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Intra-procedural intrasaccular device migration is an uncommon complication of endovascular treatment of wide-neck aneurysms. We report the case of a 52-years old Caucasian male who presented with a 3 × 3 mm posterior facing top of the basilar aneurysm in which treatment with WEB-SL (Woven EndoBridge-single layer) device was tempted. Inadvertent WEB migration in the right posterior cerebral artery occurred after detachment. Two retrieval attempts were performed using a combined technique with two different stent-retrievers and a 5-Fr distal access catheter. Upon WEBectomy attempt, the device rolled over the stents, and the passages were unsuccessful. The device was successfully removed using a microSnare, catching and retrieving it inside the 5-Fr distal access catheter. Micro-Snare is an effective bail-out technique to recover migrated intrasaccular WEB devices in cerebral arteries. [ABSTRACT FROM AUTHOR]

Background Cangrelor is an intravenous P2Y12 inhibitor with rapid onset and fast offset of antiplatelet action. Dose adjusted cangrelor based on platelet function testing is suggested to be advantageous for use during neuroendovascular procedures. In this study, we aimed to assess the efficacy and safety of this strategy. Methods This retrospective study included consecutive patients who received low dose intravenous cangrelor (5 µg/kg; infusion 1 µg/kg/min) for ruptured (RIA) and unruptured (UIA) intracranial aneurysms, and acute ischemic stroke (AIS). Indications were acute stenting or intraluminal thrombus. Outcomes were assessed at 24 hours by brain CT and CT angiography. The primary efficacy outcome was the rate of stent occlusion or persistent intraluminal thrombus. The primary safety outcome was the rate of major hemorrhages. Results 101 patients (56 men; median age (IQR) 59 (51-70) years) received low dose cangrelor for acute stenting (79/101 (78%)) and intraprocedural thrombus (22/101 (22%)). Overall, 5 (4.9%) patients experienced stent occlusion within 24 hours (RIA 3/28; AIS 2/52). There were no cases of failure among UIA patients. Stent mis-opening (fish mouthing or stenosis >50%) was significantly associated with stent occlusion (P<0.001). The overall rate of major hemorrhage was 2% (2/101), which occurred in AIS patients. Platelet reactivity unit (PRU) values were lower in those presenting with major hemorrhage (PRU 4 (SD 1.4) vs PRU 60 (SD 63); P=0.043). Mortality rate after cangrelor related hemorrhage was 1%. Conclusions Low dose cangrelor appears to be effective in preventing stent thrombosis and arterial patency with a low hemorrhagic risk. [ABSTRACT FROM AUTHOR]

Background The optimal management of chronic total carotid artery occlusion (CTO) is still debated. Endovascular treatment is being increasingly used with heterogeneous technical and clinical results. Methods Patients with CTO treated with modern endovascular approaches during the past several years (January 2018-December 2021) were retrospectively reviewed. Results Twenty patients, with a mean age of 63.7 years, were treated during the study period. Indications for treatment were recurrent stroke in 12 (60%), hemodynamic impairment in 4 (20%), and progressive stroke in 4 (20%) patients. In 6 (30%) patients, the occlusion was limited to the cervical portion, in 5 (25%) to the petrous segment, and in 9 (45%) to the cavernous segment. Technical treatment success was achieved in 80% of cases. In patients with successful recanalization, median pretreatment hypoperfusion volumes dropped from 126 mL (25-75 IQR, 33-224 mL) to 0 mL (25-75 IQR, 0-31.5 mL). Symptomatic procedure-related complications were 30% and permanent procedure-related morbidity-mortality was 5%. Early stent occlusion occurred in 5 (25%) cases. Two cases were asymptomatic and were not retreated, 3 cases presented transient symptoms of which two were successfully recanalized. Stent occlusion was not associated with permanent symptoms. In successfully recanalized patients no intraprocedural emboli were observed. Conclusions In the modern endovascular era, revascularization of CTO is a feasible procedure in most cases, and it may be offered in selected patients. However, the high re-occlusion rate is still a limitation of the technique, underlining the need for more research on the technical procedural and periprocedural management. [ABSTRACT FROM AUTHOR]

Common carotid artery (CCA) occlusion with patency of the internal carotid artery (ICA) is a rare cause of stroke with no consensus on optimal management.1 Open surgery, most often CCAsubclavian or CCA-aortic arch bypass techniques, have been used to recanalize short proximal occlusions. 1 2 Endovascular revascularization of chronic total ICA occlusion was proposed with promising results in previous reports.3-5 However, endovascular recanalization for chronic CCA occlusion has rarely been described in the literature, and the reports involved mainly right-sided occlusions or occlusions with residual CCA stumps.6 Anterograde endovascular management of chronic long left-sided CCA occlusions is problematic due to lack of support, notably when no proximal stump is present.4 In this video, we present a case of known long-chronic CCA occlusion managed by retrograde echo-guided ICA puncture and stent-assisted reconstruction.(video 1) [ABSTRACT FROM AUTHOR]

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: 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: Virtual simulation is increasingly used for aneurysm treatment. This study aimed to explore whether mechanical behavior biomarkers of the Woven EndoBridge (WEB) device as computed by Sim&Size simulation software were associated with aneurysmal occlusion status at follow-up., Methods: Consecutive patients with aneurysms treated with WEB were retrospectively enrolled (January 2014 to December 2021). Aneurysms were included if three-dimensional digital subtraction angiography and follow-up imaging were available. Device apposition and compression within the aneurysm sac were retrospectively calculated by Sim&Size simulation software. Mean global and maximum compression, mid-device and neck compression, and the Spruce index of heterogeneity of deformation of the simulated device were calculated. A multivariate Lasso regression was performed., Results: A total of 81 aneurysms in 80 patients (56 females; mean age 60±12 years) were analyzed. At a mean radiological follow-up of 3±2 years, 62 (77%) showed an adequate occlusion. Mean apposition in the inadequate and adequate occlusion group was 42.9±11% and 53.97±12%, respectively (P=0.002), mean global compression was 4.95±3% and 7.85±6% (P=0.035), respectively, and maximal compression was 13.44±6% and 20.73±11%, respectively (P=0.009). Compressions at mid-level and neck level were comparable between the two groups. The Spruce index was higher in the inadequate occlusion group (0.16±0.05 vs 0.20±0.05, P=0.005). Multivariate analysis showed that wall apposition, maximum compression and the Spruce index were independent prognosticators of aneurysm occlusion., Conclusions: Wall apposition, maximum compression and the Spruce index computed by Sim&Size software predicted the likelihood of aneurysm occlusion at follow-up, after WEB treatment., Competing Interests: Competing interests: PM reports consultancies for Medtronic, Penumbra and Stryker. AA, CC, and RAR are employees at Sim&Cure. All other authors declare no conflicts of interest regarding this article., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Surveys are increasingly used in neurointervention to gauge physicians' and patients' attitudes, practice patterns, and 'real-world' treatment strategies, particularly in conditions for which few, or no evidence-based, recommendations exist. While survey-based studies can provide valuable insights into real-world problems and management strategies, there is an inherent risk of bias., Objective: To assess key themes, sample characteristics, response metrics, and report frequencies of quality indicators of neurointerventional surveys., Methods: A systematic review compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was performed. The PubMed database was searched for neurointerventional surveys published between 2000 and 2023. Survey topics, design, respondent characteristics, and survey quality criteria suggested by the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) were assessed and described using descriptive statistics. Response rates and numbers of participants were further assessed for their dependence on sample characteristics and survey methodologies., Results: A total of 122 surveys were included in this analysis. The number of surveys published each year increased steeply between 2000 (n=1) and 2023 (n=14). The most common survey topics were stroke (51/122, 41.8%) and aneurysm treatment (49/122, 40.2%). The median response rate was 58.5% (IQR=30.4-86.3), with a median number of respondents of 79 (IQR=50-201). Sixty-eight of 122 (55.7%) surveys published the questionnaire used for data collection. Only a subset of studies reported response rates (n=89, 73%), data collection time period (n=91, 74.6%), and strategies to prevent duplicate responses (n=57, 46.7%)., Conclusion: Surveys are increasingly used by neurointerventional researchers, particularly to assess real-world practice patterns in endovascular stroke and aneurysm treatment. Adapting best-practice guidelines like the CROSS checklist might improve homogeneity and quality in neurointerventional survey research., Competing Interests: Competing interests: CSW and SLB have received travel grants to attend conferences. AS has received a stipend from the Swiss Society of Radiology for his research fellowship., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT., Methods: This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH., Results: Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001)., Conclusion: This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies., Competing Interests: Competing interests: 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 from 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 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). Dr Jabbour is a consultant for Medtronic, Microvention and Cerus. HS and VY are guarantors of the study., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO., Methods: In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts., Results: Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15)., Conclusion: Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Performing endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) allows a port of entry for intracranial biological sampling., Objective: To test the hypothesis that specific immune players are molecular contributors to disease, outcome biomarkers, and potential targets for modifying AIS., Methods: We examined 75 subjects presenting with large vessel occlusion of the anterior circulation and undergoing EVT. Intracranial blood samples were obtained by microcatheter aspiration, as positioned for stent deployment. Peripheral blood samples were collected from the femoral artery. Plasma samples were quality controlled by electrophoresis and analyzed using a Mesoscale multiplex for targeted inflammatory and vascular factors., Results: We measured 37 protein biomarkers in our sample cohort. Through multivariate analysis, adjusted for age, intravenous thrombolysis, pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores, we found that post-clot blood levels of interleukin-6 (IL-6) were significantly correlated (adjusted P value <0.05) with disability assessed by the modified Rankin Scale (mRS) score at 90 days, with medium effect size. Chemokine (C-C) ligand 17 CCL17/TARC levels were inversely correlated with the mRS score. Examination of peripheral blood showed that these correlations did not reach statistical significance after correction. Intracranial biomarker IL-6 level was specifically associated with a lower likelihood of favorable outcome, defined as a mRS score of 0-2., Conclusions: Our findings show a signature of blood inflammatory factors at the cerebrovascular occlusion site. The correlations between these acute-stage biomarkers and mRS score outcome support an avenue for add-on and localized immune modulatory strategies in AIS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)