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Background Acute intracranial internal carotid artery (ICA) occlusion lowers first-pass reperfusion rates and clinical outcomes. Aspiration catheter and stent-retriever thrombectomy (CA+SR) is becoming a first-line approach, but data on its performance versus contact aspiration alone (CA) in real-world practice using newer large-bore catheters are scarce. We compared angiographic and clinical outcomes between CA and CA+SR strategies for ICA occlusion.Methods Patients with isolated intracranial ICA occlusion treated between January and December 2024 were included in this multicenter SARA-3 registry study. Patients were grouped by first-line technique (CA or CA+SR). We compared procedural times, angiographic outcomes (modified Thrombolysis in Cerebral Infarction (mTICI) score), and clinical outcomes (24-hour National Institutes of Health Stroke Scale (NIHSS) and 3 month modified Rankin Scale (mRS) scores).Results Of 181 patients (median age, 74 years; 51% women), 53 received CA and 128 CA+SR. In CA, 75% achieved final recanalization (mTICI 2c–3) compared with 86% (CA+SR) (P=0.066), with similar procedural times and complications. No differences were found between 48% and 39% of patients who achieved first-pass mTICI 2b-3. The overall cohort had a 64% favorable outcome (mRS ≤2 at 3 months), with CA showing higher rates (70% vs 62%; P=0.4). Complete first-pass recanalization reduced symptomatic intracranial hemorrhages (ICH) and embolization but did not improve functional outcomes.Conclusion With newer large-bore aspiration catheters, CA was comparable to CA+SR as a first-line technique for intracranial ICA occlusion, with similar recanalization rates and favorable clinical outcomes.