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Backgrounds: Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-)., Methods: This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively., Results: A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results., Conclusion: In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination., Competing Interests: Competing interests: RGN reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte and Cerebrotech. DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. ARA is a consultant for Stryker Neurovascular. AEH - 1. Consultant/speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NovaSignal and Vesalio. 2. Principal investigator: COMPLETE study Penumbra, LVO SYNCHRONISE-Viz.ai. 3. Steering committee/publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR. 4. Proctor: Pipeline, FRED, Wingspan, and Onyx. 5. Supported by grants from: GE Healthcare. TNN: advisory board for Idorsia, Brainomix. SOG reports consulting fees for advisory roles with Stryker Neurovascular, Medtronic and microvention. Research support from Medtronic, Stryker, Microvention, VizAI. AA is consultant for Cerenovus. JB is an Advisory Board Member and consultant for Longeviti Neuro Solutions, and Consultant for Q’Apel Medical. BG is a consultant for Medtronic and Microvention. RAH is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel, advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. ES reports a speakers’ agreement with Stryker. AA is on the advisory board for iSchema View. JES reports consulting fees from Ceribell, speakers’ bureau for AstraZeneca (both unrelated to the present work)., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal anesthetic strategy for endovascular therapy (EVT) in acute ischemic stroke is still under debate. The aim of this study was to compare the clinical outcomes of patients with isolated posterior cerebral artery (PCA) occlusion stroke undergoing EVT by anesthesia modality with conscious sedation (non-GA) versus general anesthesia (GA)., Methods: Patients from the Posterior CerebraL Artery Occlusion (PLATO) study were analyzed with regard to anesthetic strategy. GA was compared with non-GA using multivariable logistic regression and inverse probability of weighting treatment (IPTW) methods. The primary endpoint was the 90-day distribution of the modified Rankin Scale (mRS) score. Secondary outcomes included functional independence or return to Rankin at day 90, and successful reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) 2b to 3. Safety endpoints were symptomatic intracranial hemorrhage and mortality., Results: Among 376 patients with isolated PCA occlusion stroke treated with EVT, 183 (49%) had GA. The treatment groups were comparable, although the GA group contained more patients with severe stroke and lower posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS). On IPTW analysis, there was no difference between groups with regard to ordinal mRS shift analysis (common OR 0.89, 95% CI 0.53 to 1.51, P=0.67) or functional independence (OR 0.84, 95% CI 0.50 to 1.39, P=0.49). There were greater odds for successful reperfusion with GA (OR 1.70, 95% CI 1.17 to 2.47, P=0.01). Safety outcomes were comparable between groups., Conclusion: In patients with isolated PCA occlusion undergoing EVT, patients treated with GA had higher reperfusion rates compared with non-GA. Both GA and non-GA strategies were safe and functional outcomes were similar., Competing Interests: Competing interests: NA reported employment by the American Heart Association. GD reported consultancy for Cerenovus, Penumbra, Route 92, Medtronic, MicroVention, and Stryker and stock holdings in RIST and InNeuroCo. JTF reported consultancy for Cerenovus, MicroVention, and Stryker; Data Safety Monitoring Board (DSMB) for MIVI; and stock holdings in Imperative Care and Sim&Cure. UF reported research support from the Swiss National Science Foundation (SNF), Medtronic, Stryker, Rapid Medical, Penumbra, and Phenox; consultancies for Stryker and CSL Behring; and is on the advisory board for Alexion/Portola, Boehringer Ingelheim, Biogen, and Acthera. UF reports patent US11166738B2. DCH reported consultancy for Vesalio, Cerenovus, Stryker, Brainomix, Poseydon Medical, and Chiesi USA; DSMB from Jacobs Institute; and stock options in Viz AI. CH reported consultancy for Brainomix and Speaker with Stryker. APJ reports consulting with Basking Biosciences; stock options in Gravity Medical Technology; and a patent for a novel stent retriever device licensed to Basking Biosciences. JK reported grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern. DPOK reported grants from the Joachim Herz Foundation. JBK reports grants from Alexion Pharmaceuticals, Bayer Healthcare, Sanofi Pasteur, and Biogen Idec. JPM reported consulting from Amicus Therapeutics and Boehringer Ingelheim and Speaker with Boehringer Ingelheim. PM reported grants from the University of Lausanne and Swiss National Science Foundation (SNF). MAM reported grants from Medtronic, Stryker, and MicroVention. MaM reported stock holdings in BrainQ, Serenity Medical, Synchron, and Bendit Technology and consulting from MicroVention, Medtronic, and Johnson & Johnson. SN reported consultancy for Brainomix and is a speaker with Boehringer Ingelheim and Pfizer. TNN reported research support from the Society of Vascular and Interventional Neurology (SVIN) and Medtronic and is on the advisory board with Idorsia. RGN reported consultancy for Biogen, Brainomix, Corindus, Cerenovus, Stryker, Medtronic, Ceretrieve, Anaconda Biomed, Vesalio, Imperative Care, NeuroVasc Technologies, Viz AI, Genentech, Prolong Pharmaceuticals, Perfuze, Phenox, and RapidPulse; stock options in Viz AI, Vesalio, Perfuze, Corindus, Brainomix, and Ceretrieve; and grants from Cerenovus and Stryker. CHN reported compensation (other services) from Novartis, AstraZeneca, Deutsches Zentrum für Herz-Kreislaufforschung, and Deutsches Zentrum für Neurodegenerative Erkrankungen and consultancy for Daiichi Sankyo, Bayer Healthcare, Pfizer, Alexion, and Bristol Myers Squibb. MP reported grants from Penumbra, Rapid Medical, Medtronic, Phenox, Bangerter-Rhyner Stiftung, SNF, Siemens Healthineers, and Stryker Neurovascular; travel support from Medtronic, Siemens Healthineers, Phenox, Penumbra, and Stryker; and consultancy for Siemens Healthineers. VP reported being a lecturer for Daiichi Sankyo. MR reported consultancy for Medtronic MiniMed, Cerenovus, AptaTargets, Stryker, and Philips and stock holdings in Methinks, Nora, and Anaconda Biomed. PAR reported travel support from Bayer and Bristol Myers Squibb and consultancy for Daiichi Sankyo Company and Boehringer Ingelheim. SAS reported consultancy for Imperative Care, Viz AI, and Penumbra; compensation from Motif Neurosciences (other services); and grants from the National Institutes of Health. AHS reported an ownership stake in Integra Lifesciences and Medtronic; consultancy for Cordis, Rapid Medical, MicroVention, Medtronic Vascular, Vassol, IRRAS USA, Boston Scientific, Amnis Therapeutics, Minnetronix Neuro, Canon Medical Systems USA, Cardinal Health 200, Johnson & Johnson–Latin America, Corindus, Penumbra, Apellis Pharmaceuticals, W.L. Gore & Associates, Stryker Corporation, and Viz AI; stock holdings in E8, Spinnaker Medical, Endostream Medical, Cerebrotech Medical Systems, Adona Medical, Bend IT Technologies, Whisper Medical, Neurotechnology Investors, Collavidence, Instylla, Q’Appel Medical, Serenity Medical, Borvo Medical, NeuroRadial Technologies, Sense Diagnostics, Tulavi Therapeutics, Synchron, Neurolutions, Viseon, BlinkTBI, Radical Catheter Technologies, and Truvic Medical; stock options in Viz AI, StimMed, Three Rivers Medical, Silk Road Medical, Imperative Care, CVAID, Cerevatech Medical, InspireMD, and PerFlow Medical; and security holdings in Vastrax, Launch NY, QAS.ai, VICIS, Neurovascular Diagnostics, Cognition Medical, and SongBird Therapy. The other authors report no conflicts., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Venous sinus stenting (VSS) is an increasingly performed procedure for the treatment of idiopathic intracranial hypertension (IIH) refractory to medical treatment. VSS is typically performed under general anesthesia., Objective: To present our experience of VSS in patients with IIH performed under conscious sedation., Methods: Retrospective review of a prospectively maintained database of all patients with IIH who underwent VSS in a single center between September 2019 and January 2024. The sedation protocol consisted of a remifentanil-based target-controlled infusion. Patients' clinical and radiological data, dosage of anesthesia, procedural characteristics, and outcomes were collected., Results: Twenty-six patients with IIH underwent venous manometry (VM) and VSS under awake sedation and were included in our study. Patients were predominantly women (24/26) with a median age (IQR) of 33 (13) years. The median (IQR) body mass index was 34 (10) kg/m 2 . There was no need for general anesthesia conversion. Technical success was achieved in all patients. Median (IQR) follow-up after stenting was 7 (2) months. All patients reported resolution of the pulsatile tinnitus; headaches regressed in 20/24 (83.3%) patients and papilledema improved in 16/20 (80%). Only one non-neurological complication (retroperitoneal hematoma) occurred, without any permanent morbidity or mortality., Conclusion: Our study confirms that performing VM and VSS under conscious sedation is safe and feasible. Conscious sedation is a viable alternative to general anesthesia for managing IIH in these patients., Competing Interests: Competing interests: None declared., (© 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 first-pass effect (FPE) is linked to better safety and efficacy prognosis in patients with small- to- moderate sized ischemic infarctions. We evaluated the incidence, prognosis, and predictors of FPE in patients with large core infarctions (LCIs)., Methods: We conducted a post-hoc analysis of data from the Trial of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT). The FPE was defined as a successful recanalization (expanded Thrombolysis in Cerebral Infarction (eTICI) 2 c/3, and eTICI 2b-3 as modified FPE (mFPE)) after one pass. The primary outcome was clinical functional independence, and the secondary outcomes were independent ambulation, assessed by the modified Rankin Scale (mRS) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) defined by the Heidelberg bleeding classification, any intracranial hemorrhage (ICH), and death within 90 days of stroke onset., Results: Of the 226 patients in the study, FPE and mFPE were achieved in 33 (14.6%) and 82 (36.3%) patients, respectively. Patients with FPE exhibited shorter onset-to-puncture times (adjusted odds ratio [OR] 0.915; 95% confidence interval [CI]: 0.84 to 0.996), and patients with mFPE were older (OR 1.039; 95% CI: 1.005 to 1.075). mFPE was significantly associated with favorable outcomes (modified Rankin score [mRS] 0-2: OR 2.64; 95% CI: 1.37 to 5.07; mRS 0-3: OR 3.31; 95% CI: 1.73 to 6.33). FPE tended to improve outcomes (mRS 0-3: OR 2.24; 95% CI: 0.92 to 4.97; p=0.08). ICH rates (OR 0.60; 95% CI: 0.34 to 1.05; p=0.07) and 90-day deaths (OR 0.57; 95% CI: 0.30 to 1.09; p=0.09) tended to decrease in patients who achieved mFPE but not in patients who achieved FPE., Conclusions: In the ANGEL-ASPECT trial, patients who achieved mFPE had a higher rate of independent ambulation and functional independence, and the rates of any ICH and 90-day death tended to decrease., 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: Approximately 30% of patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion have pre-stroke modified Rankin Scale (mRS) scores ≥2. We aimed to investigate the safety and outcomes of endovascular treatment (EVT) in patients with AIS with moderate pre-stroke disability (mRS score 3) in an extended time frame (ie, 6-24 hours from the last time known well)., Methods: Data were collected from five centers in Europe and the USA from January 2018 to January 2023 and included 180 patients who underwent EVT in an extended time frame. Patients were divided into two groups of 90 each (Group 1: pre-mRS 0-2; Group 2: pre-mRS 3; 71% women, mean age 80.3±11.9 years). Primary outcomes were: (1) 3-month good clinical outcome (Group 1: mRS 0-2, Group 2: mRS 0-3) and ΔmRS; (2) any hemorrhagic transformation (HT); and (3) symptomatic HT. Secondary outcomes were successful and complete recanalization after EVT and 3-month mortality., Results: No between-group differences were found in the 3-month good clinical outcome (26.6% vs 25.5%, P=0.974), any HT (26.6% vs 22%, P=0.733), and symptomatic HT (8.9 vs 4.4%, P=0.232). Unexpectedly, ΔmRS was significantly smaller in Group 2 compared with Group 1 (1.64±1.61 vs 2.97±1.69, P<0.001). No between-group differences were found in secondary outcomes., Conclusion: Patients with pre-stroke mRS 3 are likely to have similar outcomes after EVT in the extended time frame to those with pre-stroke mRS 0-2, with no difference in safety., Competing Interests: Competing interests: T.N. Nguyen discloses advisory board for Brainomix, Aruna Bio; Associate Editor of Stroke. The other authors declare that they have no conflict of interests., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) stroke is uncertain. We aimed to evaluate the association of the anesthesia modality with procedural and clinical outcomes following EVT for DMVO stroke., Methods: This is a multicenter retrospective analysis of a prospectively collected database. Patients were included if they had DMVO involving the middle cerebral artery-M3/4, anterior cerebral artery-A2/3, or posterior cerebral artery-P1/P2-3, and underwent EVT. The cohort was divided into two groups, general anesthesia (GA) and non-general anesthesia (non-GA), and compared based on the intention-to-treat principle as primary analysis. We used propensity scores to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the 90-day modified Rankin Scale (mRS). Secondary outcomes included successful reperfusion, as well as excellent (mRS 0-1) and good (mRS 0-2) clinical outcomes at 90 days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality., Results: Among 366 DMVO thrombectomies, 61 matched pairs were eligible for analysis. Median age and National Institutes of Health Stroke Scale score as well as other baseline demographic and clinical characteristics were balanced between both groups. The GA group had no difference in the overall degree of disability (common OR 1.19, 95% CI 0.52 to 2.86, P=0.67) compared with the non-GA arm. Likewise, the GA group had comparable rates of successful reperfusion (OR 2.38, 95% CI 0.80 to 7.07, P=0.12), good/excellent clinical outcomes (OR 1.14, 95% CI 0.44 to 2.96, P=0.79/(OR 0.65, 95% CI 0.24 to 1.81, P=0.41), procedural complications (OR 1.00, 95% CI 0.19 to 5.16, P>0.99), sICH (OR 3.24, 95% CI 0.83 to 12.68, P=0.09), and 90-day mortality (OR 1.43, 95% CI 0.48 to 4.27, P=0.52) compared with the non-GA group., Conclusions: In patients with DMVO, our study showed that GA and non-GA groups had similar procedural and clinical outcomes, as well as safety measures. Further larger controlled studies are warranted., Competing Interests: Competing interests: MHM: no disclosure. DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. RGN reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte and Cerebrotech. ARA is a consultant for Stryker Neurovascular. AEH: 1. Consultant/speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NovaSignal and Vesalio. 2. Principal investigator: COMPLETE study Penumbra, LVO SYNCHRONISE-Viz.ai. 3. Steering committee/publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR. 4. Proctor: Pipeline, FRED, Wingspan, and Onyx. 5. Supported by grants from: GE Healthcare. TNN: Research support from Medtronic, advisory board Brainomix, Associate Editor of Stroke. SOG: Grants-NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker, Medtronic, Microvention, Methinks, Viz.ai. Consulting fees: Medtronic, Stryker Neurovascular. AA is consultant for Cerenovus. JB is an Advisory Board Member and consultant for Longeviti Neuro Solutions, and Consultant for Q’Apel Medical. BG is a consultant for Medtronic and Microvention. RAH is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel, on advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. ES reports a speakers’ agreement with Stryker. AA is on advisory board for iSchema View. JES reports consulting fees from AstraZeneca, and research support from Medtronic and Philips (all unrelated to the present work). The other authors report no conflicts., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs., Methods: Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0-2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality., Results: Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46-117.5) mins vs 54 (21-100), P=0.607) and groin to recanalization time (59 (39.5-85.5) mins vs 54 (38-81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting., Conclusions: Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population., Competing Interests: Competing interests: SOG: research support from the NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker (N/A), Medtronic(N/A), Microvention(N/A), Methinks(N/A), IschemiaView(N/A), Viz.ai(N/A), and Siemens(N/A); and consulting fees from Medtronic and Stryker Neurovascular. TN: advisory board for Idorsia, Brainomix. NP: research support from the NIH/NINDS (K23NS110980) and Liminal Sciences (N/A). TGJ: advisor and investor for Anaconda, Route92, Viz.AI, FreeOx, Blockade Medical, and Methinks; grant support from Medtronic (N/A) and from Stryker Neurovascular (N/A) in his capacity as principal investigator for DAWN and AURORA; he received personal fees in his role on the Data Safety Monitoring Board. The other co-authors do not report conflicts of interests., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS., Methods: We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented., Results: 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, P heterogeneity =0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT., Conclusions: In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH., 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: Recent studies have shown that follow-up head CT is a strong predictor of functional outcomes in patients with middle cerebral artery stroke and mechanical thrombectomy. We sought to determine whether total and/or regional follow-up Alberta Stroke Program Early CT Score (ASPECTS fu ) are associated with important clinical outcomes during hospitalization and improve the performance of clinical prediction models of potentially lethal malignant edema (PLME)., Methods: We conducted a retrospective study of patients at three medical centers in a major North American metropolitan area with baseline and follow-up head CTs after large middle cerebral artery stroke between 2006 and 2022. We used multivariable logistic regression to test the association of total and regional ASPECTS fu with PLME (cerebral edema related death or surgery), adjusting for total baseline ASPECTS, age, sex, admission glucose, tissue plasminogen activator, and mechanical thrombectomy. We compared existing clinical risk models with and without total or regional ASPECTS fu using area under the curve., Results: In our 560 patient cohort, lower total ASPECTS fu was significantly associated with higher odds of PLME when adjusting for confounders (OR 1.69, 95% CI 1.49 to 2.0), and improved model discrimination compared with existing models and models using baseline ASPECTS. Deep territory involvement (OR 2.46, 95% CI 1.53 to 4.01) and anterior territory involvement (OR 3.23, 95% CI 1.88 to 5.71) were significantly associated with PLME., Conclusions: Lower ASPECTS fu and certain locations on regional ASPECTS fu , including deep and anterior areas, were significantly associated with PLME. Including ASPECTS fu information improved discrimination of established edema prediction models and could be used immediately to help facilitate clinical management decisions and prognostication., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The aim of the study was to establish a reliable scoring tool to identify the probability of symptomatic intracranial hemorrhage (sICH) in anterior circulation stroke patients with contrast enhancement (CE) on brain non-contrast CT (NCCT) after endovascular thrombectomy (EVT)., Methods: We retrospectively reviewed consecutive patients with acute ischemic stroke (AIS) who had CE on NCCT immediately after EVT for anterior circulation large vessel occlusion (LVO). We used the Alberta stroke program early CT score (ASPECTS) scoring system to estimate the extent and location of CE. Multivariable logistic regression was performed to derive an sICH predictive score. The discrimination and calibration of this score were assessed using the area under the receiver operator characteristic curve, calibration curve, and decision curve analysis., Results: In this study, 194 of 322 (60.25%) anterior circulation AIS-LVO patients had CE on NCCT. After excluding 85 patients, 109 patients were enrolled in the final analysis. In multivariate regression analysis, age ≥70 years (adjusted OR (aOR) 9.23, 95% CI 2.43 to 34.97, P＜0.05), atrial fibrillation (AF) (aOR 4.17, 95% CI 1.33 to 13.12, P＜0.05), serum glucose ≥11.1 mmol/L (aOR 9.39, 95% CI 2.74 to 32.14, P＜0.05), CE-ASPECTS ＜5 (aOR 3.95, 95% CI 1.30 to 12.04 P＜0.05), and CE at the internal capsule (aOR 3.45, 95% CI 1.03 to 11.59, P＜0.05) and M1 region (aOR 3.65, 95% CI 1.13 to 11.80, P＜0.05) were associated with sICH. These variables were incorporated as the CE-age-glucose-AF (CAGA) score. The CAGA score demonstrated good discrimination and calibration in this cohort, as well as the fivefold cross validation., Conclusion: The CAGA score reliably predicted sICH in patients with CE on NCCT after EVT treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Recently, a randomized controlled trial showed a beneficial effect of intra-arterial thrombolysis following successful endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation. Due to differences in response to thrombolytics in occlusion of the posterior circulation, the purpose of ATTENTION IA is to explore the adjunct benefit of intra-arterial thrombolysis after successful recanalization in patients presenting with large and medium vessel occlusion of the posterior circulation., Methods: ATTENTION-IA is an investigator-initiated, multicenter, prospective, randomized clinical trial with open-label treatment and blinded endpoint assessment (PROBE). After achieving successful recanalization (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b-3) of an occlusion of the vertebral, basilar, or posterior cerebral artery, patients will be randomized 1:1 to receive intra-arterial tenecteplase or standard of care. The primary effect parameter is a modified Rankin Score of 0-1 at day 90., Results: The trial recently completed enrollment, and data collection/verification is ongoing. The final results will be made available on completion of enrollment and follow-up., Conclusions: ATTENTION-IA will provide definitive evidence for the efficacy and safety of adjunct intra-arterial tenecteplase after successful EVT in patients with an acute posterior circulation arterial occlusion stroke presenting within 24 hours of symptom onset., Trial Registration: ClinicalTrials.gov NCT05684172., Competing Interests: Competing interests: RGN reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Philips, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, Synchron, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse and Perfuze. RGN is one of the Principal Investigators of the ‘Endovascular Therapy for Low NIHSS Ischemic Strokes (ENDOLOW)’ trial. Funding for this project is provided by Cerenovus. RGN is the Principal Investigator of the ‘Combined Thrombectomy for Distal MediUm Vessel Occlusion StroKe (DUSK)’ trial. Funding for this project is provided by Stryker Neurovascular. RGN is an investor in Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, Tulavi Therapeutics, Vastrax, Piraeus Medical, Brain4Care, Quantanosis AI, and Viseon. JLS reports consulting fees for advising on rigorous and safe clinical trial design and conduct from Abbott, Acticor, Aeromics, Amgen, Argenica, Astrocyte, Bayer, Biogen, Boehringer Ingelheim, BrainsGate, BrainQ, CSL Behring, Filterlex, Genentech, Johnson & Johnson, MindRhythm, Medtronic, NeuroMerit, Neuronics, Novo Nordisk, Occlutech, Phenox, Phillips, QuantalX, Rapid Medical, Roche, and Stream Biomedical. The other authors have no financial conflicts of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA)., Methods: We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality., Results: Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups., Conclusions: Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence., Competing Interests: Competing interests: RGN: reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte and Cerebrotech. DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. ARA is a consultant for Stryker Neurovascular. AEH - 1. Consultant/speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NovaSignal and Vesalio. 2. Principal investigator: COMPLETE study Penumbra, LVO SYNCHRONISE-Viz.ai. 3. Steering committee/publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR. 4. Proctor: Pipeline, FRED, Wingspan, and Onyx. 5. Supported by grants from: GE Healthcare. TNN: Research support from Medtronic, SVIN. SOG reports consulting fees for advisory roles with Stryker Neurovascular, Medtronic and microvention. Research support from Medtronic, Stryker, Microvention, VizAI. AA is consultant for Cerenovus. JB is an Advisory Board Member and consultant for Longeviti Neuro Solutions, and Consultant for Q’Apel Medical. BG is a consultant for Medtronic and Microvention. RAH: is a consultant for Medtronic, Stryker, Cerenovus, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel, advisory board for MiVI, eLum, Three Rivers, Shape Medical and Corindus. Unrestricted research grant from NIH, Interline Endowment, Microvention, Stryker, CNX. Investor/stockholder for InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc, Scientia, RisT, BlinkTBI, and Corindus. ES: reports a speakers’ agreement with Stryker. AA: is on advisory board for iSchema View. PK is a member of the editorial board of JNIS. JF is a member of editorial board of JNIS. JES reports consulting fees from Ceribell, speakers’ bureau for AstraZeneca (both unrelated to the present work)., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Endovascular treatment (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO)., Objective: To systematically review the available data on: (1) incidence, predictors, and outcomes of patients with reocclusion after successful EVT for AIS and, (2) the characteristics, complications, and outcomes of patients with reocclusion treated with repeated EVT (rEVT) within 30 days of the first procedure., Methods: PubMed was searched (between January 2012 and April 2021) to identify studies reporting reocclusion following successful EVT (Thrombolysis in Cerebral Infarction ≥2b) in patients with AIS due to LVO. Pooled incidence of reocclusion per 100 patients with successful recanalization following EVT was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Extracted incidences of reocclusion according to etiology and use of intravenous thrombolysis were pooled using random-effects meta-analytic models., Results: A total of 840 studies was identified and seven studies qualified for the quantitative analysis, which described 91 same-vessel reocclusions occurring within the first 7 days after treatment among 2067 patients (4.9%; 95% CI 3% to 7%, I 2 =70.2%). Large vessel atherosclerosis was associated with an increased risk of reocclusion (OR=3.44, 95% CI 1.12 to 10.61, I 2 =50%). We identified 90 patients treated with rEVT for recurrent LVO, described in five studies. The rates of procedural complications, mortality, and unfavorable functional outcome at 3 months were 18.0%, 18.9%, and 60.3%, respectively., Conclusion: In cohorts of patients with AIS due to LVO, 5% of patients experienced reocclusion within 7 days after successful EVT. Repeated EVT can be a safe and effective treatment for selected patients with reocclusion., Competing Interests: Competing interests: JPM reports consulting fees from Amicus Therapeutics and Boehringer Ingelheim, speaker fees from Boehringer Ingelheim, and support for travel from Boehringer Ingelheim, Bayer and Pfizer, outside of the submitted work. TNN reports research support from Medtronic and the Society of Vascular and Interventional Neurology (unrelated), DSMB participation for TATAM, Endolow, TESLA, CREST-2 and SELECT-2 trial, and being President-Elect of SVIN. RGN reports potential conflicts with Stryker Neurovascular (DAWN Trial principal investigator–no compensation, TREVO Registry Steering Committee–no compensation, Trevo-2 Trial principal investigator–modest; consultant–modest), Medtronic (SWIFT Trial Steering. Committee–modest; SWIFT-Prime Trial Steering Committee–no compensation; STAR Trial Angiographic Core Laboratury–significant), Penumbra (3D Separator Trial Executive Committee–no compensation), Cerenovus/ Neuravi (ENDOLOW Trial principal investigator, EXCELLENT Registry principal investigator, ARISE-2 trial Steering Committee–no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board-modest), Genentech (Physician Advisory Board–modest), Biogen (Physician Advisory Board–modest), Prolong Pharmaceuticals (Physician Advisory Board–modest), Allm Inc (Physician Advisory Board–no compensation), IschemaView (Speaker, modest), Brainomix (Research Software Use–no compensation), Sensome (Research Device Use–no compensation), Viz-AI (Physician Advisory Board, stock options), Philips (Research Software Use–no compensation, Speaker–modest), and Corindus Vascular Robotics (Physician Advisory Board, stock options). ABC reports being a Cerenovus consultant and receiving personal fees from Medtronic. DCH reports compensation from Stryker, Vesalio, and Cerenovus for consultant services; compensation from Jacobs institute for data and safety monitoring services; stock options in Viz AI. JTF reports consulting fees from Cerenovus, Stryker, Microvention, and Penumbra, being DSMB lead for MIVU medical, ownership interest from Imperative Care, and being member of the editorial board of JNIS and board member of SNIS. SO-G reports consulting fees for Medtronic, Stryker Neurovascular, and Microvention, receiving grants from Stryker, IschemiaView, Viz.ai, Methinks, and NIH, and being treasurer of SVIN. DRY reports being part of the steering committee for the TIGER clinical trial sponsored by Rapid Medical and steering committee of CALM-2 sponsored by Vascular Dynamics, consulting fees from Medtronic, Cerenovus, Poseydon, and Neurosave, Deck Therapeutics, GLG Consulting, Guidepoint Consulting, Mosaic Consulting, and Neuralanalytics. DAdS reports non-financial support from Boehringer Ingelheim, DSMB participation for the SECRET trial, advisory board participation for AstraZeneca, grants from Astrazeneca, speaker fees from Bayer and being member of the executive committee of the European Stroke Organisation. The other authors report no conflicts., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Femoral access is the primary route for neurointerventional procedures in children. However, endovascular treatment may not always be possible through a femoral approach, necessitating conversion to alternative access routes., Objective: To review the feasibility and safety of direct carotid puncture (DCP) in infants undergoing neuroendovascular interventions., Methods: We conducted a retrospective review of all infants who underwent DCP as the access route to treat neuroendovascular pathologies between January 2011 and January 2021. Patients' demographics, clinical presentation, imaging findings, and technical details were reviewed., Results: Between January 2011 and January 2021, five infants aged between 28 and 150 days underwent DCP out of 1129 neuroendovascular interventions performed in our institution (0.4%). All five infants (100%) were diagnosed with intracranial fistulas and were found to have severe tortuosity of the cervical arteries. DCP was performed as the initial access route in 2/5 patients and as crossover after a failed femoral attempt in 3/5 patients. DCP was performed under ultrasound guidance in all patients. Closure was performed by manual compression, without complications. Ultrasound showed patent cervical vessels in all patients at 3 months' follow-up., Conclusion: Direct carotid access is a feasible and safe alternative route to treat neuroendovascular pathologies in infants and can be considered in cases of inaccessible or failed transfemoral access or in cases with severe arterial tortuosity in infants with intracranial fistulas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: M2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking., Methods: A retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques., Results: There were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1-6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9-44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1-24.3)) and combined technique (OR 4.6 (1.1-20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome., Conclusion: Stent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months., Competing Interests: Competing interests: MC is a member of the JNIS editorial board., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome., Methods: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications., Results: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome., Conclusion: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Unprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown., Methods: We performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment., Results: Of the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7-21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (β adj =-73.2, 95% CI -153.8-7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (β adj =-3.85, 95% CI -36.9-29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (β adj =-46.44, 95% CI -62.8 to - -30.0, P<0.01) and higher NIHSS (β adj =-2.15, 95% CI -4.2to - -0.1, P=0.05)., Conclusions: In this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Coil migration is a complication of endovascular coiling of cerebral aneurysms that has not been well studied., Objective: To report the frequency, risk factors, management strategies, and outcomes of coil migration., Methods: This was a retrospective analysis of the clinical and radiological data of patients who underwent cerebral aneurysm coiling complicated by coil migration at five neuroendovascular centers in the United States, Canada, and France between 2008 and 2018., Results: Eighteen cases of coil migration met our study criteria with an occurrence of 0.3% (18/6071 cases) (procedural migration: 55%, delayed migration: 45%). The mean aneurysm maximal diameter, neck, and height to neck ratio in migration cases were 3.4±1.4 mm (range 2-7.6 mm), 2.4±0.9 mm (range 1.2-4.4 mm), and 1.4±0.4 (range 1-2.15), respectively. The 2 mm diameter coil was the most common (39%, range 1-2.5 mm) migrated coil. The length of the migrated coil was ≤4 cm in 95% of cases.Patients managed conservatively (5/18, 28%) did well. Thromboembolic and/or hemorrhagic complications were noted in 6/10 migration patients treated by endovascular modalities and in all migration patients who underwent surgical treatment (4/4). Three deaths occurred (3/18, 17%) related to high Hunt and Hess grade subarachnoid hemorrhage., Conclusion: Coil migration is an uncommon but important complication of cerebral aneurysm coiling. Small aneurysms, aspect ratio <1.6, and small coils are significant risk factors. Endovascular treatment, such as using a stent retriever, can be considered for procedural, proximal migration, and/or in cases of vessel occlusion. Delayed or distal migration should be managed conservatively., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter., Methods: The TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician., Results: 536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001)., Conclusions: In acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality., Competing Interests: Competing interests: TNN is a consultant for Medtronic. OOZ is a consultant/advisory board member for Stryker Neurovascular and Covidien. OOZ is overall principal investigator for TRACK–no compensation and Arise II–modest. RGN is a consultant/advisory board member for Stryker Neurovascular and Covidien. Stryker Neurovascular (Trevo-2 trial principal investigator–modest; DAWN trial principal investigator–no compensation, TREVO registry steering committee–no compensation), Medtronic (SWIFT trial steering committee–modest; SWIFT-Prime trial steering committee–no compensation; STAR Trial Angiographic Core Lab–significant), Penumbra (3D Separator trial executive committee–no compensation), Neuravi (ARISE-2 steering committee–no compensation), Genentech (physician advisory board–modest), Allm Inc (physician advisory board–no compensation), editor- in-chief Interventional Neurology journal (no compensation). SRS is a consultant for Stryker Neurovascular. JDE is a consultant for Stryker Neurovascular.
 IL is a consultant for Medtronic, Stryker, Penumbra, and Cordis., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)