah Kalsoum; Max Wintermark; Boris Lubicz; Aman B Patel; Vitor Mendes Pereira; Adrien Guenego; Adam A Dmytriw

doi:10.1177/17474930251317883

Efficacy and safety of mechanical thrombectomy in distal medium middle cerebral artery occlusion ischemic stroke patients on low-dose aspirin

Int J Stroke. 2025 Jul;20(6):669-678. doi: 10.1177/17474930251317883. Epub 2025 Jan 28.

Authors

Hamza Adel Salim^{1

2}, Vivek Yedavalli¹, Fathi Milhem², Basel Musmar³, Nimer Adeeb⁴, Motaz Daraghma², Kareem El Naamani³, Nils Henninger⁵, Sri Hari Sundararajan⁶, Anna Luisa Kühn⁷, Jane Khalife⁸, Sherief Ghozy⁹, Luca Scarcia¹⁰, Benjamin Yq Tan^{11

12}, Robert W Regenhardt², Jeremy J Heit¹³, Nicole M Cancelliere¹⁴, Joshua D Bernstock¹⁵, Aymeric Rouchaud¹⁶, Jens Fiehler¹⁷, Sunil Sheth¹⁸, Ajit S Puri⁷, Christian Dyzmann¹⁹, Marco Colasurdo²⁰, Leonardo Renieri²¹, João Pedro Filipe²², Pablo Harker²³, Răzvan Alexandru Radu²⁴, Mohamad Abdalkader²⁵, Piers Klein²⁵, Thomas R Marotta¹⁴, Julian Spears¹⁴, Takahiro Ota²⁶, Ashkan Mowla²⁷, Pascal Jabbour³, Arundhati Biswas²⁸, Frédéric Clarençon^{29

30}, James E Siegler⁸, Thanh N Nguyen²⁵, Ricardo Varela³¹, Amanda Baker³², Muhammed Amir Essibayi³², David Altschul³², Nestor R Gonzalez³³, Markus A Möhlenbruch³⁴, Vincent Costalat²⁴, Benjamin Gory^{35

36}, Christian Paul Stracke³⁷, Constantin Hecker³⁸, Hamza Shaikh⁸, Christoph J Griessenauer³⁸, David S Liebeskind³⁹, Alessandro Pedicelli⁴⁰, Andrea M Alexandre⁴⁰, Illario Tancredi⁴¹, Tobias D Faizy⁴², Erwah Kalsoum¹⁰, Max Wintermark⁴³, Boris Lubicz⁴⁴, Aman B Patel², Vitor Mendes Pereira¹⁴, Adrien Guenego⁴⁴, Adam A Dmytriw^{2

14}

Affiliations

¹ Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
² Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
³ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
⁴ Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, LA, USA.
⁵ Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
⁶ Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA.
⁷ Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
⁸ Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA.
⁹ Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA.
¹⁰ Department of Neuroradiology, Henri Mondor Hospital, Creteil, France.
¹¹ Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
¹² Division of Neurology, Department of Medicine, National University Hospital, Singapore.
¹³ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA.
¹⁴ Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
¹⁵ Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁶ University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France.
¹⁷ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹⁸ Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA.
¹⁹ Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany.
²⁰ Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA.
²¹ Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy.
²² Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
²³ Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA.
²⁴ Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
²⁵ Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA.
²⁶ Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
²⁷ Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
²⁸ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
²⁹ Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.
³⁰ GRC BioFast, Sorbonne University, Paris VI, Paris, France.
³¹ Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal.
³² Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
³³ Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³⁴ Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.
³⁵ Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France.
³⁶ INSERM U1254, IADI, Université de Lorraine, Nancy, France.
³⁷ Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany.
³⁸ Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.
³⁹ UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA.
⁴⁰ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
⁴¹ Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium.
⁴² Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Münster, Germany.
⁴³ Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, USA.
⁴⁴ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.

Abstract

Background: Acute ischemic stroke (AIS) from distal medium vessel occlusion (DMVO) presents unique treatment challenges. Mechanical thrombectomy (MT) is emerging as a viable option for these patients, yet the role of pre-stroke aspirin treatment is unclear. This study evaluates the impact of pre-stroke low-dose aspirin on outcomes in DMVO patients undergoing MT.

Methods: We conducted a multinational, multicenter, propensity score-weighted analysis within the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry. Patients with AIS due to DMVO, treated with MT, were included. We compared outcomes between patients on pre-stroke low-dose aspirin (75-100 mg) and those not on antiplatelet therapy. The primary outcome was functional independence at 90 days (modified Rankin Scale (mRS), 0-2). Secondary outcomes included excellent functional outcome at 90 days (mRS, 0-1), mortality, and day 1 post-MT National Institutes of Health Stroke Scale (NIHSS) score. Safety outcomes focused on hemorrhagic complications, including symptomatic intracerebral hemorrhage (sICH).

Results: Among 1354 patients, 150 were on pre-stroke low-dose aspirin. After applying inverse probability of treatment weighting (IPTW), aspirin use was associated with significantly better functional outcomes (mRS, 0-2: odds ratio (OR) = 1.89, 95% confidence interval (CI) = 1.14 to 3.12) and lower 90-day mortality (OR = 0.56, 95% CI = 0.32 to 1.00). The aspirin group had lower NIHSS scores on day 1 (β = -1.5, 95% CI = -2.8 to -0.27). The sICH rate was not significantly different between the groups (OR = 0.92, 95% CI = 0.60 to 1.43).

Conclusions: Pre-stroke low-dose aspirin was associated with improved functional outcomes and reduced mortality in patients with DMVO undergoing MT, without a significant increase in sICH. These findings suggest that low-dose aspirin may be safe and associated with more frequent excellent outcomes for this patient population. Further prospective studies are needed to validate these results and assess long-term outcomes.

Keywords: Acute ischemic stroke; aspirin; distal medium vessel occlusions; mechanical thrombectomy.

Publication types

Multicenter Study

MeSH terms

Aged
Aged, 80 and over
Aspirin* / administration & dosage
Aspirin* / therapeutic use
Female
Humans
Infarction, Middle Cerebral Artery* / drug therapy
Infarction, Middle Cerebral Artery* / surgery
Infarction, Middle Cerebral Artery* / therapy
Ischemic Stroke* / drug therapy
Ischemic Stroke* / surgery
Ischemic Stroke* / therapy
Male
Middle Aged
Platelet Aggregation Inhibitors* / administration & dosage
Platelet Aggregation Inhibitors* / therapeutic use
Registries
Thrombectomy* / methods
Treatment Outcome

Substances

Aspirin
Platelet Aggregation Inhibitors

Abstract

Publication types

MeSH terms

Substances

Grants and funding