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Background: The Pipeline Embolization Device has proven to be a safe and effective device for the treatment of intracranial aneurysms. The Pipeline Vantage Flow Diverter (PVFD) with Shield Technology is the new fourth generation of this implant, with modifications made compared to previous iterations. We aimed to evaluate the mechanical properties and clinical safety and efficacy of this device., Methods: Vanguard is a single arm, single center, prospective study. Between April 2021 and April 2023, all consecutive patients with an unruptured aneurysm treated with Pipeline Vantage flow-diverting stents were included. There were no aneurysm size or location exclusion criteria. Safety (neurological serious adverse events) and efficacy (device deployment and aneurysm occlusion) were independently reviewed. Imaging follow-up data, and immediate, early (<30 days), and delayed (>30 days) neurological serious adverse events were independently assessed., Results: 101 consecutive patients with a total of 115 aneurysms were included. The aneurysms were situated in the anterior (90.4%) or posterior (9.6%) circulations. A total of 124 devices were implanted. The deployment success rate was 100%. In four (4.0%) cases post-deployment angioplasty was required to optimize device wall apposition. Occlusion rates at 1 month were 54.7%, at 3 months 72.1%, and at 6 months 81.7%. Morbidity and mortality were 4.9% and 0%, respectively, at 6 months. Eight cases (6.9%) demonstrated in-stent stenosis, four of which had 'fish mouth' deformity., Conclusion: Initial results of the new generation PVFD for unruptured intracranial aneurysm treatment demonstrate overall satisfactory device performance, safety profile, and effectiveness., Competing Interests: Competing interests: HR and LV: consultants for Medtronic, Stryker, Microvention, Philips, Corindus. No disclosures or competing interests were declared by the remaining authors., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: The frequency of clinically symptomatic and asymptomatic diffusion-weighted imaging (DWI) hyperintense lesions and their correlation with the transradial artery (TRA) approach is unclear., Objective: To assess the frequency of abnormal diffusion restriction foci on DWI following cerebral angiography (digital subtraction angiography (DSA)) with the TRA or transfemoral artery (TFA) approach and identify predictors of DWI restriction foci., Methods: We analysed data from consecutive diagnostic cerebral angiograms obtained between January 2021 and October 2023 at a single tertiary center. MRI DWI was performed 2 hours after DSA. Patients underwent neurological assessment periprocedurally, as well as prior to discharge., Results: 500 patients were analysed; 277 (55%) procedures were performed via TRA and 223 (45%) via TFA. Overall, 74 (14.8%) patients had abnormal findings in the postprocedure MRI DWI. A higher incidence of positive DWI findings was noted in the TRA group, with 46 (16.6%) patients, compared with 28 (12.6%) in the TFA group (P=0.21). Symptomatic events occurred in seven (2.5%) of the TRA group and in two (0.9%) of the TFA cohort (P=0.31). At 60 days, the neurological deficit rate was one (0.4%) for the TRA group and one (0.4%) for the TFA group. Procedure time was the only significant predictor of DWI restriction (OR=1.04 per minute; P=0.0001)., Conclusion: Although there were more symptomatic or asymptomatic embolic events with TRA than with the TFA approach following elective cerebral angiography, this was not significantly different. We recommend the choice of vascular access based on patient anatomy and characteristics, aimed at improving care through enhanced safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Robotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases., Objective: To evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral aneurysms., Methods: This prospective, international, multicenter study enrolled patients with brain aneurysms that required endovascular coiling and/or stent-assisted coiling. The primary effectiveness endpoint was defined as successful completion of the robotic-assisted endovascular procedure without any unplanned conversion to manual treatment with guidewire or microcatheter navigation, embolization coil(s) or intracranial stent(s) deployment, or an inability to navigate vessel anatomy. The primary safety endpoint included intraprocedural and periprocedural events., Results: The study enrolled 117 patients (74.4% female) with mean age of 56.6 years from 10 international sites,. Headache was the most common presenting symptom in 40/117 (34.2%) subjects. Internal carotid artery was the most common location (34/122, 27.9%), and the mean aneurysm height and neck width were 5.7±2.6 mm and 3.5±1.4 mm, respectively. The overall procedure time was 117.3±47.3 min with 59.4±32.6 min robotic procedure time. Primary effectiveness was achieved in 110/117 (94%) subjects with seven subjects requiring conversion to manual for procedure completion. Only four primary safety events were recorded with two intraprocedural aneurysm ruptures and two strokes. A Raymond-Roy Classification Scale score of 1 was achieved in 71/110 (64.5%) subjects, and all subjects were discharged with a modified Rankin Scale score of ≤2., Conclusions: This first-of-its-kind robotic-assisted neurovascular trial demonstrates the effectiveness and safety of the CorPath GRX System for endovascular embolization of cerebral aneurysm procedures., Trial Registration Number: NCT04236856., Competing Interests: Competing interests: VMP is an unpaid consultant for Siemens Healthinners Endovascular Robotics. The following authors have one or more competing interests: HR, NS, FC, DH, MP, JG, MK-O, RDT, RB. These competing interests include board membership, consultancy, employment, expert testimony grants, contract research, lectures/other education events, speakers’ bureau, and receipt of equipment or supplies, royalties, stock/stock options/other forms of ownership., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis., Methods: Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality., Results: 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I 2 =48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I 2 =20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I 2 =76%) were not significantly different., Conclusion: The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT., Competing Interests: Competing interests: TNN reported research support from Medtronic and SVIN; advisory board with Idorsia. PB reported travel support from Perflow; compensation from Cerenovus, Balt USA, LLC, Vesalio, Phenox Inc, and Brainomix for consultant services. BG has received grants from the French Ministry of Health and is the primary investigator of the TITAN, DIRECT ANGIO, and IA-RESCUE trial, and consulting fees from Air Liquide, MIVI, Medtronic, Boerhinger Ingelheim, Microvention, and Penumbra. JPA is supported, in part, by an NIHR Health and Care Research Scholarship. KK is a recipient of a research fellowship awarded by the Nottingham University Hospitals NHS Trust. There are no other disclosures or competing interests declared by the remaining authors., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The radial artery approach has become popular as a 'radial first' strategy for arterial access in neuroangiography and neurointerventions. Recent studies have shown that transradial arterial access (TRA) for cerebral angiography has been associated with reduced access site complication rates and improved patient satisfaction compared with transfemoral access (TFA). The goal of this study was to evaluate the presence of abnormal MRI diffusion weighted imaging (DWI) foci following DSA and correlate their frequency with TRA or TFA., Methods: We prospective analyzed 200 consecutive adult DSAs performed from January 2021 to January 2022, at a single tertiary center., Results: Of the 200 consecutive diagnostic cerebral angiograms, 51% were performed via TRA and 49% were performed via TFA. Of the TRA cerebral angiograms, 17.5% demonstrated at least one hyperintense focus on MRI DWI. Of the TFA procedures, 5.2% were considered positive. One patient (0.5%) in the TRA group experienced a minor neurologic deficit postoperatively that had not completely resolved at 90 days after the procedure and no neurologic deficits occurred in the TFA group., Conclusions: Despite the proven benefit of TRA over TFA in neurointervention, the number of MRI DWI restriction foci were significantly more frequent during cerebral angiography when TRA was selected. Although the number of clinically symptomatic events were minimal, the widespread use of the technique may become clinically relevant. Further studies contrasting the TRA and TFA techniques will be beneficial for cerebral angiography., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Objective: To describe the results in patients treated with the Surpass Evolve (SE) device, the new generation of Surpass flow diverters., Methods: Twenty-five consecutive patients (20 women, average age 58 years), with anterior or posterior circulation aneurysms treated with SEs in two early-user centers, were included. Device properties and related technical properties, imaging and clinical follow-up data, and intraprocedural, early (<30 days) and delayed (>30 days) neurological complications, further divided into minor (silent/non-permanent) and major (permanent) complications, were recorded and analyzed., Results: Twenty-nine SEs were successfully implanted in all subjects to treat 26 aneurysms using an 0.027" microcatheter with an average of 1.2 stents per patient. No intraprocedural thromboembolic or hemorrhagic complications were seen. At clinical follow-up, 24/25 (96%) patients had a modified Rankin Score of 0-2. Mortality was 0%. Imaging follow-up, available in 22/25 (88%) patients (median follow-up time 4 months), showed a complete aneurysm occlusion in 13/23 (57%) imaged lesions. Minor, transitory neurological deficits were recorded in 5/25 (20%) patients. One (4%) major complication was seen in one patient (4%) with a left-sided hemispheric stroke on postprocedural day 4 due to an acute stent thrombosis., Conclusions: Preliminary experience in patients demonstrates a good performance of the SE. This newly designed implant maintains the engineering characteristics of Surpass flow diverters, including precise placement due to its lower foreshortening and a high mesh density, yet can be deployed through a significantly lower-profile delivery system., Competing Interests: Competing interests: VMP is a consultant for Stryker, Balt, Medtronic, and Cerenovous and holds a grant from Philips Healthcare.TK is a consultant for Medtronic, Stryker, and Penumbra and is a stockholder in Marblehead Inc. AKW has research grant from Philips Medical; serves as a consultant for Stryker and Phenox; is a stockholder of InNeuroCo, EpiEP, Neural Analytics, Rist, Analytics 4 Life, and ThrombX; and is on the Speakers’ Bureau for SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) presentations. ALC is consultant and proctor for Stryker, Medtronic, and Microvention and is on the Medical Advisory Board for InNeuroCo. HR is a consultant and proctor for, and receives educational support from, Stryker, Medtronic, Philips, Microvention, and Penumbra. All other Authors have no disclosures., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)