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A decade ago, telemedicine was considered a cumbersome and unattainable technology, but now the rapid development of telecommunications provides the basis for its dissemination as a reliable and useful direction in treatment. This method of medical care has recently begun to be used in Ukraine. Interventional neuroradiology is one of the most technologically advanced and leading areas of modern medicine with a wide range of tools for minimally invasive treatment of various vascular pathologies of the nervous system. Over the past 3 years, due to the restrictions associated with the COVID-19 pandemic, as well as the russian-ukrainian war, cooperation between specialists in this field has become much more complicated. And first of all it concerns the education of the specialists and the introduction of new methods of endovascular treatment in Ukraine. In such conditions, the integration of telemedicine into clinical practice is one of the priorities.

Zusammenfassung  Der Artikel gibt eine Übersicht über aktuelle Studien, die mit Hilfe der Schlaganfall-MRT eine Abschätzung des Blutungsrisikos nach thrombolytischer Therapie ermöglichen. Hierbei wird insbesondere auf neue Befunde zur Bedeutung der zerebralen Mikroangiopathie, von ausgedehnten Diffusionsstörungen und von Mikroblutungen eingegangen. Während die zerebrale Mikroangiopathie und die Größe der Diffusionsstörungen gesicherte Risikofaktoren für thrombolyseassoziierte Blutungen sind, scheint das Vorliegen einzelner Mikroblutungen nicht mit einer erhöhten Einblutungsrate einherzugehen. [ABSTRACT FROM AUTHOR]

Summary Space-occupying middle cerebral artery (MCA) infarction is characterized by massive brain edema associated with deterioration of consciousness. Progressive brainstem function occurs finally leading to death as a result of transtentorial herniation. We analyzed whether acute stroke MRI with perfusion weighted imaging (PWI), diffusion weighted imaging (DWI) and MR angiography (MRA) allows the prediction of space-occupying MCA stroke in patients with proximal brain vessel occlusion (MCA main stem, carotid-T). Thirty-seven patients with acute MCA stroke and proximal vessel occlusion were studied by PWI, DWI and MRA within 6 hours of symptom onset. Eleven patients developed space-occupying MCA infarction. The DWI lesion was defined by a reduction of the apparent diffusion coefficient (ADC) of less than 80% (ADC <80%) compared with the unaffected hemisphere. The PWI lesion was defined as a time to peak (TTP) delay of more than 4 seconds (TTP >+4 s), respectively. Neurological deficit was assessed using the National Institutes of Health Stroke Scale (NIHSS). Outcome was assessed 90 days after stroke with the Barthel Index (BI) and the modified Rankin Scale (MRS).Patients with space-occupying MCA infarction showed larger diffusion- and perfusion lesion volumes (median ADC <80%: 157 vs 22 ml, p<0.001; TTP >+4 s: 208 vs 125 ml), a higher frequency of carotid-T occlusion (64 vs 15%, p=0.006) and higher NIHSS scores at admission (20 vs 15, p=0.001). Clinical outcome was worse in patients with space-occupying MCA infarction (MRS: 4 vs 1, p<0.001; BI: 13 vs 100, p=0.001). The following parameters served as predictors of space-occupying MCA infarction (sensitivity, specificity): ADC <80% >82 ml (87%, 91%), TTP >+4 s >162 ml (83%, 75%), NIHSS score at admission =19 (96%, 72%).Stroke MRI with the combination of PWI, DWI and MRA allows the prediction of space-occupying MCA stroke within the 6-hour time window and can help select patients for aggressive and potentially life-saving therapies such as decompressive hemicraniectomy. [ABSTRACT FROM AUTHOR]

BackgroundMechanical thrombectomy (MT) rates for the treatment of acute ischaemic stroke due to large vessel occlusion are steadily increasing, but are delivered in heterogenic settings. We aim to investigate effects of procedural load in centers with established MT-structures by comparing high- vs. low-volume centers with regard to procedural characteristics and functional outcomes.MethodsData from 5,379 patients enrolled in the German Stroke Registry Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were compared between three groups: high volume: ≥180 MTs/year, 2,342 patients; medium volume: 135–179 MTs/year, 2,202 patients; low volume:

Background: Intrasaccular devices have broadened treatment options for wide necked aneurysms. This study presents the preliminary experience with the Artisse 2.0 device., Methods: Innovative NeurovaScular Product SurveIllance REgistry (INSPIRE) is a non-randomized, multicenter, real world clinical study with treatment arms for aneurysms (INSPIRE-A) and acute ischemic stroke (INSPIRE-S). This interim analysis included 87 patients enrolled from November 2022 to April 2024 in the INSPIRE-A Artisse cohort across 16 Europoean centers. Procedures followed standard clinical care, with 6 months of follow-up. Safety and efficacy endpoints included major stroke, neurological death, serious adverse events (SAEs), aneurysm occlusion, and retreatment rates. An independent core laboratory assessed imaging, and all SAEs were reviewed by a clinical events committee. The Artisse steering committee provided independent oversight of the data., Results: The Artisse device achieved an overall successful implantation rate of 96.6% (84/87), with satisfactory placement rates of 98.7% (74/75) for unruptured and 88.9% (8/9) for ruptured aneurysms. Following the procedure, 46.2% of unruptured aneurysm patients were receiving antiplatelet therapy (APT), predominantly aspirin monotherapy, while no ruptured aneurysm patients received APT. Device related SAE rate was 1.3% (1/87), and the overall stroke rate was 2.3% (2/87), including both ruptured and unruptured aneurysms. At 6 months, 80.0% (28/35) of patients with unruptured aneurysms showed complete obliteration, with no recurrences or retreatments., Conclusions: Preliminary experience with the Artisse 2.0 device demonstrated high technical success, favorable safety, and efficacy in aneurysm obliteration at 6 months. Larger studies with longer follow-up periods are needed to confirm these findings., Competing Interests: Competing interests: VC is a consultant for Medronic and recipient of research grants from Medtronic. MK-O is a consultant for Medronic and part of the steering committee for Innovative NeurovaScular Product SurveIllance REgistry-Aneurysm (INSPIRE-A). RR has consulting agreements with Stryker, Balt, Medtronic, Microvention, and Acandis, and is part of the steering committee for INSPIRE-A . SL receives honoraria from Medtronic in relation to proctoring, speaking, and consulting, and is part of the steering committee for INSPIRE-A. LS is a consultant for Balt, Microvention, Medtronic, Stryker, and Cerenovus; receives research consultancy fees from Medtronic to attend steering committee meetings; and is part of the steering committee for INSPIRE-A. JF is part of the steering committee for INSPIRE-A and is consultant for Medtronic. MAM received research grants from Medtronic and Stryker, is part of the steering committee for INSPIRE-A, and is a consultant for Cerenovus and Siemens., (© 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: 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 (mRS 0-2). Secondary outcomes included excellent functional outcome at 90 days (mRS 0-1), mortality, and day-one post-MT NIHSS score. Safety outcomes focused on hemorrhagic complications, including symptomatic intracerebral hemorrhage (sICH)., Results: Among 1,354 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: OR =1.89 , 95% 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 one (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.

Background and Objectives: Data from randomized trials on the treatment effect of pure thrombolysis in patients with vessel occlusion are lacking. We examined data from a corresponding subsample of patients from the multicenter, randomized, placebo-controlled WAKE-UP trial to determine whether MRI-guided IV thrombolysis with alteplase in unknown-onset ischemic stroke benefits patients presenting with vessel occlusion., Methods: Patients with an acute ischemic lesion visible on MRI diffusion-weighted imaging but no marked parenchymal hyperintensity on fluid-attenuated inversion recovery images were randomized to treatment with IV alteplase or placebo. The primary end point was a favorable outcome defined by a modified Rankin Scale score of 0-1 at 90 days after stroke. We investigated the interaction between vessel status and treatment effect using an unconditional logistic regression model. Treatment effects (adjusted odds ratio [aOR]) and their 95% CI were compared in patients with and without any vessel occlusion (AVO) and large vessel occlusion (LVO)., Results: 185 patients (mean age 64.5 years, 46% female, median NIH Stroke Scale score 9, median time between last seen well and MRI 10.26 hours) received treatment and presented with an occlusion. 98 (20%) had LVO (defined as occlusion of the internal carotid artery, middle cerebral artery trunk, or combination). A favorable outcome was observed in 30 of 94 patients with AVO (31.9%) in the alteplase group and in 18 of 91 (19.8%) in the placebo group (aOR 2.04, 95% CI 1.00-4.18). In the subgroup of patients with LVO, a favorable outcome was observed in 16 of 53 (30.2%) in the alteplase group and in 7 of 44 (15.9%) in the placebo group (aOR 2.08, 95% CI 0.71-6.10). Treatment with alteplase was associated with higher odds of favorable outcomes with no heterogeneity of treatment effect between patients with AVO and patent vessel ( p = 0.56), or between patients with and without LVO ( p = 0.69)., Discussion: Although the WAKE-UP study was not powered to demonstrate treatment efficacy in patient subpopulations, this subgroup analysis points to a benefit of MRI-guided thrombolysis in patients with unknown-onset ischemic stroke, independent of vessel occlusion., Clinical Trial Registration: Registered at ClinicalTrials.gov with unique identifier NCT01525290 (clinicaltrials.gov/study/NCT01525290). The study was first posted on February 2, 2012; the first patient was enrolled on September 24, 2012., Classification of Evidence: This study provides Class II evidence that for patients with unknown-onset ischemic stroke with AVO, MRI-guided treatment with IV tissue plasminogen activator improves outcomes.

Background: The pipeline embolization device (PED) has been increasingly used to treat brain aneurysms; however, concerns have been raised about braid stability with newer drawn filled tubing technology devices., Objective: To evaluate braid stability of PED early generations using data from the PREMIER trial., Methods: All consecutive intracranial aneurysms treated with PED (Classic and Flex) within the PREMIER trial were reviewed for braid stability (fish mouthing, foreshortening, braid bump, braid collapsing). Immediate postprocedure cone-beam CT and angiography were compared with 1- and 2- years' follow-up. Analyses included safety, measured with the modified Rankin Scale (mRS) score, including +1 mRS point and a good clinical outcome (mRS score 0-2), vessel stenosis ≥50%, effectiveness measured with Raymond-Roy Scale, and re-treatment rates., Results: 133/141 aneurysms had a complete dataset. 8/133 (6%) aneurysms showed braid deformations. Inter-reader agreement was excellent (κ=0.83). Braid deformations were statistically significantly associated with in-stent vessel stenosis >50% (P=0.029), without impact on effectiveness or safety. Fish mouthing was found in 1/133 (0.75%) at 1 year, causing >50% vessel stenosis. Foreshortening occurred in 6/133 (4.5%), and braid bump in 1/133 (0.75%) associated with severe in-stent stenosis. Four other cases (3.0%) of asymptomatic in-stent stenosis due to neointimal hyperplasia were seen without braid changes. No new braid stability deformations were found at the 2-year follow-up., Conclusion: Our study demonstrates excellent braid stability among patients treated with the PED Classic and Flex in the PREMIER trial. Within the uncommon braid changes observed, none affected the PED safety or efficacy., Trial Registration Number: NCT02186561., Competing Interests: Competing interests: DKL is a consultant for Asahi, Medtronic, and Stryker; has received honoraria from Siemens, Medtronic, Stryker, and Phenox. DFK received research support from Cerenovus, Sensome, Neurogami Medical, Insera Therapeutics, Medtronic, Microvention, Balt, Monarch Biosciences, Brainomix, MiVi, Stryker, and NIH; royalties from Medtronic; is on the DSMB of NoNO Inc and Vesalio; is a stockholder Nested Knowledge, Superior Medical Experts, Marblehead Medical, and Conway Medical. JF: research support: German Ministry of Science & Education (BMBF) and of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions, and Förderbank (IFB), Medtronic, Microvention, Route92, Stryker; consultant for: Acandis, Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Stryker, TG Med, Tonbridge. Stockholder: Tegus Medical, Vastrax, Eppdata. RAH is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel; he is on the advisory board for MiVI, eLum, Three Rivers, Shape Medical, and Corindus; he has received unrestricted research grants from NIH, Interline Endowment, Microvention, Stryker, CNX; he is an investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Isolated anterior cerebral artery occlusions (ACAo) in patients with acute ischemic stroke present significant challenges due to their rarity. The efficacy and safety of endovascular therapy (EVT) in comparison with best medical therapy (BMT) for ACAo remains unclear. This study aimed to assess the outcomes of these treatments., Methods: This multinational, multicenter study analyzed data from the MAD-MT registry. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse probability of treatment weighting (IPTW) was applied to balance confounding variables. The primary outcome was functional independence (modified Rankin Scale (mRS) scores of 0-2) at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality at 90 days, and NIH Stroke Scale (NIHSS) score on day 1 post treatment., Results: Of the 108 patients, 36 received BMT and 72 underwent EVT. The median age was 75 years, and 56% were male. At 90 days, 40% of patients achieved mRS 0-2, with no significant difference between EVT and BMT (38% vs 45%, p=0.46). Procedural success (mTICI 2b-3) was 91% in the EVT group, with a sICH rate of 2.9%. IPTW-adjusted analysis showed no significant difference between EVT and BMT for functional independence (OR 1.17, 95% CI 0.23 to 6.02, p=0.85), mortality (25% vs 21%, p=0.71) or day 1 NIHSS scores (Beta 2.2, 95% CI -0.51 to 4.8, p=0.11)., Conclusions: EVT showed high procedural success but did not significantly improve functional outcomes or mortality compared with BMT in patients with ACAo. Further randomized trials are needed to clarify EVT's role in ACAo., Competing Interests: Competing interests: RWR serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. AG reports consultancy for Rapid Medical and Phenox, not directly related to the present work. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. NH received support from NINDS NS131756, NINR NR020231, and NINDS NS113844 during the conduct of the study. All unrelated to the present work. DSL is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. LLLY reports advisory work for AstraZeneca, substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. CJG reports a proctoring agreement with Medtronic and research funding by Penumbra. GM reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt, Sim and Cure (consulting), Medtronic, Johnson & Johnson, Penumbra, Bracco, and Phenox (paid lectures), all not directly related to the present work. ASP is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). PJ is a consultant for Medtronic, Microvention and Cerus. BP reports consultancy Microvention, Stryker, Q’apel, and Nuvascular, all not directly related to the present work. JES has served as a consultant for AstraZeneca, and has received funding from the National Institutes of Health (R61NS135583), Viz.ai, Philips, and Medtronic. TNN reports Associate Editor of Stroke; advisory for Aruna Bio, Brainomix., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A sizeable proportion of stroke patients with large vessel occlusion present with minor neurological deficits. Whether mechanical thrombectomy (MT) is beneficial in these patients is controversial. We aimed to investigate factors of early neurological deterioration (END) in thrombectomy patients with minor stroke and hypothesized that END is linked to unfavorable functional outcomes., Methods: Multicenter cohort study screening all patients prospectively enrolled in the German Stroke Registry-Endovascular Treatment (n=13 082) between 2015 and 2021. Patients who underwent MT for anterior circulation vessel occlusion with baseline National Institutes of Health Stroke Scale (NIHSS) score of <6 were included. END was defined as an increase in NIHSS score of ≥4 within the first 24 hours after MT. Multivariable regression analyses were performed to investigate factors associated with END and its association with unfavorable functional outcomes 90 days after treatment (modified Rankin Scale (mRS) score ≥2)., Results: Among 817 patients included, 24% exhibited END and 48% had unfavorable functional outcomes. Prestroke mRS (adjusted odds ratio (aOR) [95% CI] 1.42 [1.13 to 1.78]), baseline NIHSS (aOR [95% CI] 0.83 [0.73 to 0.94]), time from admission to groin puncture (aOR [95% CI] 1.04 [1.02 to 1.07]), general anesthesia (aOR [95% CI] 1.68 [1.08 to 2.63]), number of passes (aOR [95% CI] 1.15 [1.03 to 1.29]), adverse events during treatment (aOR [95% CI] 1.89 [1.19 to 3.01]), successful recanalization (aOR [95% CI] 0.29 [0.17 to 0.50]), and intracranial hemorrhage on follow-up imaging (aOR [95% CI] 3.40 [1.90 to 6.07]) were independently associated with END. END was independently linked to unfavorable functional outcomes (aOR [95% CI] 7.51 [4.57 to 12.34])., Conclusions: Almost a quarter of thrombectomy patients with minor stroke developed END. These patients had twice the odds of experiencing unfavorable functional outcomes., Competing Interests: Competing interests: FF reported receiving personal fees from Eppdata GmbH outside the submitted work. HK reported an ownership stake in Eppdata GmbH and compensation from Eppdata GmbH for consultant services outside the submitted work. GB reported receiving compensation as a speaker from Balt and personal fees from Eppdata GmbH outside the submitted work. CT reported receiving personal fees from Eppdata GmbH outside the submitted work. GT reported receiving personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. JF reported an ownership stake in Eppdata GmbH and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, Phenox, and grants from Route 92 outside the submitted work. TDF reported grants from the German Research Foundation (DFG) (Project Number: 411621970) and personal fees from Eppdata GmbH outside the submitted work., (© 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: Successful recanalization defined as modified Thrombolysis in Cerebral Infarction Score (mTICI) ≥2b is not achieved in 15%-20% of patients with acute ischemic stroke. This study aims to identify patient-specific factors associated with early stopping without successful recanalization. We hypothesized that the probability of the decision for early stopping during mechanical thrombectomy (MT) is higher in patients with an unfavorable prognosis., Methods: All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were screened. Inclusion criteria were stroke in the anterior circulation and availability of relevant clinical data. For each retrieval attempt 1-3, patients with stopping and failed reperfusion (mTICI <2b) were compared with all patients with continued retrieval attempts using descriptive statistics and multivariable logistic regression., Results: Our study included 2977 patients, 350 (12%) of which had early stopping. Higher pre-stroke Modified Rankin Scale (mRS) score (adjusted odds ratio (aOR) =1.20 (95% confidence interval (CI): 1.09; 1.32), P<0.001), higher age (aOR=1.01 (1.00; 1.02), P=0.017) and distal occlusions (aOR=1.93 (1.50; 2.47), P<0.001) as well as intraprocedural dissections/perforations (aOR=4.61 (2.95; 7.20), P<0.001) and extravasation (aOR=2.43 (1.55;3.82), P<0.001) were associated with early stopping. In patients with unsuccessful recanalization (n=622), the number of retrieval attempts (aOR=1.05 (0.94; 1.18), p=0.405) was not associated with unfavorable outcomes (90d-mRS>3)., Conclusion: The probability of early stopping was higher in patients with clinical conditions associated with: a) Favorable prognosis and assumed lower impact of recanalization success on functional status, such as distal occlusions; and b) Unfavorable prognosis, such as higher age and reduced pre-stroke functional status. Adverse events during the procedure increased the probability of early stopping. The number of recanalization attempts did not increase the risk of unfavorable outcome for patients with persistent occlusion, supporting the decision for continuation of retrieval attempts., Competing Interests: Competing interests: HK and FF are consultants for Eppdata GmbH. HK is shareholder of Eppdata GmbH. GT received consultancy fees from Acandis, Boehringer Ingelheim, Bayer, and Portola, and fees as lecturer from Acandis, Alexion, Amarin, Bayer, Boehringer-Ingelheim, BMS/Pfizer, Daiichii Sankyo and Portola. He serves in the board of the TEA Stroke Study and of ESO. JF is consultant for Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche and Tonbridge. He serves on the advisory board of Stryker and Phenox. He is a stock holder of Tegus Medical, Eppdata and Vastrax. He serves as Associate Editor at JNIS., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Multiple studies and meta-analyses have described the technical and clinical outcomes in large cohorts of aneurysm patients treated with flow diverters (FDs). Variations in evaluation methodology complicate making comparisons among studies, hinder understanding of the device behavior, and pose an obstacle in the assessment of further advances in FD therapy., Methods: A multidisciplinary panel of neurointerventionalists, imaging experts, and neuroradiologists convened with the goal of establishing consensus recommendations for the standardization of image analyses in FD studies., Results: A standardized methodology is proposed for evaluating and reporting radiological outcomes of FD treatment of intracranial aneurysms. The recommendations include general imaging considerations for clinical studies and evaluations of longitudinal changes, such as neointimal lining and stenosis. They cover standards for classification of aneurysm location, morphology, measurements, as well as the assessment of aneurysm occlusion, wall apposition, and neck coverage. These reporting standards further define four specific braid deformation patterns: foreshortening, fish-mouthing, braid bump deformation, and braid collapse, collectively termed 'F2B2'., Conclusions: When widely applied, standardization of methods of measuring and reporting outcomes will help to harmonize the assessment of treatment outcomes in clinical studies, help facilitate communication of results among specialists, and help enable research and development to focus on specific aspects of FD techniques and technology., Competing Interests: Competing interests: JF: Research support: German Ministry of Science & Education (BMBF) and of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions- und Förderbank (IFB), Medtronic, Microvention, Route92, Stryker. Consultant for: Acandis, Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Stryker, TG Med, Tonbridge. Stockholder: Tegus Medical, Vastrax, Eppdata. DF: Medtronic – Consulting, Proctoring, Cerenovous – Consulting, Microvention – Consulting, Proctoring, Research Support, Penumbra – Consulting, Research Support, Stryker – Consulting, Research Support, Balt USA – Consulting, Research Support, Siemens – Research Support, MENTICE-Vascular Simulations – Consultant, Neurogami – Stockholder, Consultant, RAPID. AI – Consultant, RAPID Medical – Consultant, Qapel Medical –Consultant, Arsenal Medical – Consultant, Phenox Medical – Consultant, Scientia Medical – SAB, Consultant, Stockholder, NVMed – SAB, Stockholder, Perfuze – SAB, Consultant, Stockholder, Vesalio - ConsultantIS: Consulting and proctoring agreement with Medtronic & Microvention. SH: Consulting and proctoring agreement with Medtronic & Microvention. Stocks: Neuravention Inc., Vesalio Inc., Synchron Inc., Bend It Technologies, Sim & Size Inc., Borvo Medical Inc., Prometheus Inc., Piraeus Inc., Neuros Medical Inc. MJG: (1) Consultant on a fee-per-hour basis for Alembic, Astrocyte Pharmaceuticals, BendIt Technologies, Cerenovus, Imperative Care, Jacob’s Institute, Medtronic Neurovascular, Mivi Neurosciences, Phenox GMbH, Q’Apel, Route 92 Medical, Scientia, Simcerre, Stryker Neurovascular, Stryker Sustainability Solutions, Wallaby Medical; holds stock in Imperative Care, InNeuroCo, Galaxy Therapeutics, Kapto, Neurogami and Synchron; (2) Research support from the National Institutes of Health (NIH), the United States–Israel Binational Science Foundation, Anaconda, ApicBio, Arsenal Medical, Axovant, Balt, Cerenovus, Ceretrieve, CereVasc, Cook Medical, Galaxy Therapeutics, Gentuity, Gilbert Foundation, Imperative Care, InNeuroCo, Insera, Jacob’s Institute, Magneto, MicroBot, Microvention, Medtronic Neurovascular, MIVI Neurosciences, Naglreiter MDDO, Neurogami, Q’Apel, Philips Healthcare, Progressive Medical, Pulse Medical, Rapid Medical, Route 92 Medical, Scientia, Stryker Neurovascular, Syntheon, ThrombX Medical, Wallaby Medical, the Wyss Institute, Xtract Medical; and (3) Associate Editor of Basic Science on the JNIS Editorial Board., (© 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: A direct aspiration first pass technique (ADAPT) is an effective alternative to stent retriever thrombectomy for patients with large vessel occlusion (LVO). The PERFECT study evaluated direct aspiration with the EMBOVAC large bore aspiration catheter in patients with LVO strokes., Methods: PERFECT was a prospective, post-market, single-arm, multicenter, observational study of patients enrolled across 11 European centers between October 2020 and July 2022. Three direct aspiration passes with EMBOVAC were mandated before switching strategy. The primary endpoint was core-lab assessed successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) post-procedure. Other outcomes included first pass mTICI ≥2c, independent 90-day modified Rankin Scale (mRS) evaluation, and symptomatic intracerebral hemorrhage (sICH) at 24 hours by a clinical events committee., Results: EMBOVAC was used in 100 patients (mean age 70.4±14.0 years, 59.0% (59/100) female). Final mTICI ≥2b was achieved in 98.0% (97/99), final mTICI ≥2b with no change in frontline therapy or thrombolytics use during the procedure was achieved in 87.9% (87/99), final mTICI ≥2c in 86.9% (86/99), and first pass mTICI ≥2c in 53.5% (53/99). sICH at 24 hours was 0%. The 90-day mRS ≤2 rate was 56.6% (56/99) and all-cause mortality was 12.9%. One device-related serious adverse event occurred within 90 days (1.0%)., Conclusions: PERFECT demonstrates that EMBOVAC achieves successful reperfusion rates and favorable clinical outcomes when used in the endovascular treatment of acute ischemic stroke (AIS) using a direct aspiration technique as first line therapy in a real-world setting in patients with AIS secondary to large vessel occlusion., Trial Registration: www., Clinicaltrials: gov Unique identifier: NCT04531904., Competing Interests: Competing interests: OJ: personal fees: Fa. Arcandis/Germany. GM: payment/honoraria for lectures, presentations, Speakers Bureaus, manuscript writing, educational events: Medtronic, Microvention; consulting fees: Stryker Neurovascular, Microvention Europe, Balt SAS, Sim and Size; paid lectures: Medtronic 675, Cerenovus, Bracco, Phenox. BG: consulting fees: Surge2surgery. HN: payment/honoraria for lectures, presentations, educational events: Acandis, Cerenovus, Phenox, Rapid medical. CC: payment/honoraria for lectures, presentations, Speakers bureaus, manuscript writing, educational events: Medtronic, Microvention, MIVI, Stryker. CL: proctoring/consultant services: Phenox; consultant services: Penumbra; travel and meeting expenses: Acandis, Penumbra; payment of honoraria for lectures and support for attending meetings: Phenox, Penumbra, Acandis. AS: employed by/holds shares: GSK. JF: research support: German Ministry of Science and Education, German Ministry of Economy and Innovation, German Research Foundation, European Union, Hamburgische Investitions-/ Förderbank, Medtronic, Microvention, Philips, Stryker; consultancy appointments: Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Medtronic, Microvention, Penumbra, Phenox, Roche, Route92, Stryker, Tonbridge, TG Medical; stock holdings: Tegus Medical, Vastrax, Eppdata. KD: academic grants: Science Foundation Ireland. MP, BE, AP, MZ, AM, KL: nothing to disclose., (© 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: Current randomized controlled trials are investigating the efficacy and safety of mechanical thrombectomy (MT) in patients with medium vessel occlusion (MeVO) stroke. Whether best medical management (MM) is more efficient than unsuccessful vessel recanalization during MT remains unknown., Methods: This was a retrospective cohort study using data from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. Only patients with occlusion of the distal branches (M2 and M3) of the middle cerebral artery territory were included. Unsuccessful MT was defined as a modified Thrombolysis in Cerebral Infarction score of 0-2a. Propensity score matching was used to control for confounders. The primary outcome was functional independence, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after treatment. Multivariable regression analysis was used to assess factors associated with the primary outcome., Results: Of 2903 patients screened for eligibility, 532 patients were analyzed (266 per group) after propensity score matching. The MM group had superior functional outcomes, with 32% achieving mRS 0-1 at 90 days compared with 21% in the MT group (P=0.011). Patients in the MM group also had significantly lower rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 16%, P<0.001) and any hemorrhage (18% vs 48%, P<0.001). On multivariable regression, unsuccessful MT was associated with reduced odds of functional independence (OR 0.50, 95% CI 0.29 to 0.85, P=0.011) and increased odds of sICH (OR 4.32, 95% CI 1.84 to 10.10, P<0.001). Mortality rates were similar between groups (27% in MM vs 29% in MT, P=0.73)., Conclusion: Unsuccessful MT for MeVO was linked to worse outcomes than best MM. These findings highlight the risks of prolonged attempts and emphasize the importance of efficient procedural decision-making to reduce complications and improve patient outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction: Mechanical thrombectomy (MT) efficacy in medium vessel occlusion (MeVO) stroke, particularly in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS), remains less explored., Methods: This retrospective study analyzed data from 443 AIS patients treated with MT for MeVO and low ASPECTS (4-7) at 37 centers across North America, Asia, and Europe, from September 2017 to July 2021. Patients were categorized into ASPECTS of 4-5 and 6-7., Results: Of 443 patients, 51 (12%) had ASPECTS of 4-5, and 392 (88%) had scores of 6-7. The median age was 65 years (IQR: 46-79), with a balanced sex distribution between the groups. The most common site of initial occlusion was M2 branch in both groups (92% in ASPECTS 4-5 and 85% in ASPECTS 6-7) (p = 0.68). The ASPECTS 4-5 group had lower TICI 2c-3 achievement (31% vs. 55%, p = 0.002) and poorer functional outcomes (mRS 0-1 at 90 days: 12% vs. 29%, p = 0.03) compared to the ASPECTS 6-7 group. Intracranial hemorrhagic complications were higher in the ASPECTS 4-5 group (69% vs. 47%, p = 0.007). Multivariable analysis revealed ASPECTS 6-7 to be associated with higher odds of TICI 2c-3 (OR: 2.5; CI: 1.28 to 4.89, p = 0.007) and lower odds of intracranial hemorrhagic complications (OR: 0.4; CI: 0.19 to 0.81, p = 0.012)., Conclusion: MT may be associated with improved outcomes in patients with moderate-to-low ASPECTS (6-7), though the lack of a control group limits definitive conclusions about its effectiveness. In patients with very low ASPECTS (4-5), higher rates of hemorrhagic complications and poorer outcomes were observed, but this does not necessarily preclude the use of MT. These findings highlight the need for further research and careful patient selection., Competing Interests: Declarations. Informed consent and ethical approval: The study received approval from the local ethical standards committee at each participating site, and informed consent from patients was waived. The data supporting this study’s findings are available from the corresponding author upon reasonable request. Conflicts of interest/Competing interests (appropriate disclosures): Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr. Jabbour is a consultant for Medtronic, Microvention and Cerus., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Mechanical thrombectomy (MT) is the standard of care in anterior circulation large vessel occlusion. A vital modifiable factor is successful reperfusion. While multiple passes improve the rates of successful reperfusion, previous studies have reported progressively diminishing returns. This study aimed to investigate the relationship between number of passes and outcomes in basilar artery occlusion (BAO)., Methods: This multicentre retrospective cohort study included patients who were treated with MT for acute BAO from eight comprehensive stroke centres between 2015 and 2020. The primary outcome was favourable functional outcome (FFO) defined as modified Rankin Scale (mRS) 0-3 measured at 90 days. Secondary outcomes included spontaneous intracranial haemorrhage and mortality. Patients were stratified according to reperfusion status and the number of passes for further analysis., Results: The adjusted odds ratio (OR) for FFO 90 days for each additional pass of a thrombectomy device was 0.56 ( P = 0.003). When ≤3 passes of the thrombectomy device were made, achieving reperfusion led to higher rates of FFOs. However, when >3 passes of the thrombectomy device were made, achieving reperfusion no longer led to higher rates of FFOs (FFO = 0% in patients who did not achieve reperfusion vs. FFO = 14.5 in patients who achieved reperfusion; P = 0.200). Notably, increasing number of passes was associated with a non-significant trend towards higher rate of parenchymal haemorrhage (OR 1.55, P = 0.055)., Conclusion: Acute BAO patients treated with up to three passes of a thrombectomy device derived improved functional outcomes from reperfusion compared to those with more than three passes. Further prospective cohort studies are necessary to validate these findings., (Copyright © 2025 Singapore Medical Journal.)

Background Symptomatic acute occlusions of the internal carotid artery (ICA) below the circle of Willis can cause a variety of stroke symptoms, even if the major intracranial cerebral arteries remain patent; however, outcome and safety data are limited. Purpose To compare treatment effects and procedural safety of endovascular treatment (EVT) and best medical treatment (BMT) in patients with symptomatic acute occlusions of the ICA below the circle of Willis. Materials and Methods This retrospective, multicenter cohort study from 22 comprehensive stroke centers in Europe and Asia includes patients treated between January 1, 2008, and December 31, 2022. Functional (modified Rankin Scale [mRS]) and clinical (National Institutes of Health Stroke Scale [NIHSS]) outcomes, safety measures (symptomatic intracerebral hemorrhage), mortality, and procedural complications were assessed. Results A total 354 patients met the inclusion criteria (median age, 72 years [IQR, 60-81 years]; median NIHSS, 13 [IQR, 7-19]). Most frequent occlusions were in the C1 segment (243 of 354; 68.6%). Of 354 patients, 82.2% (291 patients) were administered EVT. In the overall population, favorable outcomes (mRS 0-2), mortality, and symptomatic intracerebral hemorrhage occurred in 40.6% (108 of 266 patients), 25.2% (67 of 266 patients), and 7.1% (25 of 350 patients), respectively. After adjustment, no statistically significant difference in functional outcome was observed (adjusted odds ratio [AOR], 0.82 [95% CI: 0.31, 2.12]; average treatment effect, -12.7%; P = .19) in the EVT compared with BMT group. Symptomatic intracerebral hemorrhage (average treatment effect, -0.28%; P = .95) and mortality did not differ between both groups (average treatment effect, -17.1%; P = .07). EVT resulted in complete recanalization of the occlusion in 80.9% (229 of 283) of cases. Periprocedural distal embolization occurred in 27.8% (81 of 291 patients) and was associated with poor outcomes (AOR, 0.41; 95% CI: 0.18, 0.93; P = .03). Conclusion EVT did not reveal a favorable treatment effect over BMT, and both therapies were safe. EVT had a risk for periprocedural distal embolization associated with poor outcomes. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Daou and Chaudhary in this issue.

Acute ischemic stroke (AIS) remains a global health challenge, leading to long-term functional disabilities without timely intervention. Spatio-temporal (4D) Computed Tomography Perfusion (CTP) imaging is crucial for diagnosing and treating AIS due to its ability to rapidly assess the ischemic core and penumbra. Although traditionally used to assess acute tissue status in clinical settings, 4D CTP has also been explored in research for predicting stroke tissue outcomes. However, its potential for predicting functional outcomes, especially in combination with clinical metadata, remains unexplored. Thus, this work aims to develop and evaluate a novel multimodal deep learning model for predicting functional outcomes (specifically, 90-day modified Rankin Scale) in AIS patients by combining 4D CTP and clinical metadata. To achieve this, an intermediate fusion strategy with a cross-attention mechanism is introduced to enable a selective focus on the most relevant features and patterns from both modalities. Evaluated on a dataset comprising 70 AIS patients who underwent endovascular mechanical thrombectomy, the proposed model achieves an accuracy (ACC) of 0.77, outperforming conventional late fusion strategies (ACC = 0.73) and unimodal models based on either 4D CTP (ACC = 0.61) or clinical metadata (ACC = 0.71). The results demonstrate the superior capability of the proposed model to leverage complex inter-modal relationships, emphasizing the value of advanced multimodal fusion techniques for predicting functional stroke outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: A potential benefit of mechanical thrombectomy for patients with distal medium vessel occlusions is currently being investigated in randomized trials. Computed tomography perfusion imaging has not yet been tested as a method to guide mechanical thrombectomy for distal medium vessel occlusions. The purpose of this study was to assess penumbral imaging as an imaging-based method for triaging patients with ischemic stroke and acute M2-middle cerebral artery occlusion., Methods: This observational retrospective study of M2-middle cerebral artery patients with ischemic stroke triaged by multimodal computed tomography undergoing mechanical thrombectomy at a high-volume stroke center between January 2015 and January 2023. The effect of recanalization was analyzed according to computed tomography perfusion-derived lesion volumes (defined using relative cerebral blood flow <30% and T max >6 seconds) using logistic regression analysis, and interaction terms between the independent variables and recanalization were tested. The primary end point was functional independence at day 90, defined using modified Rankin Scale scores of 0 to 2., Results: A total of 140 patients with M2-middle cerebral artery occlusion were included. In multivariable logistic regression analysis, recanalization was not associated with better functional outcome (adjusted odds ratio, 1.85 [95% CI, 0.87-3.90]; P =0.11). After including interaction terms, a significant treatment effect between recanalization and computed tomography perfusion-derived lesion volumes was observed in patients with >150 mL hypoperfusion volume (adjusted odds ratio, 1.02 [95% CI, 1.00-1.03]; P =0.007) or >125 mL penumbral volumes (adjusted odds ratio, 1.02 [95% CI, 1.01-1.03]; P =0.005), as well as for baseline ischemic core volume within the range of 15 to 40 mL (adjusted odds ratio, 1.11 [95% CI, 1.01-1.22]; P =0.03)., Conclusions: Penumbral imaging might serve as a useful tool for treatment decision-making in distal medium vessel occlusions, particularly in cases of suspected non- or codominant M2-middle cerebral artery vessel occlusions. A hypoperfusion volume threshold of >150 mL emphasizes the potential value of computed tomography perfusion as a standardized tool directly showing the volumetric relevance in distal medium vessel occlusion cases., Competing Interests: Dr Broocks reports consulting for EppData GmbH and a research grant from the Foundation of the American Society of Neuroradiology. Dr Fiehler reports compensation from TG Medical for consulting services; compensation from Penumbra, Inc for consulting services; employment with Eppdata; compensation from Cerenovus for consulting services; compensation from MicroVention, Inc, for consulting services; compensation from Roche for consulting services; stock holdings in Eppdata; compensation from Tonbridge for consulting services; compensation from Medtronic USA, Inc, for consulting services; stock holdings in Eppdata; compensation from Phenox for consulting services; stock holdings in Vastrax; stock holdings in Tegus Medical; compensation from Stryker Corporation for consulting services; and compensation from Acandis for consulting services. Dr Kemmling has a research collaboration agreement with Siemens Healthcare (company involved in CT/MRI distribution). Dr Kniep: Educational presentation for Asklepios Kliniken; consulting for EppData GmbH. The other authors report no conflicts.

Intracerebral hemorrhage (ICH) and perihematomal edema (PHE) are key imaging markers of primary and secondary brain injury in hemorrhagic stroke. Accurate segmentation and quantification of ICH and PHE can help with prognostication and guide treatment planning. In this study, we combined Swin-Unet Transformers with nnU-NETv2 convolutional network for segmentation of ICH and PHE on non-contrast head CTs. We also applied test-time data augmentations to assess individual-level prediction uncertainty, ensuring high confidence in prediction. The model was trained on 1782 CT scans from a multicentric trial and tested in two independent datasets from Yale (n = 396) and University of Berlin Charité Hospital and University Medical Center Hamburg-Eppendorf (n = 943). Model performance was evaluated with the Dice coefficient and Volume Similarity (VS). Our dual Swin-nnUNET model achieved a median (95% confidence interval) Dice = 0.93 (0.90-0.95) and VS = 0.97 (0.95-0.98) for ICH, and Dice = 0.70 (0.64-0.75) and VS = 0.87 (0.80-0.93) for PHE segmentation in the Yale cohort. Dice = 0.86 (0.80-0.90) and VS = 0.91 (0.85-0.95) for ICH and Dice = 0.65 (0.56-0.70) and VS = 0.86 (0.77-0.93) for PHE segmentation in the Berlin/Hamburg-Eppendorf cohort. Prediction uncertainty was associated with lower segmentation accuracy, smaller ICH/PHE volumes, and infratentorial location. Our results highlight the benefits of a dual transformer-convolutional neural network architecture for ICH/PHE segmentation and test-time augmentation for uncertainty quantification.

Background: There is yet no randomized controlled evidence that mechanical thrombectomy (MT) is superior to best medical treatment in patients with large vessel occlusion but minor stroke symptoms (National Institutes of Health Stroke Scale (NIHSS) <6). Prior studies of patients with admission NIHSS scores ≥ 6 observed unfavorable functional outcomes despite successful recanalization, commonly termed as futile recanalization (FR), in up to 50% of cases., Aim: The aim of this study is to determine the prevalence of FR in patients with minor stroke and identify associated patient-specific risk factors., Methods: Our multicenter cohort study screened all patients prospectively enrolled in the German Stroke Registry Endovascular Treatment from 2015 to 2021 (n = 13,082). Included were patients who underwent MT for anterior circulation vessel occlusion with a baseline NIHSS score of <6 and successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) scores of 2b-3). FR was defined by modified Rankin Scale (mRS) scores of 2-6 at 90 days. Multivariable logistic regression analysis was conducted to explore factors associated with FR., Results: A total of 674 patients met the inclusion criteria. FR occurred in 268 (40%) patients. Multivariable logistic regression analysis indicates that higher age (adjusted odds ratio (aOR) = 1.04 (95% confidence interval (CI) = 1.02-1.06)), pre-stroke mRS 1 (aOR = 2.70 (95% CI = 1.51-4.84)), transfer from admission hospital to comprehensive stroke center (aOR = 1.67 (95% CI = 1.08-2.56)), longer time from symptom onset/last seen well to admission (aOR = 1.02 (95% CI = 1.00-1.04)), MT under general anesthesia (aOR = 1.78 (95% CI = 1.13-2.82)), higher NIHSS after 24 h (aOR = 1.09 (95% CI = 1.05-1.14)), and symptomatic intracranial hemorrhage (aOR = 16.88 (95% CI = 2.03-140.14)) increased the odds of FR. There was no significant difference in primary outcome between achieving mTICI score of 2b or 3., Conclusions: Unfavorable functional outcomes despite successful vessel recanalization were frequent in acute ischemic stroke patients with low NIHSS scores on admission. We provide patient-specific risk factors that indicate an increased risk of FR and should be considered when treating patients with minor stroke., Data Accessibility Statement: The data that support the findings of our study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declared the following potential conflicts of interest: F.F. reported receiving personal fees from Eppdata GmbH outside the submitted work. H.C.K. reported an ownership stake in Eppdata GmbH and compensation from Eppdata GmbH for consultant services outside the submitted work. G.B. reported receiving compensation as a speaker from Balt and personal fees from Eppdata GmbH outside the submitted work. C.T. reported receiving personal fees from Eppdata GmbH outside the submitted work. J.J.H. reported consulting for Medtronic and MicroVention and Medical and Scientific Advisory Board membership for iSchemaView. G.W.A. reported equity and consulting for iSchemaView and consulting from Medtronic. G.T. reported receiving personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. J.F. reported an ownership stake in Eppdata GmbH and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, and Phenox and grants from Route 92 outside the submitted work. T.D.F. reported grants from the German Research Foundation (DFG) (project no. 411621970) and personal fees from Eppdata GmbH outside the submitted work. A.H., L.W., M.S., and C.H. reported no disclosure.

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty)., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in Supplemental Table 1.

Background: Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support a general anesthesia (GA) strategy in these patients., Methods: We conducted an international retrospective study of MeVO cases. A propensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of a favourable outcome and sICH were evaluated with backward logistic regression., Results: After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as a predictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained a significant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72)., Conclusion: Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality., Competing Interests: Conflict of interest R.W. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. A. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. F. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board) ; all not directly related to the present work. N. Henninger received support from NINDS NS131756, during the conduct of the study. D.S. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. T.N. Nguyen reports advisory board with Idorsia. L.L.L. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. C.J. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. G. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. I. Sibon reports conflict of interest with Medtronic, Sanofi, Bayer, Boehringer-Ingelheim, Novartis, Novo-nordisk, BMS-Pfizer (Board and paid lectures), all not directly related to the present work. V. Yedavalli is a consultant for RAPID (Ischemaview, Menlo Park, CA). A. Vagal is a consultant for Viz AI. She is also PI of the Imaging core lab for the ENDOLOW study funded by Cerenovus (monies go to the institution). A. Gopinathan reports conflicts of interest with Microvention, Stryker Neurovascular, Medtronic, BD, and Penumbra (paid lectures, workshops, and proctoring), all not directly related to the present work. R. A. Radu, V. Costalat, M. Romoli, B. Musmar, J.E. Siegler, S. Ghozy, J. Khalife, H. Salim, H. Shaikh, N. Adeeb, H.H. Cuellar-Saenz, A.J. Thomas, R. Kadirvel, M. Abdalkader, P. Klein, J.J. Heit, J.D. Bernstock, A.B. Patel, J.D. Rabinov, C.J. Stapleton, N.M. Cancelliere, T.R. Marotta, V. Mendes Pereira, K. El Naamani, A. Amllay, S.I. Tjoumakaris, P. Jabbour, L. Meyer, J. Fiehler, T.D. Faizy, H. Guerreiro, A. Dusart, F. Bellante, G. Forestier, A. Rouchaud, C. Mounayer, A.L. Kühn, A.S. Puri, C. Dyzmann, P.T. Kan, M. Colasurdo, J. Berge, X. Barreau, S. Nedelcu, T. Ota, S. Dofuku, B.Y. Tan, J.C. Martinez-Gutierrez, S. Salazar-Marioni, S. Sheth, L. Renieri, C. Capirossi, A. Mowla, L.M. Chervak, P. Khandelwal, A. Biswas, M. Elhorany, K. Premat, I. Valente, A. Pedicelli, A.M. Alexandre, J.P. Filipe, R. Varela, M. Quintero-Consuegra, N.R. Gonzalez, M.A. YMD, J. Jesser, C. Weyland, A. ter Schiphorst, P. Harker, Y. Aziz, B. Gory, C. Paul Stracke, C. Hecker, M. Killer-Oberpfalzer, C.-Y. Hsieh, I. Tancredi, R. Fahed, B. Lubicz, M.A. Essibayi, A. Baker, D. Altschul, L. Scarcia, E. Kalsoum and A.A. Dmytriw for the MAD-MT Consortium declare that they have no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: The EXCELLENT registry aimed to evaluate the effectiveness of the EMBOTRAP Revascularization Device in an all-comer population in a real-world setting, with a focus on the composition of retrieved clots., Methods: EXCELLENT is a prospective, global registry of patients with acute ischemic stroke treated with EMBOTRAP as the first-line mechanical thrombectomy device conducted at 34 sites (25 sites contributing clot) from September 2018 to March 2021, utilizing core imaging and central histology laboratories blinded to clinical data, independent 90-day modified Rankin Scale assessment and Clinical Events Committee., Results: After screening 3799 patients, a total of 997 subjects (mean age, 70.0±14.2 years; 51.8% women; 19.7% non-White) were included. The first-pass modified Treatment in Cerebral Infarction (mTICI) ≥2b rate was 64.5% (623/966), first-pass mTICI ≥2c was 39.1% (378/966), and final mTICI ≥2b was 94.5% (931/985). A total of 427/912 (46.8%) patients achieved a 90-day modified Rankin Scale of 0 to 2 or ≤baseline. Embolization to a new territory occurred in 0.2% (2/984), and symptomatic intracranial hemorrhage at 24 hours in 1.6% (16/997). The 90-day mortality was 19.1% (175/918). Device- and/or procedure-related serious adverse events occurred in 5.9% (54/912) through 90 days. The mean RBC percentage of retrieved clots was 45.62±21.372. Among patients who achieved mTICI ≥2b with the first pass, 15.7% (52/331) and 9.7% (32/331), respectively, had RBC-poor (<25%) and RBC-rich (>75%) clots. Patients with no clot retrieved in any procedural pass had a lower percentage of hyperdense or susceptibility vessel sign on baseline imaging (58.9% versus 74.7%; P <0.001), pointing to a potential preprocedure indicator of challenging clot., Conclusions: The EXCELLENT registry informs real-world practices in mechanical thrombectomy and sheds light on the range of clots effectively retrieved by current technology. This is the first report of detailed patient characteristics where mechanical thrombectomy maneuvers failed to remove any clot material. Although the composition of nonretrievable clots cannot be assessed histologically, the results support the notion that no retrieval may be correlated with imaging findings suggesting clots lower in RBC., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03685578., Competing Interests: Dr Nogueira: consulting for Anaconda, Medtronic, Cerenovus, Genentech, Viz-AI, Stryker, Prolong Pharmaceuticals, Perfuze, Biogen, Shanghai Wallaby, Brainomix, Hybernia, RapidPulse, Imperative Care, Corindus, NeuroVasc Technologies, Vesalio, Cerebrotech, Phenox, Astrocyte, Ceretrieve, Philips; grants from Stryker, Cerenovus; data safety monitoring for Synchron; ownership/investment interest in Ceretrieve, Corindus, Brainomix, Perfuze, Truvic, Viz-AI, Reist, Q’Apel, Vesalio, Cerebrotech, Viseon, Piraeus, Brain4Care, Quantanosis-AI. Dr Andersson: consulting for Neuravi, Anaconda, Johnson & Johnson (J&J), Rapid Medical; ownership/investment interest in Ceroflo. Dr Haussen: consulting for Brainomix, Vesalio, Stryker, Poseydon, Chiesi, Cerenovus; ownership/investment interest in Viz-AI; data safety monitoring for Jacobs Institute. Dr Yoo: consulting for Philips, Nicolab, ZOLL Circulation, Vesalio, Rapid Medical; grants and consulting for J&J, Medtronic, Penumbra; grants from Stryker, Genentech; ownership/investment interest in Gravity, Galaxy Therapeutics, Insera, Nicolab; data safety monitoring for NIH; employment with HCA Healthcare; other services for AHA. Dr Hanel: consulting for Balt, MicroVention, Medtronic, Rapid Medical, Stryker, Phenox, Cerenovus, Q’Apel; ownership/investment interest in Cerebrotech, Three Rivers Medical, NTI, Endostream, BlinkTBI, RisT, InNeuroCo, Corindus, eLum, Scientia. Dr Zaidat: consulting for J&J; patent holder. Dr Hacke: consulting for J&J. Dr Jovin: consulting for Contego Medical; grants from Medtronic, Stryker; employment with Cooper University Healthcare; data safety monitoring for Cerenovus; ownership/investment interest in Anaconda, StataDx, Galaxy, Basking, Freeox Biotech, Kandu, Viz-AI, Route92, Gravity. Dr Fiehler: consulting for Stryker, Cerenovus, Penumbra, MicroVention, Roche, Tonbridge, Phenox, TG Medical, Medtronic, Acandis; ownership/investment interest in Vastrax, Eppdata, Tegus; employment with Eppdata. Dr De Meyer: travel support from J&J. Dr Brinjikji: consulting for Cerenovus, MicroVention, Medtronic, Balt, Imperative Care, MIVI; ownership interest in Piraeus, Nested Knowledge, MIVI; research funding from Cerenovus, Brainomix, NIH. Dr Doyle: grants from SFI, Cerenovus. Dr Kallmes: grants from MIVI, Cerenovus, Balt, Vesalio, Stryker, MicroVention, Insera, Medtronic, Brainomix; ownership/investment interest in Superior Medical Experts, Conway Medical, Piraeus, Monarch Biosciences, Marblehead, Nested Knowledge; patent holder. Dr Liebeskind: consulting for Cerenovus, Medtronic, Genentech, Stryker, Rapid Medical. Dr Virmani: grants from Endotronix, L&J Bio, W.L. Gore, Recombinetics, Transverse Medical, Profusa, Lutonix, MicroVention, Envision, Neovasc, Cerus EndoVascular, MedAlliance, Interface Biologics, Biotronik, Mercator MedSystems, Spectrawave, Cook Medical, SoundPipe, Ossio, Bolt Medical, CardioMech, Olympus, Spartan Micro, Intact Vascular, Inc, Whiteswell, Vascudyne, Imperative Care, Biotyx Medical, SMT, Innovative Medical Devices, Cardiovascular Solutions, Dexcom, Emboline, Cooper Health, Children’s National, Concept Medical, Filterlex, eLum Technologies, Protembis, Boston Scientific, Polares, MDS, CeloNova, UCSF Foundation, Croivalve, Canon, Terumo, BD Biosciences, Limflow, Renata, Vetex, Recor, Mayo Clinic, CSI, Ohio Health, UPMC, Regencor, Vesper, Ripple Therapeutics, Polyvascular, Invatin, Innovative Cardiovascular Solutions, TruLeaf, Coramaze, ProKidney, 480 Biomedical, Transmural Systems, Intershunt Technologies, Pi-Cardia, Lyra Therapeutics, Sanofi, Phenox, Qool Therapeutics, Chansu Vascular Technologies, Nyra Medical, Surmodics, Microport, Leducq Foundation, OrbusNeich, Cardiac Implants, Rush University, Edwards Lifesciences, Cardionomic, Restore Medical, Medanex, CRL, Lahav, Pulse Biosciences, Jacobs Institute, Nova Vascular, Nephronyx, Maywell, Innovalve, Elucid Bioimaging, Medtronic, Biosensors International Group, ShockWave Medical, Cardiawave, NIH, Occlutech; consulting for Terumo, Recor Medical, Sino Medical, Medtronic, Cook, W.L. Gore, CSI, Surmodics, CeloNova, Edwards Lifesciences, BARD, Xeltis; other services for Xeltis, Medtronic; employment with CVPath Institute. Dr Kokoszka: employment with Cerenovus. Dr Inoa: consulting for Siemens, Viz-AI, Medtronic, Cerenovus, MicroVention, Penumbra; grants from Medtronic; employment with Semmes Murphey Clinic. Dr Humphries: consulting for Cerenovus. Dr Jabbour: consulting for Medtronic. Dr François: consulting for iVascular. Dr Levy: consulting for Guidepoint, GLG Consulting, Clarion, StimMed, Mosaic; other services for Penumbra, Medtronic, MicroVention; ownership/investment interest in Imperative Care, StimMed, Three Rivers Medical, NeXtGen Biologics, Q’Apel, Claret Medical, Rapid Medical. Dr Dashti: consulting for MicroVention, J&J, Cerenovus. Dr Schirmer: consulting for Balt, Medtronic, Stryker, Viz-AI, MicroVention; grants from Route92, MicroVention, Penumbra, Cerenovus, Balt, MIVI, Medtronic; employment with Geisinger; other services for Werfen, Cerenovus, NIH, Stryker, Neurotechnology Investors; ownership interest in Reist. Dr Hussain: consulting for J&J. Dr De Leacy: consulting for J&J, Imperative Care, Stryker; ownership/investment interest in Vastrax, Q’Apel, Spartan Micro, Synchron, Endostream. Dr Puri: consulting for J&J, MicroVention, Merit Medical, Stryker, Medtronic, Balt. Dr Chitale: grants, consulting, and data safety monitoring for Medtronic; grants from J&J. Dr Siddiqui: consulting for Cerebrotech, Boston Scientific, Rapid Medical, Cordis, W.L. Gore, Peijia Medical, Corindus, StimMed, J&J, Viz-AI, Silk Road Medical, Piraeus, Medtronic, Penumbra, Hyperfine Operations, Cerenovus, Endostream, Minnetronix Neuro, Stryker, Canon Medical Systems, Integra LifeSciences, Imperative Care, Apellis, Amnis Therapeutics, Vassol, IRRAS, Cardinal Health 200, Q’Apel, InspireMD, MicroVention, Serenity Medical; grants from Brain Aneurysm Foundation, NIH; other services for Rapid Medical, MicroVention, MIVI, Medical University of South Carolina, Penumbra, Cerenovus, InspireMD, Medtronic; ownership/investment interest in Willow Medtech, Cognition Medical, Whisper Medical, Spinnaker, Sim & Cure, Hyperion, BlinkTBI, Surgical, Inc, Radical Catheter Technologies, Imperative Care, Code Zero Medical, E8, Truvic, Tulavi, Bend IT, Neurolutions, Q’Apel, Endostream, Cerebrotech, Instylla, Collavidence Medical, Sense Diagnostics, Neurotechnology Investors, Peijia Medical, Synchron, Viseon, Borvo, E8, Galaxy Therapeutics, Piraeus, Adona Medical, NeuroRadial Technologies, NextGen Biologics, Viz-AI, Three Rivers Medical, StimMed, Serenity Medical, Cerevatech, Cvaid, Silk Road Medical, PerFlow Medical, InspireMD, VICIS, QAS.ai, SongBird, Launch NY, Neurovascular Diagnostics, Vastrax, Cognition Medical, Integra LifeSciences, Medtronic; employment with University at Buffalo Neurosurgery, Jacobs Institute; patent holder. The other authors report no conflicts.

Background: Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood., Methods: This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications., Results: Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p  < 0.001) and had a higher prevalence of atrial fibrillation (77% vs 26%; p  < 0.001). Their baseline National Institutes of Health Stroke Scale (NIHSS) scores were also higher (median 12 vs 9; p  = 0.002). Before propensity score matching (PSM), anticoagulated patients had similar rates of favorable 90-day outcomes (mRS 0-1: 30% vs 37%, p  = 0.1; mRS 0-2: 47% vs 50%, p  = 0.41) but higher mortality (26% vs 17%, p  = 0.008). After PSM, there were no significant differences in outcomes between the two groups., Conclusion: Anticoagulated patients undergoing MT for AIS due to DMVO did not show significant differences in 90-day mRS outcomes, reperfusion, or hemorrhage compared to non-anticoagulated patients after adjustment for covariates., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation.Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work.Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work.Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work.Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical.Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work.Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra.Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work.Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI.Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally).Dr. Jabbour is a consultant for Medtronic, Microvention and Cerus.

Background: Acute ischemic stroke (AIS) from primary medium vessel occlusions (MeVO) is a prevalent condition associated with substantial morbidity and mortality. Despite the common use of mechanical thrombectomy (MT) in AIS, predictors of poor outcomes in MeVO remain poorly characterized., Methods: In this prospectively collected, retrospectively reviewed, multicenter, multinational study, data from the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry were analyzed. The study included 1568 patients from 37 academic centers across North America, Asia, and Europe, treated with MT, with or without intravenous tissue plasminogen activator (IVtPA), between September 2017 and July 2021., Results: Among the 1568 patients, 347 (22.2%) experienced very poor outcomes (modified Rankin score (mRS), 5-6). Key predictors of poor outcomes were advanced age (odds ratio (OR): 1.03; 95% confidence interval (CI): 1.02 to 1.04; p < 0.001), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (OR: 1.07; 95% CI: 1.05 to 1.10; p < 0.001), pre-operative glucose levels (OR: 1.01; 95% CI: 1.00 to 1.02; p < 0.001), and a baseline mRS of 4 (OR: 2.69; 95% CI: 1.25 to 5.82; p = 0.011). The multivariable model demonstrated good predictive accuracy with an area under the receiver-operating characteristic (ROC) curve of 0.76., Conclusions: This study demonstrates that advanced age, higher NIHSS scores, elevated pre-stroke mRS, and pre-operative glucose levels significantly predict very poor outcomes in AIS-MeVO patients who received MT. These findings highlight the importance of a comprehensive risk assessment in primary MeVO patients for personalized treatment strategies. However, they also suggest a need for cautious patient selection for endovascular thrombectomy. Further prospective studies are needed to confirm these findings and explore targeted therapeutic interventions., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading), and Artedrone (Board); all not directly related to the present work. Dr Henninger received support from CDMRP/DoD W81XWH-19-PRARP-RPA and NINDS NS131756, during the conduct of the study. Dr Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, and Rapid Medical. Dr Yeo reports Advisory work for AstraZeneca, substantial support from NMRC Singapore, and is a medical advisor for See-mode, Cortiro, and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson, and Phenox (paid lectures), all not directly related to the present work. Dr Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc, and Arsenal Medical; he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular, and Stryker Neurovascular; and he holds stocks in InNeuroCo, Agile, Perfuze, Galaxy, and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr Jabbour is a consultant for Medtronic, Microvention, and Cerus.

Background: Emerging evidence suggests that endovascular thrombectomy is beneficial for treatment of childhood stroke, but the safety and effectiveness of endovascular thrombectomy has not been compared with best medical treatment. We aimed to prospectively analyse functional outcomes of endovascular thrombectomy versus best medical treatment in children with intracranial arterial occlusion stroke., Methods: In this prospective registry study, 45 centres in 12 countries across Asia and Australia, Europe, North America, and South America reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischaemic stroke caused by a large-vessel or medium-vessel occlusion who received either endovascular thrombectomy plus best medical practice or best medical treatment alone. Intravenous thrombolysis was considered part of best medical treatment and therefore permitted in both groups. The primary outcome was the difference in median modified Rankin Scale (mRS) score between baseline (pre-stroke) and 90 days (±10 days) post-stroke, assessed by the Wilcoxon rank test (α=0·05). Efficacy outcomes in the endovascular thrombectomy and best medical treatment groups were compared in sensitivity analyses using propensity score matching. The Save ChildS Pro study is registered at the German Clinical Trials Registry, DRKS00018960., Findings: Between Jan 1, 2020, and Aug 31, 2023, of the 241 patients in the Save ChildS Pro registry, 208 were included in the analysis (115 [55%] boys and 93 [45%] girls). 117 patients underwent endovascular thrombectomy (median age 11 years [IQR 6-14]), and 91 patients received best medical treatment (6 years [3-12]; p<0·0001). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score on admission was 14 (IQR 10-19) in the endovascular thrombectomy group and 9 (5-13) in the best medical treatment group (p<0·0001). Both treatment groups had a median pre-stroke mRS score of 0 (IQR 0-0) at baseline. The change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·020). One (1%) patient developed a symptomatic intracranial haemorrhage (this patient was in the endovascular thrombectomy group). Six (5%) patients in the endovascular thrombectomy group and four (5%) patients in the best medical treatment group had died by day 90 (p=0·89). After propensity score matching for age, sex, and PedNIHSS score at hospital admission (n=79 from each group), the change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·029). Regarding the primary outcome for patients with suspected focal cerebral arteriopathy, endovascular thrombectomy (n=18) and best medical treatment (n=33) showed no difference in 90-day median mRS scores (2 [IQR 1-3] vs 2 [1-4]; p=0·074)., Interpretation: Clinical centres tended to select children with more severe strokes (higher PedNIHSS score) for endovascular thrombectomy. Nevertheless, endovascular thrombectomy was associated with improved functional outcomes in paediatric patients with large-vessel or medium-vessel occlusions compared with best medical treatment. Future studies need to investigate whether the positive effect of endovascular thrombectomy is confined to older and more severely affected children., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy., Methods: This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes., Results: 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence., Conclusion: A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy., Competing Interests: Competing interests: TDF reports research grants from the German Research Foundation (DFG, Project Number: 411621970) for his work as a postdoctoral scholar at Stanford University. GB reports research grants from the German Research Foundation (DFG) outside of the submitted work. GWA reports equity and consulting for iSchemaView and consulting from Medtronic. MW reports grants and funding from the NIH under the grant numbers (1U01 NS086872-01, 1U01 NS087748-01 and 1R01 NS104094). He reports compensation from Subtle Medical, Magnetic Insight, Icometrix and EMTensor for consultant services and employment by the University of Texas MD Anderson Cancer Center. JF reports stock holdings in Tegus Medical and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, Phenox and grants from Route 92 outside the submitted work. JJH reports consulting for Medtronic and MicroVention and Medical and Scientific Advisory Board membership for iSchemaView., (© 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: Challenges to revascularization of large vessel occlusions (LVOs) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed to capture organized thrombi within the scaffold during retrieval., Objective: To evaluate the safety and effectiveness of revascularization of acute LVOs with the NeVa device., Methods: Prospective, international, multicenter, single-arm, Investigational Device Exemption study to evaluate the performance of the NeVa device in recanalizing LVOs including internal carotid artery, M1/M2 middle cerebral artery, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of expanded Treatment in Cerebral Ischemia (eTICI) score 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a -10% margin. Additional endpoints included first pass success and 90-day modified Rankin Scale (mRS) score 0-2. Primary composite safety endpoint was 90-day mortality and/or 24-hour symptomatic intracranial hemorrhage (sICH)., Results: From April 2021 to April 2022, 139 subjects were enrolled at 25 centers. Median National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 12-20). In the primary analysis population (n=107), eTICI 2b-3 within 3 NeVa passes occurred in 90.7% (97/107; non-inferiority P<0.0001; post hoc superiority P<0.0001). First pass eTICI 2b-3 was observed in 73.8% (79/107), with first pass eTICI 2b67-3 in 69.2% (74/107) and eTICI 2c-3 in 48.6% (52/107). Median number of passes was 1 (IQR 1-2). Final eTICI 2b-3 rate was 99.1% (106/107); final eTICI 2b67-3 rate was 91.6% (98/107); final eTICI 2c-3 rate was 72.9% (78/107). Good outcome (90-day mRS score 0-2) was seen in 65.1% (69/106). Mortality was 9.4% (13/138) with sICH in 5.0% (7/139)., Conclusions: The NeVa device is highly effective and safe for revascularization of LVO strokes and demonstrates superior first pass success compared with a predicate performance goal., Trial Registration Number: NCT04514562., Competing Interests: Competing interests: AJY: consultant: Penumbra, Cerenovus, Vesalio, Zoll Circulation, Philips Neurovascular; individual stocks/stock options: Nicolab; ownership interest: Insera Therapeutics, Galaxy Therapeutics; research funding (principal investigator (PI) or named investigator): Medtronic, Cerenovus, Penumbra, Stryker, Genentech. LS: consultant: Balt, Medtronic, Microvention, Stryker; research funding (PI or named investigator): Philips. AH: consultant: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care. AS: consultant: Microvention, Stryker, Vesalio. AHS: consultant: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc; inidividual stocks/stock options: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd., BlinkTBI, Inc, Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, Collavidence, I; other; Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial; CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, Research Funding (PI or named investigator); co-investigator for NIH - 1R01EB030092-01, Project Title: High speed angiography at 1000 frames per second; Mentor for Brain Aneurysm Foundation Carol W. Harvey Chair of Research, Sharon Epperson Chai. SG: Consultant; Stryker, Microvention, Medtronic. TRM: Advisor; Carpl AI. MTF: advisor; Cerenovus; research funding (PI or named investigator): Medtronic Neurovascular; researcher: Stryker Neurovascular, Cerenovus, Rapid Medical. DCH: consultant; Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical; individual stocks/stock options: VizAI and Motif; other: Jacobs Institute/Medtronic, Vesalio., Frontiers in Neurology. MIC: advisor: Celt/Vasorum; consultant: Microvention, Medtronic, Imperative Care, Q'Apel; individual stocks/stock options: Imperative Care, Celt/Vasorum, Synchron, Endostream, Cerebrotech, Q'Apel, RIST, Three Rivers Medical, Neuolutions, Radical Medical, Tulavi, viseon, VMT, Vastrax, Serenity Medical. MF: consultant: Cerenovus, Balt, Jacobs Institute, Kai Medical, Oculus; research funding (PI or named investigator): Vesalio, Genentech, Siemens. MS: consultant: Vesalio., (© 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: Subacute and chronic subdural hematomas are common and frequently recur after surgical evacuation. The effect of adjunctive middle meningeal artery embolization on the risk of reoperation remains unclear., Methods: In a prospective, multicenter, interventional, adaptive-design trial, we randomly assigned patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary end point was hematoma recurrence or progression that led to repeat surgery within 90 days after the index treatment. The clinical secondary end point was deterioration of neurologic function at 90 days, which was assessed with the modified Rankin scale in a noninferiority analysis (margin for risk difference, 15 percentage points)., Results: A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Surgery occurred before randomization in 136 of 400 patients (34.0%). Hematoma recurrence or progression leading to repeat surgery occurred in 8 patients (4.1%) in the treatment group, as compared with 23 patients (11.3%) in the control group (relative risk, 0.36; 95% confidence interval [CI], 0.11 to 0.80; P = 0.008). Functional deterioration occurred in 11.9% of the patients in the treatment group and in 9.8% of those in the control group (risk difference, 2.1 percentage points; 95% CI, -4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 30 days, serious adverse events related to the embolization procedure had occurred in 4 patients (2.0%) in the treatment group, including disabling stroke in 2 patients; no additional events had occurred by 180 days., Conclusions: Among patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression leading to reoperation than surgery alone. Further study is needed to evaluate the safety of middle meningeal artery embolization in the management of subdural hematoma. (Funded by Medtronic; EMBOLISE ClinicalTrials.gov number, NCT04402632.)., (Copyright © 2024 Massachusetts Medical Society.)

Background and Purpose: Neuronal ceroid lipofuscinoses are a group of neurodegenerative disorders. Recently, enzyme replacement therapy (ERT) was approved for neuronal ceroid lipofuscinosis type 2 (CLN2), a subtype of neuronal ceroid lipofuscinoses. The aim of this study was to quantify brain volume loss in CLN2 disease in patients on ERT in comparison with a natural history cohort using MRI., Materials and Methods: Nineteen (14 female, 5 male) patients with CLN2 disease at 1 UK center were studied using serial 3D T1-weighted MRI (follow-up time, 1-9 years). Brain segmentation was performed using FreeSurfer. Volume measurements for supratentorial gray and white matter, deep gray matter (basal ganglia/thalami), the lateral ventricles, and cerebellar gray and white matter were recorded. The volume change with time was analyzed using a linear mixed-effects model excluding scans before treatment onset. Comparison was made with a published natural history cohort of 12 patients (8 female, 4 male), which was re-analyzed using the same method., Results: Brain volume loss of all segmented brain regions was much slower in treated patients compared with the natural history cohort. For example, supratentorial gray matter volume in treated patients decreased by a mean of 3% (SD, 0.74%) ( P < .001) annually compared with an annual volume loss of a mean of 16.8% (SD, 1.5%) ( P < .001) in the natural history cohort., Conclusions: Our treatment cohort showed a significantly slower rate of brain parenchymal volume loss compared with a natural history cohort in several anatomic regions. Our results complement prior clinical data that found a positive response to ERT. We demonstrate that automated MRI volumetry is a sensitive tool to monitor treatment response in children with CLN2 disease., (© 2024 by American Journal of Neuroradiology.)

Overweight/obese patients experience a lower incidence of subarachnoid hemorrhage (SAH) compared to non-overweight patients, even though elevated body mass index (BMI) has been associated with various SAH risk factors. Given that intracranial aneurysms are a primary cause of SAH, a potential protective effect of a high BMI on intracranial aneurysms is likely but remains insufficiently investigated. This population-based MRI study aims to conduct detailed analyses on risk factors associated with the incidence of unruptured intracranial aneurysms (UIA). Retrospective analysis of subjects enrolled in the prospective Hamburg City Health study who underwent intracranial magnetic resonance imaging (MRI) was done. MRI scans were screened for UIA using time-of-flight angiography. Subject data including medical history, laboratory examinations, and risk factors for UIA were collected, and a multivariable logistic regression model was used to investigate the relationship between risk factors and UIA incidence. 2688 subjects (mean (IQR) age, 65 (58-71); 1176 female (43.8%) were included. An UIA was detected in 214 subjects with an incidence of 10.6% (6.0%) in females (males). Determinants for UIA were female sex (OR 2.00, 95%CI 1.45-2.77, p < 0.001), hypertension (OR 1.48, 95%CI 1.08-2.04, p = 0.015), smoking (OR 1.41, 95%CI 1.03-1.95, p = 0.036), and BMI (OR 0.95, 95%CI 0.91-0.98, p = 0.004). Among subjects with UIA, 9.4% with a BMI > 25 had multiple aneurysms, compared to 21.6% with BMI ≤ 25 (p = 0.012). This study suggests that a high BMI exhibits a protective effect on UIA incidence and the development of multiple aneurysms. Additionally, the data confirms established risk factors for UIA development, such as female sex, hypertension, and smoking., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Medical three-dimensional (3D) printing is playing an increasingly important role in clinical practice. The use of 3D printed models in patient care offers a wide range of possibilities in terms of personalized medicine, training and education of medical professionals, and communication with patients. DICOM files from imaging modalities such as CT and MRI provide the basis for the majority of the 3D models in medicine. The image acquisition, processing, and interpretation of these lies within the responsibility of radiology, which can therefore play a key role in the application and further development of 3D printing.The purpose of this review article is to provide an overview of the principles of 3D printing in medicine and summarize its most important clinical applications. It highlights the role of radiology as central to developing and administering 3D models in everyday clinical practice.This is a narrative review article on medical 3D printing that incorporates expert opinions based on the current literature and practices from our own medical centers.While the use of 3D printing is becoming increasingly established in many medical specialties in Germany and is finding its way into everyday clinical practice, centralized "3D printing labs" are a rarity in Germany but can be found internationally. These labs are usually managed by radiology departments, as radiology is a connecting discipline that - thanks to the imaging technology used to produce data for 3D printing - can play a leading role in the application of medical 3D printing. Copying this approach should be discussed in Germany in order to efficiently use the necessary resources and promote research and development in the future. · 3D printing in medicine is a rapidly growing field.. · Image acquisition and processing provides an important basis for high-quality 3D models.. · Radiology, as the specialist discipline responsible for imaging, has a crucial role to play.. · Radiology should play a leading role in the introduction of 3D printing in everyday clinical practice. . · Streckenbach A, Schubert N, Streckenbach F et al. Current State and Outlook in Medical 3 D Printing and the Role of Radiology. Fortschr Röntgenstr 2024; DOI 10.1055/a-2436-7185., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Despite the proven effectiveness of endovascular therapy (EVT) in acute ischemic strokes (AIS) involving anterior circulation large vessel occlusions, isolated posterior cerebral artery (PCA) occlusions (iPCAo) remain underexplored in clinical trials. This study investigates the comparative effectiveness and safety of EVT against medical management (MM) in patients with iPCAo., Methods: This multinational, multicenter propensity score-weighted study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. We included iPCAo patients treated with either EVT or MM. The primary outcome was the modified Rankin Scale (mRS) at 90 days, with secondary outcomes including functional independence, mortality, and safety profiles such as hemorrhagic complications., Results: A total of 177 patients were analyzed (88 MM and 89 EVT). EVT showed a statistically significant improvement in 90-day mRS scores (OR = 0.55, 95% CI = 0.30-1.00, p  = 0.048), functional independence (OR = 2.52, 95% CI = 1.02-6.20, p  = 0.045), and a reduction in 90-day mortality (OR = 0.12, 95% CI = 0.03-0.54, p  = 0.006) compared to MM. Hemorrhagic complications were not significantly different between the groups., Conclusion: EVT for iPCAo is associated with better neurological outcomes and lower mortality compared to MM, without an increased risk of hemorrhagic complications. Nevertheless, these results should be interpreted with caution due to the study's observational design. The findings are hypothesis-generating and highlight the need for future randomized controlled trials to confirm these observations and establish definitive treatment guidelines for this patient population., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading), and Artedrone (Board); all not directly related to the present work. Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work. Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro, and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work. Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson, and Phenox (paid lectures), all not directly related to the present work. Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc, and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular, and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy, and NTI. Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr. Jabbour is a consultant for Medtronic, Microvention, and Cerus.

Purpose: Glioma is a complex cancer comprising various subtypes and mutations, which may have different metabolic characteristics that can potentially be investigated and identified using perfusion imaging. Therefore, the aim of this work was to use radiomics and machine learning analysis of arterial spin labeling MRI data to automatically differentiate glioma subtypes and mutations., Methods: A total of 495 Arterial Spin Labeling (ASL) perfusion imaging datasets from the UCSF Glioma database were used in this study. These datasets were segmented to delineate the tumor volume and classified according to tumor grade, pathological diagnosis, and IDH status. Perfusion image data was obtained from a 3T MRI scanner using pseudo-continuous ASL. High level texture features were extracted for each ASL dataset using PyRadiomics after tumor volume segmentation and then analyzed using a machine learning framework consisting of ReliefF feature ranking and logistic model tree classification algorithms., Results: The results of the evaluation revealed balanced accuracies for the three endpoints ranging from 55.76% (SD = 4.28, 95% CI: 53.90-57.65) for the tumor grade using 25.4 ± 37.21 features, 62.53% (SD = 2.86, 95% CI: 61.27-63.78) for the mutation status with 23.3 ± 29.17 picked features, and 80.97% (SD = 1.83, 95% CI: 80.17-81.78) for the pathological diagnosis which used 47.3 ± 32.72 selected features., Conclusions: Radiomics and machine learning analysis of ASL perfusion data in glioma patients hold potential for aiding in the diagnosis and treatment of glioma, mainly for discerning glioblastoma from astrocytoma, while performance for tumor grading and mutation status appears limited., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Landmark thrombectomy trials have provided evidence that selected patients with large ischemic stroke benefit from successful endovascular therapy, commonly defined as incomplete (modified Thrombolysis In Cerebral Infarction (mTICI) 2b) or complete reperfusion (mTICI 3). We aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in large ischemic strokes., Methods: This retrospective multicenter cohort study was conducted to compare mTICI 2b versus mTICI 3 in large ischemic strokes in the anterior circulation. Patients enrolled in the German Stroke Registry between 2015-2021 were analyzed. Large ischemic stroke was defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. Patients were matched by final mTICI grade using propensity score matching. Primary outcome was the 90-day modified Rankin Scale (mRS) score., Results: After matching, 226 patients were included. Baseline and imaging characteristics were balanced between mTICI 2b and mTICI 3 patients. There was no shift on the mRS favoring mTICI 3 compared with mTICI 2b in large ischemic strokes (adjusted common odds ratio (acOR) 1.12, 95% confidence interval (95% CI) 0.64 to 1.94, P=0.70). The rate of symptomatic intracranial hemorrhage was higher in mTICI 2b than in mTICI 3 patients (12.6% vs 4.5%, P=0.03). Mortality at 90 days did not differ between mTICI 3 and mTICI 2b (33.6% vs 37.2%; adjusted OR 0.69, 95% CI 0.33 to 1.45, P=0.33)., Conclusions: In endovascular therapy for large ischemic strokes, mTICI 3 was not associated with better 90-day functional outcomes compared with mTICI 2b. This study suggests that mTICI 2b might be warranted as the final angiographic result, questioning the benefit/risk ratio of additional maneuvers to seek for mTICI 3 in large ischemic strokes., Trial Registration Number: NCT03356392., Competing Interests: Competing interests: TDF reported grants from the German Research Foundation (DFG; Project Number: 411621970). GB reported receiving personal fees from Eppdata GmbH and compensation as a speaker from Balt outside the submitted work. HK reported an ownership stake in Eppdata GmbH and compensation from Eppdata GmbH for consultant services outside the submitted work. GH reported receiving personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. JF reported compensation from Acandis, Cerenovus, MicroVention, Medtronic, Penumbra, Phenox, Roche, Stryker, Tonbridge and stock holdings in Eppdata GmbH and Tegus Medical outside the submitted work. FF reported receiving personal fees from Eppdata GmbH outside the submitted work., (© 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: The study aimed to compare outcomes of mechanical thrombectomy (MT) in pediatric patients with acute ischemic stroke (AIS) caused by focal cerebral arteriopathy (FCA) versus cardioembolism (CE)., Methods: Data from the Save ChildS and KidClot cohorts were merged. Children with AIS because of FCA or CE that underwent MT were included. The study used the Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation (CASCADE) for stroke cause assessment. Descriptive statistics and multivariable regression models were used to analyze final modified thrombolysis in cerebral infarction (mTICI) scores, periprocedural complications, and functional outcomes assessed by the modified Rankin scale (mRS) at 6 to 12 months., Results: The analysis included 60 children with 14 FCA and 46 CE cases. CE etiology was associated with better revascularization (good to excellent thrombolysis in cerebral infarction scores) and shift toward better outcomes (common adjusted odds ratio of mRs for CE vs FCA: 0.27, 95% CI: [0.06-0.97], p = 0.039), with no difference in favorable outcome rates. FCA was associated with significantly lower rates of excellent revascularization (21% vs 65%, p < 0.001). No difference in complications' rates was observed between the groups (7.2% in FCA vs 5.5%, p = 0.69)., Interpretation: We found that pediatric AIS because of CE etiology has more favorable procedural outcomes compared to FCA following MT. This translated to mixed functional outcomes that may be more favorable in the CE group. These findings highlight the need for further research to refine treatment protocols for pediatric stroke, particularly in understanding and managing FCA in children. ANN NEUROL 2024., (© 2024 American Neurological Association.)

Background and Purpose: Mechanical thrombectomy (MT) has revolutionized the prognosis of acute ischemic stroke. Indications for MT are constantly expanding across countries, presenting healthcare professionals, and institutions with the challenge of offering MT to the entire population despite geographic constraints, while also training enough interventional neuroradiologists (INR) for this highly technical-level procedure. We aimed to provide an overview of current European MT practices and organizations in 2021., Materials and Methods: Members of the European Society of Minimally Invasive Neurological Therapy (ESMINT) were invited to complete two different online surveys from March to November 2021 to collect data on MT practice., Results: A total of 240 individual responses from INR (from 33 European countries) were received. These included information from 56 thrombectomy-capable stroke centers (TCSC) data (across 26 European countries). The mean number of INR per center was 3.8 ± 1.43, median 4 (IQR, 3-4.5). Half of the centers (28/56, 50.00%) performed less than 150 MT per year. Most INR used a balloon guide catheter in less than 50% of cases (160/240, 66.67%), and limited the number of recanalization attempts to six passes to restore flow (209/240, 87.08%). Additionally, 37.92% of the respondents (91/240, 37.92%) indicated that they already performed MT for distal occlusions (M3, M4) as part of their routine practice. Other details of the MT procedure, anesthetic management, and patient selection are also presented and discussed., Conclusions: This European survey emphasizes the differences between TCSC and INR in modern thrombectomy practices. Even if most centers remain understaffed to meet current and future MT needs, most European TCSCs are actively training young INR., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Recent advances have highlighted the efficacy of endovascular thrombectomy (EVT) in patients with large ischemic core stroke, yet a significant portion still experience very poor outcomes, defined as a 90-day modified Rankin Score (mRS) of 5-6. This study aims to investigate the hypoperfusion intensity ratio (HIR) as a prognostic imaging parameter for these outcomes., Methods: In a multicenter retrospective cohort study, data from consecutive patients undergoing EVT for acute ischemic stroke with large vessel occlusion (AIS-LVO) at two comprehensive stroke centers were analyzed. The study included patients with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less and utilized pretreatment perfusion imaging to calculate HIR. The primary outcome was very poor outcomes (90 days mRS 5-6)., Results: Among 102 patients included, 59 (57.8%) had very poor outcome (90 days mRS 5-6). Multivariable logistic regression analysis adjusting for multiple covariates including admission National Institutes of Health Stroke Scale (NIHSS) and EVT revealed that higher admission NIHSS (adjusted odds ratio [aOR] 1.224, 95% CI 1.089-1.374, p = 0.001) and HIR (aOR per 0.1 incremental change, 1.34, 95% CI 1.02-1.82, P = 0.042) were independently associated with very poor outcomes., Conclusion: This study demonstrates that admission NIHSS and HIR are independently associated with very poor outcome (90 days mRS 5-6) in patients with large ischemic core strokes. These findings highlight the importance of collateral status and perfusion imaging in predicting outcomes in this patient population, suggesting a potential role for HIR in the triage and management of large core stroke patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objectives: Ischemic edema is associated with worse clinical outcomes, especially in large infarcts. Computed tomography (CT)-based densitometry allows direct quantification of absolute edema volume (EV), which challenges indirect biomarkers like midline shift (MLS). We compared EV and MLS as imaging biomarkers of ischemic edema and predictors of malignant infarction (MI) and very poor clinical outcome (VPCO) in early follow-up CT of patients with large infarcts., Materials and Methods: Patients with anterior circulation stroke, large vessel occlusion, and Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5 were included. VPCO was defined as modified Rankin scale (mRS) ≥ 5 at discharge. MLS and EV were quantified at admission and in follow-up CT 24 h after admission. Correlation was analyzed between MLS, EV, and total infarct volume (TIV). Multivariable logistic regression and receiver operating characteristics curve analyses were performed to compare MLS and EV as predictors of MI and VPCO., Results: Seventy patients (median TIV 110 mL) were analyzed. EV showed strong correlation to TIV (r = 0.91, p < 0.001) and good diagnostic accuracy to classify MI (EV AUC 0.74 [95%CI 0.61-0.88] vs. MLS AUC 0.82 [95%CI 0.71-0.94]; p = 0.48) and VPCO (EV AUC 0.72 [95%CI 0.60-0.84] vs. MLS AUC 0.69 [95%CI 0.57-0.81]; p = 0.5) with no significant difference compared to MLS, which did not correlate with TIV < 110 mL (r = 0.17, p = 0.33)., Conclusion: EV might serve as an imaging biomarker of ischemic edema in future studies, as it is applicable to infarcts of all volumes and predicts MI and VPCO in patients with large infarcts with the same accuracy as MLS., Clinical Relevance Statement: Utilization of edema volume instead of midline shift as an edema parameter would allow differentiation of patients with large and small infarcts based on the extent of edema, with possible advantages in the prediction of treatment effects, complications, and outcome., Key Points: • CT densitometry-based absolute edema volume challenges midline shift as current gold standard measure of ischemic edema. • Edema volume predicts malignant infarction and poor clinical outcome in patients with large infarcts with similar accuracy compared to MLS irrespective of the lesion extent. • Edema volume might serve as a reliable quantitative imaging biomarker of ischemic edema in acute stroke triage independent of lesion size., (© 2024. The Author(s).)

Purpose: Since perfusion imaging may be unavailable in smaller hospitals, alternative imaging selection methods for acute ischemic stroke can improve outcomes and optimize resources. This study assessed the safety and effectiveness of using imaging criteria other than DEFUSE 3 and DAWN for thrombectomy beyond 6 h from symptom onset in patients stroke in the anterior circulation., Methods: This is a retrospective, single-center analysis of consecutive patients with large vessel occlusion in the anterior circulation undergoing thrombectomy. Patients were categorized into two groups based on the collateral status (moderate collaterals and good collaterals)., Results: Among 198 patients, 106 (54%) met the inclusion criteria and were analyzed. Good collateral status was observed in 78 (74%) patients. Patients with good collaterals showed significantly lower mRS scores at discharge and at 90 days compared to their counterparts with moderate collateral status (4 (3-4) vs. 4 (4-5); p = 0.001 and 2 (0-4) vs. 6 (3-6); p < 0.001, respectively). More patients with good collateral status achieved favorable outcomes at 90 days compared to those with moderate status (48 (61.5%) vs. 5 (17.9%); p < 0.001). Good collaterals were an independent predictor of good clinical outcomes at 90 days (OR = 1.31, 95% CI: 1.13-1.53, p < 0.001)., Conclusion: Selecting patients for endovascular treatment of acute ischemic stroke using non-contrast CT and CT angiography shows 90-day outcomes similar to the DAWN and DEFUSE-3 trials. Using collateral status on CT angiography can predict favorable outcomes after mechanical thrombectomy in resource-limited settings where perfusion imaging is unavailable., (© 2024. The Author(s).)

Background: Mechanical thrombectomy is a cornerstone treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO), yet the optimal technique remains debated. The SOFIA/SOFIA PLUS catheter has emerged as a promising tool for direct aspiration thrombectomy., Purpose: This prospective multi-center study, adhering Good-Clinical-Practice guidelines, aimed to evaluate the safety and efficacy of the SOFIA/SOFIA PLUS catheter for direct aspiration as a first-line treatment technique in patients with acute anterior circulation LVO., Materials and Methods: Between 10/2017 and 12/2021, 246 consecutive patients presenting with AIS due to anterior circulation LVO were enrolled from 14 European centers. Primary treatment with SOFIA catheters was performed within 6 h of symptom onset. Clinical and radiological data were collected, and statistical analyses were conducted., Results: The mean age of the included patients was 71.6 ± 13.9 years, with 44.7% being male. Primary aspiration achieved complete recanalization in 72.8% of patients, with functional independence observed in 63.8% after 90 days. Secondary outcomes included a median NIHSS of 4 at 24 h post-procedure, median ASPECTS of 7 on follow-up imaging, and a mortality rate of 24.4% at 90 days. No device malfunctions were observed, and the rate of symptomatic intracranial hemorrhage was 4.4%., Conclusion: Primary aspiration with the SOFIA/SOFIA PLUS catheter demonstrates favorable safety and efficacy profiles in the treatment of anterior circulation LVO. These findings support the utilization of this technique as a first-line approach in mechanical thrombectomy for AIS, contributing to the growing body of evidence endorsing the effectiveness of direct aspiration thrombectomy in stroke management., Competing Interests: GT has received compensation by the University Heidelberg for activities as member of the CEC within the study, and fees as consultant or lecturer from Acandis, Alexion, Amarin, Astra Zeneca, Bayer, Boehringer Ingelheim, BristolMyersSquibb, Daiichi Sankyo, Portoly, Stryker outside this study. GM reports consulting fees from Microvention Europe, Stryker Neurovascular, Balt SAS, Sim and Cure and paid lectures from Medtronic, Phenox, Cerenovus, Bracco. All of these were outside this study. AP is the principal investigator of the SEALANT study sponsored by Microvention. MM received research grants from Acandis, Balt, Medtronic, Microvention, Phenox, Stryker* (*industry payments are made to the research fund of the institution), receives payment or honoraria for lectures from Balt, Medtronic, Stryker* (*industry payments are made to the research fund of the institution). SESAME was an investigator-initiated study (IIT). A grant for conducting the study was provided by Microvention. However, Microvention did not exert any influence on the study’ design. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Neuberger, Marnat, Barreau, Pitrone, Caragliano, Killer-Oberpfalzer, Pfaff, Maurer, Berlis, Bokkers, Uyttenboogaart, Sourour, Clarençon, Wodarg, Cognard, Bohner, Trenkler, Spelle, Weber, Nouri, Bonekamp, Thomalla, Fiehler, Bendszus and Möhlenbruch.)

Background: The aim of this study is to assess the feasibility of identifying the hemodynamic status of intracranial atherosclerotic stenosis (ICAS) using angio-based fractional flow (FF) calculated from a single angiographic view, with wire-based FF as the reference standard., Method: The study retrospectively recruited 100 ICAS patients who underwent pressure wire measurement and digital subtraction angiography. The AccuICAD software was used to calculate angio-based FF, with the wire-measured value serving as the reference standard for evaluating the accuracy, consistency, and diagnostic performance of angio-based FF., Results: The mean±SD value of wire-based FF was 0.77±0.18, while the mean value of angio-based FF was 0.77±0.19. A good correlation between angio-based FF and wire-based FF was evident (r=0.90, P<0.001), with good agreement (mean difference 0.00±0.08). The diagnostic accuracy of angio-based FF and percent diameter stenosis (DS%) were 93.23% versus 72.18%, 91.73% versus 72.93%, and 89.47% versus 78.95% for predicted wire-based FF thresholds of 0.70, 0.75, and 0.80, respectively. The area under the curve (AUC) values for angio-based FF and DS% were 0.975 versus 0.822, 0.970 versus 0.814, and 0.943 versus 0.826 at the respective thresholds, respectively., Conclusion: The FF calculated from a single angiographic view can be considered an effective tool for functional assessment of cerebral arterial stenosis., Competing Interests: Competing interests: JX, CR, RZ, and YH are employees of ArteryFlow Technology Co, Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Robust venous outflow (VO) profiles, measured by degree of venous opacification on pre-thrombectomy CT angiography (CTA) studies, are strongly correlated with favorable outcomes in patients with large vessel occlusion acute ischemic stroke treated by thrombectomy. However, VO measurements are laborious and require neuroimaging expertise., Objective: To develop a semi-automated method to measure VO using CTA and CT perfusion imaging studies., Methods: We developed a graphical interface using The Visualization Toolkit, allowing for voxel selection at the confluence and bilateral internal cerebral veins on CTA along with arterial input functions (AIFs) from both internal carotid arteries. We extracted concentration-time curves from the CT perfusion study at the corresponding locations associated with AIF and venous output function (VOF). Outcome analyses were primarily conducted by the Mann-Whitney U and Jonckheere-Terpstra tests., Results: Segmentation at the pre-selected AIF and VOF locations was performed on a sample of 97 patients. 65 patients had favorable VO (VO+) and 32 patients had unfavorable VO (VO-). VO+ patients were found to have a significantly shorter VOF time to peak (8.26; 95% CI 7.07 to 10.34) than VO- patients (9.44; 95% CI 8.61 to 10.91), P=0.007. No significant difference was found in VOF curve width and the difference in time between AIF and VOF peaks., Conclusions: Time to peak of VOF at the confluence of sinuses was significantly associated with manually scored venous outflow. Further studies should aim to understand better the association between arterial inflow and venous outflow, and capture quantitative metrics of venous outflow at other locations., Competing Interests: Competing interests: GA, NY, MM, TDF, MGL have no relevant relationships to disclose. SC discloses equity and consulting for iSchemaView. GWA discloses equity and consulting for iSchemaView and consulting for Genentech. JF discloses grants and personal fees from Acandis, Cerenovus, MicroVention,Medtronic, and Stryker; grants from Route 92; and personal fees from Phenox and Penumbra outside of the submitted work. JJH discloses consulting for Medtronic and MicroVention and membership of the medical and scientific advisory board for iSchemaView., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Medium vessel occlusion (MeVO) strokes, particularly affecting the M2 segment of the middle cerebral artery, represent a critical proportion of acute ischemic strokes, posing significant challenges in management and outcome prediction. The efficacy of mechanical thrombectomy (MT) in MeVO stroke may warrant reliable predictors of functional outcomes. This study aimed to investigate the prognostic value of follow-up infarct volume (FIV) for predicting 90-day functional outcomes in MeVO stroke patients undergoing MT., Methods: This multicenter, retrospective cohort study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, covering patients with acute ischemic stroke due to M2 segment occlusion treated with MT. We examined the relationship between 90-day functional outcomes, measured by the modified Rankin Scale (mRS), and follow-up infarct volume (FIV), assessed through CT or MRI within 12-36 h post-MT., Results: Among 130 participants, specific FIV thresholds were identified with high specificity and sensitivity for predicting outcomes. A FIV ⩽5 ml was highly specific for predicting favorable and excellent outcomes. The optimal cut-off for both prognostications was identified at ⩽15 ml by the Youden Index, with significant reductions in the likelihood of favorable outcomes observed above a 40 ml threshold. Receiver Operator Curve (ROC) analyses confirmed FIV as a superior predictor of functional outcomes compared to traditional recanalization scores, such as final modified thrombolysis in cerebral infarction score (mTICI). Multivariable analysis further highlighted the inverse relationship between FIV and positive functional outcomes., Conclusions: FIV within 36 h post-MT serves as a potent predictor of 90-day functional outcomes in patients with M2 segment MeVO strokes. Establishing FIV thresholds may aid in the prognostication of stroke outcomes, suggesting a role for FIV in guiding post intervention treatment decisions and informing clinical practice. Future research should focus on validating these findings across diverse patient populations and exploring the integration of FIV measurements with other clinical and imaging markers to enhance outcome prediction accuracy., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation.Dr. Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work.Dr. Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work.Dr. Henninger received support from W81XWH-19-PRARP-RPA form the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc. and General Dynamics during the conduct of this study unrelated to this work.Dr. Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical.Dr. Yeo reports Advisory work for AstraZeneca, Substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo. All unrelated to the present work.Dr. Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra.Dr. Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work.Dr. Puri is a consultant for Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI.Dr. Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally).Dr. Jabbour is a consultant for Medtronic, Microvention and Cerus.

Background and Purpose: The management of acute ischemic stroke (AIS) due to distal medium vessel occlusion (DMVO) remains uncertain, particularly in comparing the effectiveness of intravenous thrombolysis (IVT) plus mechanical thrombectomy (MT) versus IVT alone. This study aimed to evaluate the safety and efficacy in DMVO patients treated with either MT-IVT or IVT alone., Methods: This multinational study analyzed data from 37 centers across North America, Asia, and Europe. Patients with AIS due to DMVO were included, with data collected from September 2017 to July 2023. The primary outcome was functional independence, with secondary outcomes including mortality and safety measures such as types of intracerebral hemorrhage., Results: The study involved 1,057 patients before matching, and 640 patients post-matching. Functional outcomes at 90 days showed no significant difference between groups in achieving good functional recovery (modified Rankin Scale 0-1 and 0-2), with adjusted odds ratios (OR) of 1.21 (95% confidence interval [CI] 0.81 to 1.79; P=0.35) and 1.00 (95% CI 0.66 to 1.51; P>0.99), respectively. Mortality rates at 90 days were similar between the two groups (OR 0.75, 95% CI 0.44 to 1.29; P=0.30). The incidence of symptomatic intracerebral hemorrhage was comparable, but any type of intracranial hemorrhage was significantly higher in the MT-IVT group (OR 0.43, 95% CI 0.29 to 0.63; P<0.001)., Conclusion: The results of this study indicate that while MT-IVT and IVT alone show similar functional and mortality outcomes in DMVO patients, MT-IVT presents a higher risk of hemorrhagic complications, thus MT-IVT may not routinely offer additional benefits over IVT alone for all DMVO stroke patients. Further prospective randomized trials are needed to identify patient subgroups most likely to benefit from MT-IVT treatment in DMVO.