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Background The Pipeline Embolization Device has proven to be a safe and effective device for the treatment of intracranial aneurysms. The Pipeline Vantage Flow Diverter (PVFD) with Shield Technology is the new fourth generation of this implant, with modifications made compared to previous iterations. We aimed to evaluate the mechanical properties and clinical safety and efficacy of this device. Methods Vanguard is a single arm, single center, prospective study. Between April 2021 and April 2023, all consecutive patients with an unruptured aneurysm treated with Pipeline Vantage flow-diverting stents were included. There were no aneurysm size or location exclusion criteria. Safety (neurological serious adverse events) and efficacy (device deployment and aneurysm occlusion) were independently reviewed. Imaging follow-up data, and immediate, early (<30 days), and delayed (>30 days) neurological serious adverse events were independently assessed. Results 101 consecutive patients with a total of 115 aneurysms were included. The aneurysms were situated in the anterior (90.4%) or posterior (9.6%) circulations. A total of 124 devices were implanted. The deployment success rate was 100%. In four (4.0%) cases post-deployment angioplasty was required to optimize device wall apposition. Occlusion rates at 1 month were 54.7%, at 3 months 72.1%, and at 6 months 81.7%. Morbidity and mortality were 4.9% and 0%, respectively, at 6 months. Eight cases (6.9%) demonstrated in-stent stenosis, four of which had 'fish mouth' deformity. Conclusion Initial results of the new generation PVFD for unruptured intracranial aneurysm treatment demonstrate overall satisfactory device performance, safety profile, and effectiveness. [ABSTRACT FROM AUTHOR]

Introduction: This research evaluates the budget impact of treating acute ischaemic stroke (AIS) using a combination of mechanical thrombectomy (MT) with stent retrievers (SR) and intravenous tissue‐plasminogen activator (IV‐tPA) in Australia. Methods: This study examined the economic impact over five years for a patient cohort based on the number of patients treated with MT+ IV‐tPA in Australia 2021, versus treatment with IV‐tPA alone. A budget impact (BI) model was developed to project direct medical costs (economic impact) of IV‐tPA+ MT with SR vs. Intravenous tissue‐plasminogen activator alone over a five‐year period (2021–2025 inclusive) from a healthcare perspective. The model is composed of a short‐run decision tree model based on a 3‐month post‐treatment modified Rankin Scale (mRS) from the EXTEND‐IA study and a published long‐run Markov state transition model. Acute, mid‐term and long‐term care costs were projected based on anticipated mRS scores from the EXTEND‐IA trial. Estimated yearly and cumulative budget impact were reported to indicate the economic impact of the two treatment strategies for AIS in the Australian healthcare system. Results: MT+IV‐tPA had a greater budgetary impact than IV‐tPA alone, with annual savings starting at Year 1 and continuing through to Year 5. Cost savings of 21% or approximately $36 million can be achieved over five years for the patient cohort treated in Australia in 2021. Each MT procedure performed delivers approximately $3280 in annual health system savings per patient. Conclusion: Treatment of AIS with a combination of MT+IV‐tPA generates significant savings in the Australian healthcare system compared with IV‐tPA alone. [ABSTRACT FROM AUTHOR]

Background: The use of balloon microcatheters in interventional neuroradiology is well documented. However, their use is sometimes limited by the small diameter and excessive tortuosity of the vasculature. The Scepter Mini dual-lumen balloon microcatheter (SMBM) (Microvention, Aliso Viejo, CA) has been designed to address these challenges by decreasing the distal catheter profile, allowing distal access to the target vessel. Methods: This is a single-centre retrospective analysis of the initial cases performed using the Scepter Mini balloon microcatheter. The targeted conditions were vascular malformations. Patient clinical data, angiographic features of the vascular abnormalities and operation reports were reviewed and the procedural parameters, radiation doses, occlusion rates and complications were assessed. Results: A total of 15 SMBM were used in 11 cases. In all cases the procedure performed was balloon inflation and antegrade delivery of precipitating hydrophobic injectable liquid (PHIL) (Microvention, Aliso Viejo, CA) for embolisation of a targeted feeding vessel and cranial and spinal vascular malformations. Successful feeding vessel distal access and antegrade liquid embolisation was achieved in 100% of the cases. One of the 11 cases was an emergency procedure. One procedural target vessel rupture, likely due to overinflation, and three minor post-procedure complications were observed. Conclusion: The SMBM represents a significant advance in the treatment of cerebrospinal vascular malformations, allowing balloon catheter access into tortuous and small calibre vessels. [ABSTRACT FROM AUTHOR]

Purpose: To examine whether the muscle typology of elite and world-class swimmers could discriminate between their best distance event, swimming stroke style, or performance level. Methodology: The muscle carnosine content of 43 male (860 [76] FINA [Fédération Internationale de Natation] points) and 30 female (881 [63] FINA points) swimmers was measured in the soleus and gastrocnemius by proton magnetic resonance spectroscopy and expressed as a carnosine aggregate Z score (CAZ score) to estimate muscle typology. A higher CAZ score is associated with a higher estimated proportion of type II fibers. Swimmers were categorized by their best stroke, distance category (sprinters, 50–100 m; middle distance, 200–400 m; or long distance, 800 m–open water), and performance level (world-class, world top 10, or elite and world top 100 swimmers outside of the world top 10). Results: There was no significant difference in the CAZ score of sprint- (−0.08 [0.55]), middle- (−0.17 [0.70]), or long-distance swimmers (−0.30 [0.75], P =.693). World-class sprint swimmers (all strokes included) had a significantly higher CAZ score (0.37 [0.70]) when compared to elite sprint swimmers (−0.25 [0.61], P =.024, d = 0.94). Breaststroke swimmers (0.69 [0.73]) had a significantly higher CAZ score compared to freestyle (−0.24 [0.54], P <.001, d = 1.46), backstroke (−0.16 [0.47], P =.006, d = 1.42), and butterfly swimmers (−0.39 [0.53], P <.001, d = 1.70). Furthermore, within the cohort of breaststroke swimmers, there was a significant positive correlation between FINA points and CAZ score (r =.728, P =.011); however, this association was not evident in other strokes. Conclusion: While there was no clear association between muscle typology and event distance specialization, world-class sprint swimmers possess a greater estimated proportion of type II fibers compared to elite sprint swimmers, as well as breaststroke swimmers compared to freestyle, backstroke, and butterfly swimmers. [ABSTRACT FROM AUTHOR]

Background Robotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases. Objective To evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral aneurysms. Methods This prospective, international, multicenter study enrolled patients with brain aneurysms that required endovascular coiling and/or stent-assisted coiling. The primary effectiveness endpoint was defined as successful completion of the robotic-assisted endovascular procedure without any unplanned conversion to manual treatment with guidewire or microcatheter navigation, embolization coil(s) or intracranial stent(s) deployment, or an inability to navigate vessel anatomy. The primary safety endpoint included intraprocedural and periprocedural events. Results The study enrolled 117 patients (74.4% female) with mean age of 56.6 years from 10 international sites,. Headache was the most common presenting symptom in 40/117 (34.2%) subjects. Internal carotid artery was the most common location (34/122, 27.9%), and the mean aneurysm height and neck width were 5.7±2.6 mm and 3.5±1.4 mm, respectively. The overall procedure time was 117.3±47.3 min with 59.4±32.6 min robotic procedure time. Primary effectiveness was achieved in 110/117 (94%) subjects with seven subjects requiring conversion to manual for procedure completion. Only four primary safety events were recorded with two intraprocedural aneurysm ruptures and two strokes. A Raymond-Roy Classification Scale score of 1 was achieved in 71/110 (64.5%) subjects, and all subjects were discharged with a modified Rankin Scale score of ≤2. Conclusions This first-of-its-kind robotic-assisted neurovascular trial demonstrates the effectiveness and safety of the CorPath GRX System for endovascular embolization of cerebral aneurysm procedures. [ABSTRACT FROM AUTHOR]

Background The radial artery approach has become popular as a 'radial first' strategy for arterial access in neuroangiography and neurointerventions. Recent studies have shown that transradial arterial access (TRA) for cerebral angiography has been associated with reduced access site complication rates and improved patient satisfaction compared with transfemoral access (TFA). The goal of this study was to evaluate the presence of abnormal MRI diffusion weighted imaging (DWI) foci following DSA and correlate their frequency with TRA or TFA. Methods We prospective analyzed 200 consecutive adult DSAs performed from January 2021 to January 2022, at a single tertiary center. Results Of the 200 consecutive diagnostic cerebral angiograms, 51% were performed via TRA and 49% were performed via TFA. Of the TRA cerebral angiograms, 17.5% demonstrated at least one hyperintense focus on MRI DWI. Of the TFA procedures, 5.2% were considered positive. One patient (0.5%) in the TRA group experienced a minor neurologic deficit postoperatively that had not completely resolved at 90 days after the procedure and no neurologic deficits occurred in the TFA group. Conclusions Despite the proven benefit of TRA over TFA in neurointervention, the number of MRI DWI restriction foci were significantly more frequent during cerebral angiography when TRA was selected. Although the number of clinically symptomatic events were minimal, the widespread use of the technique may become clinically relevant. Further studies contrasting the TRA and TFA techniques will be beneficial for cerebral angiography. [ABSTRACT FROM AUTHOR]

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

Background: The aim of this study was to evaluate the overall rates of braid changes associated with flow diverter (FD) treatment for intracranial aneurysms (IAs). Additionally, we sought to provide an overview of the currently reported definitions related to these complications., Methods: A systematic search was conducted from the inception of relevant literature up to April 2023, encompassing six databases. The included studies focused on patients with IAs treated with FDs. We considered four main outcome measures as FD braid changes: (1) fish-mouthing, (2) device braid narrowing, (3) device braid collapsing, and (4) device braid deformation. The data from these studies were pooled using a random-effects model., Results: A total of 48 studies involving 3572 patients were included in the analysis. Among them, 14 studies (39%) provided definitions for fish-mouthing. However, none of the included studies offered specific definitions for device braid narrowing, collapsing, or deformation, despite reporting rates for these complications in six, five, and three studies, respectively. The pooled rates for braid changes were as follows: 3% (95% CI 2% to 4%, I 2 =27%) for fish-mouthing, 7% (95% CI 2% to 20%, I 2 =85%) for narrowing, 1% (95% CI 0% to 3%, I 2 =0%) for collapsing, and 1% (95% CI 1% to 4%, I 2 =0%) for deformation., Conclusion: The findings of this study suggest that FD treatment for IAs generally exhibits low rates of fish-mouthing, device braid narrowing, collapsing, and deformation. However, the lack of standardized definitions hinders the ability to compare device outcomes objectively, emphasizing the need for uniform definitions for FD braid changes in future prospective studies on FD., Competing Interests: Competing interests: SO-G: grants from NIH, Stryker, Medtronic, Microvention, MEthinks, IschemiaView, Viz.ai, Siemens; consulting fees from Medtronic and Stryker. HSC receives consulting fees from Medtronic and MicroVention and holds stock or stock options in Neuravention Inc, Vesalio Inc, Bend It Tech, Syncron, Prometheus Inc, Piraeus Inc, Sim Research Support: Microvention, Stryker, Balt USA, Siemens; Scientific Advisory Boards: Scientia Medical, NVMed, Perfuze; holds stock in: MENTICE-Vascular Simulations, Neurogami, Marblehead, Scientia Medical, NVMed, Perfuze. PL receives consulting fees from Medtronic, Cerevasc, and Phenox GmbH (paid to his institution); honoraria from Medtronic (paid to him); and support for attending meetings and/or travel from Cerevasc, Medtronic, and Philips (paid to him); and participates on the Cerevasc data safe monitoring board. VMP is an unpaid consultant for Siemens Healthinners Endovascular Robotics. 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., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)