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Background: Atlantoaxial subluxation (AAS) is a diagnosis describing misalignment of the C1 vertebra relative to C2. Excessive translation of this joint, located adjacent to the medullary brain stem, can lead to devastating neurological consequences. A higher prevalence of AAS within the Down syndrome (DS) population has been well-established. This study aims to establish a prevalence rate of DS in patients hospitalized for AAS and compare outcomes between AAS patients with and without DS. Methods: This study utilized the National Inpatient Sample (NIS) provided by the Healthcare Cost and Utilization Project (HCUP). In accordance with HCUP 2023 Clinical Classifications Software Refined files, data were queried using the International Classification of Diseases 10th Edition codes for DS and AAS. Demographics, comorbidities, hospital course, and outcomes were examined and compared using binary and linear multivariate regression. IBM SPSS software was used for data analysis. Results: Of the 213,095 patients in the NIS database admitted between 2016 and 2020 with AAS as their primary diagnosis, 7.2% were DS patients. DS patients were significantly younger (26.56 ± 20.81 vs. 49.39 ± 27.63, P < 0.01), less likely to be female (33.30% vs. 52.10%), and had fewer comorbidities (diabetes mellitus, hypertension, and hyperlipidemia) than non-DS patients. There was no significant difference in likelihood to undergo surgical fusion between DS patients and non-DS patients with AAS. Conclusion: This large-scale study using NIS data determined that 7.2% of all patients admitted to hospitals for AAS are DS patients. The analysis of demographics, hospital course, and outcomes can influence the development of treatment protocols for AAS in the DS population.

Background This study proposes a modification to the traditional Hunt and Hess (tHH) grading scale for prognostication in aneurysmal subarachnoid hemorrhage (aSAH), which differentiates the most severe‐grade patients based on the presence or absence of brainstem dysfunction [determined by Glasgow Coma Scale (GCS) scores 3‐5]. Methods Weighted aSAH hospitalizations were retrospectively identified in the National Inpatient Sample from 2015 to 2019 and were stratified by tHH and modified HH (mHH) grades. mHH grade 5 was defined as tHH grade 5 with GCS score 3–5, while mHH grade 4 comprised tHH grade 5 with GCS score 6–8 and tHH grade 4. HH grades 1–3 do not differ between the traditional and modified scales. Measures of diagnostic performance were compared for the primary study end point [poor outcome as determined by the previously validated NIS‐SAH Outcome Measure (NIS‐SOM), shown to have high concordance with modified Rankin Scale scores > 2]. External validation of the mHH was performed using data from a prospectively maintained aSAH registry. Results Among 6130 aSAH hospitalizations, 2245 (36%) were tHH grade 5. Seven hundred and eighty‐five (35%) of these had a GCS 3–5 and were designated as mHH grade 5. Poor outcomes were identified in 78% and 77% of grade 4 tHH and mHH, respectively, and in 83% and 95% of grade 5 tHH and mHH, respectively. In comparison with the tHH, the mHH achieved superior discrimination [c‐statistic 0.793 (95% CI 0.768, 0.818) versus 0.780 (95% CI 0.750, 0.807); DeLong p < 0.001] for poor outcome, as well as improved specificity (0.929 versus 0.304) and positive predictive value (PPV) (0.949 versus 0.827). External registry validation of the mHH demonstrated excellent discrimination [c‐statistic 0.835 (95% CI 0.801, 0.870)], with a specificity of 0.950 and PPV of 0.905. Conclusion The mHH achieved a favorable diagnostic performance profile using retrospective data and may aid in the prognostication of high‐severity patients with aSAH.

As the incidence of subdural hematoma is increasing, it is important to understand symptomatology and clinical variables associated with treatment outcomes and mortality in this population; patients with subdural hematoma were selected from the National Inpatient Sample (NIS) Database between 2016 and 2020 using International Classification of Disease 10th Edition (ICD10) codes. Moderate-to-severe subdural hematoma patients were identified using the Glasgow Coma Scale (GCS). Multivariate regression was first used to identify predictors of in-hospital mortality and then beta coefficients were used to create a weighted mortality score. Of 29,915 patients admitted with moderate-to-severe subdural hematomas, 12,135 (40.6%) died within the same hospital admission. In a multivariate model of relevant demographic and clinical covariates, age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were independent predictors of mortality (p < 0.001 for all). Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were assigned a “1” in a weighted mortality score. The ROC curve for our model showed an area under the curve of 0.64. Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were predictive of mortality. We created the first clinically relevant weighted mortality score that can be used to stratify risk, guide prognosis, and inform family discussions.

Background In 2019 and 2020, 2 randomized trials of basilar artery occlusion (BAO) thrombectomy reported no improvement in functional outcomes with thrombectomy, despite observational evidence. The objective of this study was to assess whether neutral clinical trials may have influenced BAO thrombectomy practice. Methods The National Inpatient Sample (2018–2020) was queried for US patients with BAO, and comparisons were made between patients admitted in 2020 versus 2018 to 2019 for the primary outcome of thrombectomy. Unadjusted and adjusted multivariable regression was used, accounting for demographic and clinical covariates, with propensity‐score matching to balance clinical and hospital‐level characteristics between years. Results Of the 14 945 patients with BAO, 3,605 (24.1%) underwent thrombectomy,with an increase in the unadjusted rate of thrombectomy between 2020 and 2018–2019 (26.9% vs 22.9%, P = 0.04). Following multivariable adjustment, BAO thrombectomy was not independently associated with a year of treatment (adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 0.95–1.54, P = 0.12). Thrombectomy was independently associated with having a NIHSS of 10–19 (OR: 3.67, 95% CI: 2.79–4.83, P < 0.01) or >19 (OR: 5.80, 95% CI: 4.41–7.64) versus a NIHSS of 10, while uinsured patiends hadal owe likelihood of receiving a thombectomy (OR: 0.49, 95% C: 0.26–0.92). These relationships were preserved in the PSM cohort, and admission year lacked association with thrombectomy for BAO (aOR: 1.10, 95% CI: 0.83–1.45, P = 0.52). Conclusion Following publication of neutral BAO randomized clinical trials in late 2019 and 2020, there was no significant change in thrombectomy rate among US patients with BAO. The latest trials support thrombectomy for select patients with moderate‐to‐severe BAO symptoms, and this appears consistent with the practice of US clinicians before these trials.

Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only. Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only. Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

Introduction Endovascular thrombectomy (EVT) is the gold standard treatment for patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and there are several factors that can influence the outcomes of EVT in AIS‐LVO patients. We conducted this meta‐analysis to investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of EVT in patients with AIS caused by LVO. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included observational studies that recruited AIS‐LVO patients, used susceptibility‐sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The outcomes of interest included functional independence, revascularization success, and hemorrhagic adverse events. We conducted a meta‐analysis using the Mantel‐Haenszel method and calculated the risk ratios. Results Four studies involving 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome, as measured by the modified Rankin Scale (mRS), was observed in patients with CMBs (Risk Ratio (RR) 0.70, 95% Confidence Interval (CI): 0.53 ‐ 0.91, P=0.01). No significant differences were observed between the two groups in terms of successful revascularization (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), mortality (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), hemorrhagic transformation (RR 0.93, 95% CI [0.59 to 1.45], P=0.74), and parenchymal hematoma (RR 1.23, 95% CI [0.79 to 1.91], P=0.35). Conclusion The presence of CMBs significantly reduced the likelihood of achieving a favorable functional outcome after EVT in AIS‐LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic complications. Future research should explore the mechanisms of this association and strategies to mitigate its impact.

Introduction Due to the relative rarity of unruptured intracranial aneurysms (UIA) in the pediatric population, evidence regarding treatment modalities and clinical outcomes remains limited. This study aims to characterize the utilization and clinical outcomes of endovascular therapy (EVT) and microsurgical clipping (MSC) for pediatric UIAs over a two‐decade interval using a large national registry. Methods Pediatric (< 18 years of age) UIA hospitalizations were identified in the National Inpatient Sample from 2002 to 2019. Temporal utilization and clinical outcomes were compared for treatment with EVT and MSC. Results Among 734 UIAs identified during the study period, 64.9% (n = 476) were treated with EVT. Utilization of EVT significantly increased during the study period from 54.3% (2002‐2004) to 78.6% (2017‐2019) (p = 0.002 by Cochrane‐Armitage test). Treatment with EVT did not differ as a function of increasing age, but was mostly highly utilized in the youngest age grouping [70.4% (0‐2 years), 64.0% (3‐12 years), 64.3% (13‐17 years); p = 0.578]. In comparison with those treated with MSC, pediatric patients treated with EVT demonstrated higher rates of favorable outcomes (discharge to home without services) (96.0% vs. 91.1%, p = 0.006), shorter durations of hospital stay (4.6 vs. 10.0 days, p < 0.001), and lower rates of ischemic or hemorrhagic procedural‐related complications (1% vs. 4%, p = 0.010). Conclusion A retrospective evaluation of nearly twenty years of population‐level data from the United States demonstrates increasing utilization of EVT for the treatment of pediatric UIAs with high rates of favorable outcomes and shorter hospital stays in comparison to those treated with microsurgery. However, limitations of available registry data (such as absence of radiographic parameters and aneurysm morphological characteristics) temper any definitive claims regarding treatment efficacy.

Introduction Existing evidence remains conflicting regarding the association between oral hormonal contraceptive (OCP) use and the risk of acute ischemic stroke (AIS). Large‐scale analyses and observational data evaluating this clinical question in recent years are scarce, despite widespread use of hormonal contraception in adult females of child‐bearing age. Modern OCP formulations contain lower doses of estrogen, the putative causative agent for AIS in this population, and underscores the need to re‐evaluate the risk initially demonstrated in older formulations containing higher levels of estrogen. Methods Hospitalizations for female patients aged 15‐50 were identified in the National Inpatient Sample (NIS) registry from 2015‐2020, excluding admissions associated with pregnancy or the postpartum period. The study exposure was use of OCPs and the primary endpoint was AIS, identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) coding. Propensity score (PS) adjustment by inverse probability weighting (IPW) was used to mimic the effects of randomization by balancing baseline clinical characteristics associated with stroke between OCP and non‐OCP users to reduce measured confounding. In addition to age and race/ethnicity, a battery of more than forty confounding covariates representing established risk factors for AIS in the general and young population were identified (cardiovascular disease, lifestyle risk factors, congenital abnormalities, vasculopathies, hypercoagulable states, migraine with aura, among others) and balanced between OCP and non‐OCP users. Sensitivity testing was performed by evaluating stroke incidence in a sub‐group of patients without any risk factors present and by assessing a negative control (head trauma), with which an association of OCP use would not be expected. The effect size of the association between OCPs and AIS was presented as an adjusted odds ratio (aOR) with 95% confidence interval (CI), with statistical significance evaluated at p < 0.001. Results PS adjustment by IPW to balance all available AIS risk factors between OCP users and non‐users yielded 23,253,209 hospitalizations, 11,654,398 (50.1%) of which were associated with OCP use. The incidence of AIS was significantly greater in OCP users compared to non‐OCP users (2.8% vs. 0.4%; aOR 7.50, 95% CI 7.43 to 7.58; p < 0.001). Sub‐group analysis of hospitalizations without any stroke risk factors also demonstrated a significant association of OCP use with the development of AIS (1.3% vs. 0.1%; aOR 14.84, 95% CI 13.16 to 16.72; p < 0.001) following adjustment for age and race/ethnicity. In negative control analysis, OCP use was not associated with admissions associated with head trauma (1.4% vs. 1.4%; OR 1.03, 95% CI 0.95 to 1.10; p = 0.485). Conclusion Retrospective observational data from the United States in recent years suggests an association between OCP use and AIS, independent of well‐established risk factors for stroke and despite widespread adoption of lower estrogen formulations.

Introduction Virtual reality (VR) has shown great promise in stroke rehabilitation, providing interactive exercises that target motor and cognitive impairments with minimal adverse events and positive outcomes in improving motor function, balance, and patient motivation. However, most post‐stroke rehabilitation focuses on recovery after discharge, emphasizing the need for efficient interventions like VR to make the most of limited hospital rehab time for stroke survivors. This study aimed to evaluate the safety and feasibility of incorporating hyperacute virtual reality augmented rehabilitation (VRAR) as part of acute stroke care. Methods A prospective, proof‐of‐concept study was conducted with 13 eligible patients who experienced hemorrhagic or ischemic stroke between July 1st, 2021, and January 1st, 2022. Enrolled patients received VRAR in addition to the standard‐of‐care rehabilitation. Patients with dementia, expressive aphasia, delirium, or were unable to participate in physical therapy/ utilize the virtual reality hardware were excluded. Demographic data, functional scores, and complications were collected. Results Of the 13 patients who used the VRAR rehabilitation program, ten completed up to three visits. The cohort consisted of 50% male patients with a mean age of 73.6 years. Half of the patients had a primary diagnosis of ischemic stroke, while the rest were diagnosed with either hemorrhagic stroke (30%) or transient ischemic attack (20%). The mean length of hospital stay was 11.1 days, and the median time from admission to rehabilitation was 4 days. Most patients (80%) were discharged to outpatient rehabilitation, while 20% were discharged home. The median number of sessions was one, with four patients using the VRAR program multiple times. Despite the withdrawal of two patients (15.4%) who expressed mild discontent, there were no adverse events reported during the use of the VRAR rehabilitation program. Conclusion The findings of this study offer evidence backing the safety and feasibility of integrating VRAR as a supplementary tool in hyperacute stroke care. These results underscore the potential of VR therapy as a promising addition to conventional stroke rehabilitation methods.

Introduction Heparin‐induced thrombocytopenia (HIT) is a rare complication characterized by a decreased platelet count and hypercoagulability following heparin and light‐molecular weight heparin administration. Both anticoagulants can be used intraoperatively and postoperatively for DVT prophylaxis in patients undergoing subarachnoid hemorrhage (SAH) treatment. Patients with SAH are an understudied population in terms of assessing incidence and impact of HIT. This study aims to investigate the incidence, complications, and outcomes of SAH patients who develop HIT. Methods ICD‐9‐CM and ICD‐10‐CM codes were used to query the National Inpatient Sample for patients with SAH between 2010 and 2019. Subgroup analysis was stratified by HIT development. SAH severity was determined using the National Institute of Health Stroke Scale as a template. Patients from both groups were assessed for baseline clinical characteristics, comorbidities, interventions, complications, and outcomes. Cohorts containing ten or fewer patients must only be described qualitatively. Descriptive statistics, multivariate regressions, and propensity score‐matching were all performed using IBM SPSS 28. Results 76,387 patients were diagnosed with SAH between 2010 and 2019. 166 (.22%) had developed HIT in response to anticoagulant administration. The incidence of HIT was higher in patients who were younger (58.04 vs 61.39, p = 0.01), obese (0.4% vs 0.2%, p < 0.01), on long‐term anticoagulant use (10.84% vs 5.72%, p < 0.01), and had an implanted cerebrospinal fluid drainage device (p < 0.01). Patients with HIT were associated with higher SAH severity (1.42 vs 1.06, p < 0.01). Through both the complete cohort and propensity score‐matched cohort, patients with HIT were associated with higher rates of endovascular coiling, external ventricular drain placement (p < 0.01), and ventriculoperitoneal shunt placement (p < 0.01). HIT patients had significantly higher rates of deep vein thrombosis (p < 0.01), pulmonary embolism (p < 0.01), central venous sinus thrombosis (p = 0.01), pneumonia (p < 0.01), urinary tract infection (p < 0.01), acute kidney injury (p < 0.01), and cerebral vasospasm (p < 0.01). Patients who develop HIT had a longer length of stay (LOS) (24.04 vs 10.48, p < 0.01). HIT continued to be a significant predictor of having an above average LOS (OR: 6.799, CI: 3.985 ‐ 11.6, p < 0.01) when controlling for age, SAH severity, and significant comorbidities. Conclusion Our study revealed that younger SAH patients with various comorbidities are more prone to developing HIT, leading to higher rates of thrombotic events, acute kidney injury, and nosocomial infections, which can significantly prolong their hospital stay. Considering the extended postoperative recovery period for SAH, investigating the causes of HIT can facilitate earlier detection and prevention of thrombotic complications. This nationwide, multicenter, retrospective study provides valuable insights for clinicians on how to prevent and manage HIT in patients with subarachnoid hemorrhage.

Introduction Subarachnoid Hemorrhage (SAH) resulting from the spontaneous rupture of an aneurysm is a rare and highly debilitating condition. Despite its severity, patients with aneurysmal SAH remain understudied, particularly concerning the evaluation of the incidence and consequences of subsequent acute kidney injury (AKI). Thus, the objective of this study was to explore the predictors and ramifications of AKI in patients with aneurysmal SAH. Further research and attention to this area are crucial for improving patient outcomes and guiding clinical interventions in this challenging condition. Methods ICD‐10‐CM codes were used to query the National Inpatient Sample (NIS) for patients with AIS between 2010 and 2019. Subgroup analysis was stratified by the presence of a definitive AKI diagnosis. The AKI and non‐AKI groups were assessed for baseline clinical characteristics, interventions, complications, and outcomes. Descriptive statistics, multivariate regressions, and propensity score‐matching were all performed using IBM SPSS 28. Results 76,553 patients within the NIS were diagnosed with nontraumatic SAH between 2010 and 2019, of which 10,634 (13.89%) had a comorbid diagnosis of AKI. Patients with AKI were on average older (63.29 vs 61.07, p < 0.01), more often obese (12.15% vs 9.32%, p < 0.01), of the white race (55.82% vs 51%, p < 0.01), and considered long‐term users of anticoagulants (8.12% vs 5.34%, p < 0.01) when compared to the non‐AKI group. In terms of complications, patients within the AKI cohort had lower rates of decompressive hemicraniectomy (1.37% vs. 2.38%, p = 0.52) and, interestingly, cerebral vasospasms (4.47% vs. 8.22%, p < 0.01). However, AKI patients had higher rates of deep vein thrombosis (6.36% vs. 3.54%, p < 0.01), pulmonary embolism (4.22% vs. 1.42%, p < 0.01), pneumonia (21.39% vs. 8.84%, p < 0.01), urinary tract infection (19.07% vs. 13.32%, p < 0.01), sepsis (20.27% vs. 4.18%, p < 0.01), acute myocardial infarction (12.14% vs. 3.21%, p < 0.01), and cardiac arrest (10.25% vs. 3.23%, p < 0.01). In a multivariate regression assessing the impact of AKI on SAH outcome, this diagnosis was found to be independently correlated with poor functional outcome (OR: 3.306, CI: 3.11 – 3.513, p < 0.001) above average LOS (OR: 1.503, CI: 1.438 ‐ 1.571, p

Introduction Neurointervention has become one of the most competitive specialties in the United States due to the limited number of training spots, and a larger pool of applicants from different backgrounds: neurosurgery, neurology, and radiology. The training standards are continuously updated to ensure solid learning experiences, which ultimately factors in better outcomes and fewer complications. There is a move towards a structured competency assessment of training requirements via collaboration among several professional societies. However, the substantial drivers of candidate selection by program directors (PDs) have not been fully established yet. The goal of our study is to investigate the factors influencing the selection of fellowship candidates. Methods We distributed a 52‐question electronic survey via REDCap to 93 PDs. The questionnaire was divided into 5 categories: program characteristics; candidate demographics; educational credentials; personal traits; and research and extracurricular activities. The PDs were then asked to rank 5 pre‐selected factors from across all 5 categories. Each category included a subset of multiple‐choice questions to be graded as indicated for each category. Characteristics for these categories were scored from a range of 1 through 10 and means with standard deviations (SD) were calculated for each characteristic. Results Of the 93 PDs surveyed, 55 PDs filled the survey with a response rate of 59.1%. As per the programs’ characteristics, Neurosurgery was the most involved specialty in running the training programs (69.1%), followed by neurology (38.2%), and radiology (30.9%). Most programs were based in academic hospitals (87.3%, n=48/55). The most important criterion for candidate’s demographic characteristics was the need for visa sponsorship, followed by career gap and number of years from graduation from residency program, as summarized in Figure 1A. The most important criteria for educational credentials were being a graduate from a neurosurgical residency program (5.4 ± 2.9), and the institution where the candidate’s residency training is/was based (5.4 ± 2.5). Regarding the candidate’s personal traits, assessment by faculty members at the interview had the highest score (8.9 ± 1). In terms of research and extracurricular activities, fluency in English had the highest score (7.2 ± 1.9), followed by the number of peer‐reviewed/PubMed‐indexed publications (6.4 ± 2.2). Ranking of a final set of 5 characteristics from across all categories is summarized in Figure 1B, with knowledge of the candidate being the single most important contributing factor. Conclusion Neurointerventional training is open to candidates in neurosurgery, neurology, and radiology. To our knowledge, our survey is the first to investigate the factors that might be implicated in the final decision made by PDs when choosing the future neurointerventional trainee, including demographic, educational, research and extracurricular activities.

BACKGROUND: Intracerebral hemorrhage (ICH) carries significant morbidity and mortality. Previous single-center retrospective analysis suggests that end-stage renal disease (ESRD) is a risk factor for severe ICH and worse outcomes. This investigation aims to examine the impact of ESRD on ICH severity, complications, and outcomes using a multicenter national database. METHODS: The International Classification of Disease, Ninth and Tenth Revision Clinical Modification codes were used to query the National Inpatient Sample for patients with ICH and ESRD between 2010 and 2019. Primary endpoints were the functional outcome, length of stay (LOS), and in-hospital mortality. Multivariate variable regression models and a propensity-score matched analysis were established to analyze patient outcomes associated with baseline patient characteristics. RESULTS: We identified 211,266 patients with ICH, and among them, 7,864 (3.77%) patients had a concurrent diagnosis of ESRD. Patients with ESRD were younger (60.85 vs. 67.64, P < 0.01) and demonstrated increased ICH severity (0.78 vs. 0.77, P < 0.01). ESRD patients experienced higher rates of sepsis (15.9% vs. 6.15%, P < 0.01), acute myocardial infarction (8.05% vs. 3.65%, P < 0.01), and cardiac arrest (5.94% vs. 2.4%, P < 0.01). In addition, ESRD predicted poor discharge disposition (odds ratio [OR]: 2.385, 95% confidence interval [CI]: 2.227–2.555, P < 0.01), longer hospital LOS (OR: 1.629, 95% CI: 1.553–1.709, P < 0.01), and in-hospital mortality (OR: 2.786, 95% CI: 2.647–2.932, P < 0.01). CONCLUSIONS: This study utilizes a multicenter database to analyze the effect of ESRD on ICH outcomes. ESRD is a significant predictor of poor functional outcomes, in-hospital mortality, and prolonged stay in the ICH population.

Background and Purpose Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials. Methods We searched the National Readmission Database for LVO patients treated with MT between 2016–2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders. Results Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P

Background and Purpose Venous thromboembolism (VTE) is a life-threatening complication of stroke. We evaluated nationwide rates and risk factors for hospital readmissions with VTE after an intracerebral hemorrhage (ICH) or acute ischemic stroke (AIS) hospitalization. Methods Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included patients with a principal discharge diagnosis of ICH or AIS from 2016 to 2019. Patients who had VTE diagnosis or history of VTE during the index admission were excluded. We performed Cox regression models to determine factors associated with VTE readmission, compared rates between AIS and ICH and developed post-stroke VTE risk score. We estimated VTE readmission rates per day over a 90-day time window post-discharge using linear splines. Results Of the total 1,459,865 patients with stroke, readmission with VTE as the principal diagnosis within 90 days occurred in 0.26% (3,407/1,330,584) AIS and 0.65% (843/129,281) ICH patients. The rate of VTE readmission decreased within first 4–6 weeks (P

Background Flow diverters are now considered first‐line tools for treating intracranial aneurysms. However, few devices are available for patients with large‐diameter vessels (LDVs). Hence, we evaluated the performance of the largest diameter Surpass Streamline for aneurysms in LDVs. Methods We performed a subanalysis of the SESSIA (Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms) multicenter cohort study of patients treated with Surpass Streamline between 2018 and 2021. Patients in whom a 5‐mm diameter Surpass Streamline was implanted were divided into 2 groups according to vessel diameter at the landing zones (LDV, ≥5.3 mm versus non‐LDV [N‐LDV],

Background In patients undergoing mechanical thrombectomy for acute ischemic stroke, a few studies have compared transradial access (TRA) to transfemoral access (TFA) with inconsistent results. We conducted this systematic review and meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of TRA versus TFA in patients with acute ischemic stroke undergoing mechanical thrombectomy. Methods We performed a comprehensive literature search of 4 electronic databases from inception until May 1, 2022. After title and full text screening, relevant data were extracted and then analyzed. For outcomes that constituted continuous data, the mean difference between the 2 groups and its SD were pooled. For outcomes that constituted dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the 2 groups. Results Nine observational studies were included in this meta‐analysis. The population of the studies was homogenous comprising a total of 2161 patients undergoing mechanical thrombectomy, including 446 patients via TRA and 1715 patients via TFA. There were no significant differences across the 2 groups in terms of successful recanalization (OR, 0.83 [95% CI, 0.55–1.25]; P=0.36), complete recanalization (OR 1.16 [95% CI, 0.50–2.68]; P=0.73), favorable functional outcomes (OR, 0.86 [95% CI, 0.53–1.41]; P=0.56), first‐pass reperfusion (OR, 0.88 [95% CI, 0.64–1.19]; P=0.41), number of passes (mean difference, 0.12 [95% CI, −0.18 to 0.42]; P=0.43), access‐to‐reperfusion time (mean difference, −3.92 minutes [95% CI, −9.49 to 1.65]; P=0.17), or symptomatic intracranial hemorrhage (OR, 0.86 [95% CI, 0.47–1.57]; P=0.62). However, access site complications were significantly less frequent in the TRA group as compared with the TFA group (OR, 0.18 [95% CI, 0.06–0.51; P=0.001). Conclusion In patients undergoing mechanical thrombectomy for acute ischemic stroke, the collective evidence suggests that TRA seems to result in lower rates of access site complications than TFA without significant compromise in other clinical or procedural metrics. Randomized or prospective studies are warranted to confirm these results.

Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using “Subarachnoid hemorrhage AND frailty” and “subarachnoid hemorrhage AND frail” as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.

Introduction The safe and effective profile of flow diverters (FD) has allowed neuro‐interventionalists to consider them as a versatile tool for the treatment of aneurysms with different morphologies, locations, and characteristics. Optimal deployment with complete wall apposition affects FD performance. However, few devices are suitable for aneurysms in large caliber vessels. Herein, we aimed to describe the safety and efficacy of a large caliber (5 mm) FD for the treatment of intracranial aneurysms. Methods We performed a retrospective, multi‐center cohort study of adult patients in whom a 5 mm Surpass Streamline FD was implanted between 2018 and 2021 in the United States. Efficacy outcome was complete occlusion at final follow‐up. Safety outcomes were ischemic/hemorrhagic events and mortality up to 30 days following the procedure. Secondary safety was assessed by the rate of adjunctive devices/treatments to overcome technical complications and improve wall apposition. Results A total of 29 patients harboring 29 aneurysms were treated with 39 FDs (36 large‐diameter devices). Mean age was 57.8 ± 15.7 years. Aneurysm morphologies were saccular (n = 15), pseudoaneurysm (n = 7), fusiform (n = 6), and dissecting (n = 1). Locations were internal carotid artery (ICA) petro‐cavernous segment (n = 15), ICA paraophthalmic (n = 5), ICA cervical (n = 4), basilar artery (n = 3), and vertebral artery (n = 2). Aneurysm size mean was 11.4 ± 6.7 mm, and neck size mean 6.5 ± 3.9 mm. Proximal FD landing zone vessel diameter was 4.8 ± 1.3 mm and distal 4.5 ± 1.2 mm. At a mean final follow‐up of 12 ± 6 months, 18 (65%) aneurysms were completely occluded. Ischemic/hemorrhagic events occurred in 2 (7%), and 1 patient died during hospitalization. Balloon‐assisted angioplasty was performed in 19 (66%) cases, adjunctive stenting in 8 (28%), and coiling in 1 (3%). Patients who received an adjunctive device/treatment had an 82% (14/17) complete occlusion compared to 66% (4/6) in those who did not. Conclusions The use of large caliber FDs to treat complex intracranial aneurysms located in large‐diameter dysplastic vessels is technically feasible and safe. The use of adjunctive devices and techniques to achieve optimal wall apposition seems crucial to optimize treatment outcomes. Comparative studies with devices specially designed for this patient population might provide further insights into the best device selection.

Introduction Although intravenous thrombolysis (IVT) represents standard‐of‐care treatment for acute ischemic stroke (AIS) in eligible adult patients, definitive evidence‐based guidelines and randomized clinical trial data evaluating its safety and efficacy in the pediatric population remain absent from the literature. We aim to evaluate the utilization and outcomes of IVT for the treatment of pediatric AIS using a large national registry. Methods Weighted hospitalizations for pediatric (

Introduction Two recent trials demonstrated a benefit for endovascular thrombectomy (EVT) in the treatment of basilar artery occlusion (BAO). Considering the expected increase in the utilization of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists currently performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January to March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Results More than 3,000 participants were invited yielding 1,245 respondents, of which 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the PCA, without regard for prior IVT. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method with 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease (ICAD) etiology, combined stent retriever and aspiration thrombectomy was the preferred method with 40.5% of neurointerventionalists (Figure 1). The majority of neurointerventionalists (88.0%) would proceed to stenting after three or fewer failed passes for patients with BAO of ICAD etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Amongst the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to ICAD, the majority of neurointerventionalists were willing to stent and do so most often after three or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without ICAD.

Introduction In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and a computed tomography scanner may offer faster therapy with tissue plasminogen activator (tPA) for stroke patients who need immediate treatment. We conducted a systematic review and meta‐analysis to compare clinical outcomes in MSU patients to those in conventional care. Methods We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 days and 90 days. The secondary outcomes included modified Rankin scale (mRS) at 90 days, alarm to intravenous thrombolysis (IVT) or intra‐arterial recanalization, and time from symptom onset or last known well (LKW) to thrombolysis. Results We included nineteen controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90‐day mortality rate significantly declined in MSU group as compared to conventional care group (OR = 0.81, 95%CI [0.69,0.95]), while there was no significant difference at 7 days (OR = 0.88, 95%CI [0.68,1.15]). As regard achieving functional independence at 90 days (mRS = 0–2), MSU showed better results (OR = 1.24, 95%CI [1.03,1.49]). MSU was associated with shorter time from symptoms onset or LKW to thrombolysis (MD = ‐36.79, 95%CI [‐47.48, ‐26.10]) and alarm to IV thrombolysis or intra‐arterial recanalization (MD = ‐29.69, 95%CI [‐34.46, ‐24.92]). Conclusions Stroke patients treated in MSU had a lower incidence of the 90‐day mortality. They also had better functional independence at 90 days and time from symptom onset or LKW to thrombolysis than those treated with conventional care.

Introduction Previous studies have compared the transradial access (TRA) with the transfemoral access (TFA) in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We conducted this meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of the TRA versus the TFA in AIS patients undergoing MT. Methods We performed a comprehensive literature search of four electronic databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL) from inception until 1 May 2022. All duplicates were removed, and all references of the included studies were screened manually for any eligible studies. The full‐text articles of eligible abstracts were retrieved and screened for continued eligibility. Relevant data were extracted and then analyzed. For outcomes that constitute continuous data, the mean difference (MD) between the two groups and its standard deviation (SD) were pooled. For outcomes that constitute dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the two groups. Results Nine studies were included in this meta‐analysis, all of which were observational studies. The population of the studies was homogenous comprising a total of 2,161 patients who underwent MT, including 446 in the TRA group and 1,715 in the TFA group. There were no significant differences across the two groups in terms of successful recanalization (Thrombolysis in cerebral Infarction [TICI] score of 2b‐3: OR 0.83, 95% CI [0.55 to 1.25], P = 0.36) (Figure 1, A), complete recanalization (TICI 3: OR 1.16, 95% CI [0.50 to 2.68], P = 0.73), favorable functional outcome (90‐day modified Rankin scale [mRS] score of 0–2 (OR 0.86, 95% CI [0.53 to 1.41], P = 0.56), first‐pass reperfusion (OR 0.88, 95% CI [0.64 to 1.19], P = 0.41), number of passes (MD 0.12, 95% CI [‐0.18 to 0.42], P = 0.43) (Figure 1, B), access‐to‐reperfusion time (MD ‐3.92 minutes, 95% CI [‐9.49 to 1.65], P = 0.17), the amount of contrast used (MD 5.03 mL, 95% CI [‐20.27 to 30.33], P = 0.70), or symptomatic intracranial hemorrhage (OR 0.86, 95% CI [0.47 to 1.57], P = 0.62). However, access‐site complications were significantly less frequent in the TRA group as compared to the TFA group (OR 0.18, 95% CI [0.06 to 0.51], P = 0.001) (Finger 1, C). Conclusions In patients undergoing MT for AIS, the collective evidence suggests that the TRA seems to result in lower rates of access‐site complications than the TFA without any significant compromise in other clinical or procedural metrics. Large prospective studies are warranted.

Introduction Flow diverters (FDs) have demonstrated a safe and effective profile for the treatment of intracranial aneurysms with complex morphologies and variable anatomic locations. However, aneurysmal persistence after flow diversion still presents in up to 25% of treated aneurysms. Herein, we aimed to perform a pooled analysis of two large studies (SCENT [Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Neck Wide Neck Aneurysms] and SESSIA [Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms]) to evaluate the predictors of occlusion at final follow‐up after treatment with a 72–96 wire device. Methods We pooled all data from the SCENT (prospective) and SESSIA (retrospective) studies that included patients treated with the Surpass Streamline. From the studies, a subset of patients with unruptured saccular aneurysms located in the internal carotid artery (ICA) up to its terminus were included. The authors collected baseline demographics, comorbidities, aneurysm dimensions, and procedural and follow‐up characteristics for each patient. For our analysis, the outcome was complete aneurysm occlusion, as reported by the studies. We performed a multivariable logistic regression to identify the predictors of complete occlusion. Next, we performed a mediation analysis framework to identify the causal relationship of the predictors with the outcome. Finally, we calculated the predicted probability of occlusion for the continuous predictors. Results A total of 348 patients with 348 aneurysms were included, 394 devices were implanted (1.13 per patient). Median age was 61 [22‐85] years, and 83.6% were females. Hypertension was the most common comorbidity (57%) followed by hyperlipidemia (36%). The ICA paraophthalmic segment was the most common location (45%), followed by the petrocavernous (29%) and supraclinoid (25%). Median aneurysm size was 7.5 [1‐29] mm, and neck size was 4.3 [1‐23] mm. At the final follow‐up, the complete occlusion rate was 73% (255/348). After adjusting for confounders and accounting for collinearity, the multivariable analysis identified aneurysm size (OR 0.89; 95% CI 0.85‐0.93;p< .001), procedural technical events (OR 0.31; 95% CI 0.15‐0.65;p = .002), and first device length (OR 0.98; 95% CI 0.96‐1.00;p = .036) as predictors of complete occlusion. Age had a non‐significant direct effect on complete occlusion (p = .091) but a significant indirect effect mediated through aneurysm size (p< .001) and technical events (p< .02). Using our model, the predicted probability of occlusion is≥ 75% in aneurysms measuring < 10 mm when no technical events are encountered. However, when technical events are encountered, the probability decreases to 50–75%. Conclusions Successful aneurysm occlusion after flow diversion is associated with aneurysm size, procedural technical events, and FD length. Age does not directly affect occlusion, but its influence is mediated through the aneurysm size and technical events. Therefore, a priori knowledge of the patient and aneurysm characteristics might guide FD selection to favor the best treatment outcomes.

Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be associated with high rates of mortality and lifelong disability. In the past few years, two clinical trials (the BEST and the BASICS trials) investigated the benefits and safety of mechanical thrombectomy (MT) for BAO and did not provide evidence to support the efficacy of MT in BAO patients. Given the recent positive results from the ATTENTION and the BAOCHE clinical trials, we conducted this meta‐analysis to provide updated collective evidence regarding the benefits of MT in patients with BAO. Methods We searched for eligible papers till June 1st, 2021, in five databases: PubMed, Web of Science, Scopus, and Embase databases using keywords and/or medical subject (MeSH) terms. We included all randomized controlled trials (RCTs) with no restrictions on publication date, data, or language of the included studies to avoid missing any relevant papers. All data were analyzed using R software. We computed the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI), using a random‐effect model or fixed‐effect model depending on heterogeneity among the included studies. Heterogeneity was assessed with Q statistics and the I2 test considering it significant with I2 value > 50% or P‐value < 0.05. Results Four trials were included in this meta‐analysis, namely the BEST, the BASICS, the BAOCHE, and the ATTENTION trials. The four trials recruited a total of 988 patients. The MT group achieved a significantly higher rate of modified Rankin scale (mRS) score of 0–3 was as compared to the best medical treatment (BMT) one (RR = 1.54; 95% CI = 1.16‐2.04; P‐value = 0.002). Similarly, the mRS 0–2 rate was significantly higher in the MT group as compared to the BMT group (RR = 1.79; 95% CI = 1.09‐2.95; P‐value = 0.022). Nevertheless, heterogeneity was noticed amongst the included studies. Moreover, there was a significant reduction in the 90‐day mortality in the MT group as compared to the BMT group (RR = 0.76; 95% CI = 0.65‐0.89; P‐value = 0.002). On the other hand, there was a significantly higher rate of symptomatic intracerebral hemorrhage (sICH) in the MT group compared to the BMT group (RR = 7.48; 95% CI = 2.27‐24.61; P‐value< 0.001). There with no heterogeneity observed in both outcomes of mortality and sICH. Noted that there were no significant differences in overall parenchymal hemorrhage (PH) and type I PH rates, yet type II PH was more prevalent in the MT group compared to the BMT one (RR = 5.53; 95% CI = 1.47‐20.84; P‐value = 0.011). Conclusions The current evidence favors MT for basilar artery occlusions over the conservative approach in terms of achieving higher rates of good functional outcomes and decreasing mortality rates. Further large‐scale trials of different populations are needed to corroborate these results and also to ensure generalizability.

Introduction Public stroke education campaigns have traditionally utilized mass media. We hypothesized that a worldwide stroke awareness social media campaign, utilizing dance videos to express the BE‐FAST acronym for stroke signs and symptoms, could reach a large audience at a low cost. Methods Mission Thrombectomy 2020+ officially launched the #BEFASTChallenge, a Social Media (SoMe) public stroke educational campaign, on May 15, 2022, World Stroke Thrombectomy Day, after an internal “lead‐in” phase starting the first week of May 2022. The campaign was volunteer designed and implemented. The public and their followers were encouraged to post a video of their dance depicting each letter of BE‐FAST, tag the post with #BEFASTChallenge, and nominate others to participate. We tracked the SoMe posts from May 4th through July 13, 2022, on Facebook (FB), Twitter (TW), and Instagram (IG) platforms by searching #BEFASTChallenge on each SoMe site. We ascertained campaign adoption, public reach, and interaction by measuring original posts, views, likes, retweets, shares, and comments. Results There were 4 countries represented in the original posts on SoMe with the vast majority being from the US. The first post was on May 4, and the last was on July 13 (71 days), resulting in a daily average of 0.55 posts. The largest number of posts occurred on the launch date (16 posts). There were 39 original posts, which accumulated 170 retweets, 44 quote tweets, 755 likes, 32 comments, and 14 shares. The videos had 13,821views (Table 1). Conclusions We report that the preliminary analysis of a volunteer‐driven SoMe public stroke campaign utilizing dance to express stroke symptoms demonstrates feasibility, reaching a modest audience directly with good interaction. A similar professionally implemented SoMe campaign could lead to increased and more sustained user engagement to raise public stroke symptom awareness.

Introduction Patients with a psychiatric diagnosis have been shown to have higher rates of illness and premature death due to various diseases when compared to the general population [1]. Previous research has shown higher rates of stroke and lower rates of carotid endarterectomy/stenting for those with psychiatric disorders [2]. This study aimed to investigate differences in interventions and outcomes of patients with acute ischemic stroke (AIS) in those with and without psychiatric disorders. Methods We identified patients with AIS in the Nationwide Inpatient Sample (NIS) database using ICD‐9‐CM/ICD‐10‐CM codes, including a sub‐group of AIS patients with a co‐occurring psychiatric diagnosis. Psychiatric diagnosis included major depressive disorder, schizophrenia, bipolar disorder, and generalized anxiety disorder. Baseline demographic characteristics such as age, race, psychiatric disorder status, stroke severity, obesity, hypertension, diabetes, long term anticoagulant use, and COPD were assessed in both groups. Both groups were then evaluated for differences in rates of intervention (IV thrombolytic therapy and endovascular mechanical thrombectomy) as well as in‐hospital mortality and poor functional outcome, which was defined as discharge to long‐term rehabilitation facilities (skilled nursing facilities and hospice), subsequent placement of respiratory or alimentary tubes, or death. Results We identified 1,609,817 patients with acute ischemic stroke, of which 218,549 (13.5%) had a comorbid psychiatric condition. AIS patients with a psychiatric condition were more likely to have risk factors such as obesity, hypertension, tobacco use, and COPD. Patients with a psychiatric condition were less likely to be treated with mechanical thrombectomy (1.18% vs 1.33%, p < 0.01) as compared to those without a psychiatric condition. In the entire cohort, patients with a psychiatric condition had higher rates of poor functional outcome (61.25% vs 57.6%, p < 0.01). AIS patients with a psychiatric condition who were offered mechanical thrombectomy had lower rates of poor functional outcome (74.67% vs 81.04%, p < 0.01) and in‐hospital mortality (11.34% vs 15.45%, p < 0.01) than their non‐psychiatric condition counterparts. This decrease in poor functional outcome and mortality persisted with propensity score matching for baseline characteristics in the entire cohort, regardless of intervention offered. Conclusions To our knowledge, this is the first study to investigate treatments and outcomes of AIS patients with psychiatric conditions. Patients with psychiatric disorders were less likely to be treated with mechanical thrombectomy even when controlling for all baseline risk factors. In both the unadjusted and propensity score analysis, patients with psychiatric disorders who were offered mechanical thrombectomy had lower rates of poor functional outcome, suggesting the need for further investigation into the reasons for the disparities in treatment being offered. Exclusion of patients with psychiatric disorders in clinical trials should be reconsidered to better serve this population.

Introduction Mechanical thrombectomy (MT) is the gold standard for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although >70% of patients in the randomized clinical trials (RCTs) assessing the efficacy of MT for AIS‐LVO had successful recanalization, only up to 27% were free of disability according to the 90‐day modified Rankin scale (mRS) score. It is suggested that microcirculation disruption distal to the LVO might contribute to futile recanalization. Hence, combining intra‐arterial (IA) tissue plasminogen activator (tPA) with MT was investigated in a few studies in an attempt to reduce the burden of distal microthrombi and microcirculation disruption. We conducted this meta‐analysis to provide collective evidence in this regard. Methods We performed this meta‐analysis following the Preferred Reporting Items for Systematic Review and Meta‐Analyses statement recommendations. We aimed to include all original studies investigating the benefits of IA tPA in AIS patients undergoing MT.All screening and extraction stages were conducted by two authors, with a third author resolving any conflicts. Using R software, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). A fixed‐effect model was adopted to pool all data due to the absence of significant heterogeneity among the included studies. Heterogeneity was assessed using Q statistics and the I2test, where I2> 50% or P‐value < 0.05 were considered significant. Results Following the database search, a manual search of references, and different screening phases, we included 5 studies (2,686 patients) satisfying the predefined inclusion criteria. Successful recanalization rates were comparable between both groups. The 90‐day functional independence was reported in 4 studies (2,474 patients), with comparable rates between both groups (OR = 1.25; 95%CI = 0.92‐1.70; P‐value = 0.154). Mortality was reported in 3 studies (368 patients), with comparable rates between both groups (OR = 0.73; 95%CI = 0.44‐1.23; P‐value = 0.240). Symptomatic intracranial hemorrhage (sICH) was reported in 5 studies (2,678 patients) with no significant difference between the two groups (OR = 0.66; 95%CI = 0.34‐1.26; P‐value = 0.304). Conclusions The current evidence does not show any significant differences between MT alone versus MT plus IA tPA in terms of 90‐day functional independence, mortality, and sICH. With the limited number of studies and included patients, more studies are needed to investigate the benefits and safety of the combined MT and IA tPA.

Background Two recent trials demonstrated a benefit for endovascular therapy (EVT) in the treatment of basilar artery occlusion (BAO). In light of the expected increase in the use of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January and March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Responses from neurointerventionalists were analyzed. Results More than 3000 participants were invited yielding 1245 respondents, of whom 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the posterior cerebral artery, without regard for prior intravenous thrombolysis. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method of 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease etiology, combined stent retriever and aspiration thrombectomy was the preferred method of 40.5% of neurointerventionalists. The majority of neurointerventionalists (88.0%) would proceed to stenting after 3 or fewer failed passes for patients with BAO of intracranial atherosclerotic disease etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Among the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to intracranial atherosclerotic disease, the majority of neurointerventionalists were willing to stent and do so most often after 3 or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without intracranial atherosclerotic disease. Key Words

Background Pulmonary arteriovenous malformations (PAVM) are pathological connections between arterial and venous circulations in the lung. The anomalous channel provides a conduit for emboli of venous origin to migrate paradoxically. With access to systemic circulation, thromboembolic processes such as deep vein thrombosis may increase the risk of cerebrovascular accidents such as acute ischemic strokes (AIS). This retrospective cross‐sectional study aims to characterize the contribution of PAVMs to the development of AIS in the setting of thromboembolic processes. Methods The 2010 to 2019 National Inpatient Sample was queried for patients with PAVM and AIS using International Classification of Diseases, Ninth/Tenth Revision (ICD‐9; ICD‐10) codes. Baseline demographics and outcomes of interest, including complications and hospitalization metrics, were retrospectively analyzed. Results Of 7 465 187 patients treated for an AIS, 1 864 (0.02%) were found to have a concomitant PAVM. Multivariate regression found patients with AIS‐PAVM were more likely to be aged

Background The findings of the ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformation) trial, which determined that medical management was superior to prophylactic interventional therapy for the treatment of unruptured cerebral arteriovenous malformations (cAVMs), remain polarizing and controversial. Methods Adult cAVM patient admissions were identified in the National Inpatient Sample from 2009 to 2019. The incidence of cAVM rupture and in‐hospital mortality were compared between the pre‐ (2009–2013) and post‐ARUBA trial eras (2014–2019) using complex samples‐weighted estimates and multivariable logistic regression analyses. A control cohort composed of an alternate pathology (ruptured and unruptured cerebral aneurysms) was also assessed during the study period to evaluate potential bias. Results Among 121 415 hospitalizations for cAVM during the study period, 31 389 (25.9%) were admissions for ruptured malformations. The incidence of ruptured cAVM increased in the post‐ARUBA trial era (13.3% versus 34.4%; P

Abstract Delayed cerebral ischemia (DCI) secondary to vasospasm is a determinate of outcomes following non-traumatic subarachnoid hemorrhage (SAH). SAH patients are monitored using transcranial doppler (TCD) to measure cerebral blood flow velocities (CBFv). However, the accuracy and precision of manually acquired TCD can be operator dependent. The NovaGuide robotic TCD system attempts to standardize acquisition. This investigation evaluated the safety and efficacy of the NovaGuide system in SAH patients in a Neuro ICU. We retrospectively identified 48 NovaGuide scans conducted on SAH patients. Mean and maximum middle cerebral artery (MCA) CBFv were obtained from the NovaGuide and the level of agreement between CBFv and computed tomography angiography (CTA) for vasospasm was determined. Safety of NovaGuide acquisition of CBFv was evaluated based on number of complications with central venous lines (CVL) and external ventricular drains (EVD). There was significant agreement between the NovaGuide and CTA (Cohen’s Kappa = 0.74) when maximum MCA CBFv ≥ 120 cm/s was the threshold for vasospasm. 27/48 scans were carried out with CVLs and EVDs present without negative outcomes. The lack of adverse events associated with EVDs/CVLs and the strong congruence between maximal MCA CBFv and CTA illustrates the diagnostic utility of the NovaGuide.

Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.

The Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device for the treatment of wide-necked saccular cerebral aneurysms. As with any neuroendovascular device, complications in the form of malpositioning and migration must be managed quickly and safely. Few studies have reported complication management techniques in instances of dislocated or migrated WEB devices. We retrospectively describe a case of a malpositioned WEB device that was successfully adjusted with the use of a gooseneck snare. Multiple other intra-procedural bailout strategies for management of WEB malposition and migration were considered, and are herein discussed. Operators should be aware of the causes of WEB malposition and a variety of bailout strategies.

Background Cerebral venous thrombosis usually presents as dural sinus thrombosis. More rarely, it occurs in an isolated form (isolated cortical vein thrombosis; ICoVT). ICoVT is poorly recognized and underdiagnosed, and noninvasive imaging remains nebulous. The digital subtraction angiographic (DSA) patterns of ICoVT are neither well known nor documented. We present clinical and imaging details of the largest series of ICoVT, with all cases demonstrating both noninvasive imaging findings, along with angiographic confirmation. We propose a preliminary compilation of the DSA patterns of ICoVT. Methods We identified all patients with cerebral venous thrombosis at our institution between January 2013 and June 2019. Only patients in whom ICoVT was diagnosed and/or suspected with computed tomographic venography and/or magnetic resonance imaging/MR venogram with subsequent DSA confirmation were included. DSA imaging was reviewed for direct and indirect signs. Clinical data, outcomes, and follow‐up imaging were analyzed. Results We identified 109 patients with cerebral venous thrombosis; in 21 patients ICoVT was suspected on noninvasive imaging and eventually had DSA confirmation. Headache and focal neurological deficit were the most common presentations (each 67%). Ten patients (47%) presented with parenchymal changes due to ICoVT and 15 patients (71%) presented with subarachnoid hemorrhage. We identified 5 DSA patterns of ICoVT (3 direct; 2 indirect). Filling defects in cortical veins and the regional absence of cortical veins and decreased subcortical opacification were the most common patterns (52% and 90%, respectively). Sixteen patients (76%) were anticoagulated. Eighteen patients were discharged without disability or minor disability (84%). No deaths occurred. Conclusions Catheter angiography/venography may be important in diagnosing ICoVT, especially when magnetic resonance imaging/MR venogram is unclear. The angiographic patterns of ICoVT are presented.

(1) Background: Celiac disease (CD) can cause long-term inflammation and endothelial dysfunction and has been cited as a risk factor for acute ischemic stroke (AIS) in pediatric patients. However, the rate and outcomes of AIS in pediatric patients with CD has not been explored in a large population. Our objective is to explore the rate, severity, and outcomes of CD amongst pediatric AIS patients on a nationwide level. (2) Methods: The National Inpatient Sample (NIS) database was queried from 2016 to 2020 for pediatric patients with a principal diagnosis of AIS. Patients with a concurrent diagnosis of CD (AIS-CD) were compared to those without (AIS). Baseline demographics and comorbidities, clinical variables of severity, hospital complications, and the rates of tissue plasminogen activator (tPA) and mechanical thrombectomy were compared between the two groups. The main outcomes studied were mortality, discharge disposition, length of stay (LOS), and total hospital charges. (3) Results: Of 12,755 pediatric patients with a principal diagnosis of AIS, 75 (0.6%) had concurrent CD. There were no differences in the severity, discharge disposition, or mortality between the AIS-CD and AIS patients. Patients with AIS-CD were more likely to receive tPA at an outside hospital within 24 h of admission (p < 0.01) and more likely to undergo mechanical thrombectomy (p < 0.01) compared to the AIS patients. (4) Conclusions: CD patients made up only 0.6% of all pediatric AIS patients. No differences in the severity, mortality, or discharge disposition suggests a minimal to absent role of CD in the etiology of stroke. The CD-AIS patients were more likely to receive a tPA or undergo a mechanical thrombectomy; studies are needed to confirm the safety and efficacy of these interventions in pediatric patients.

Background The purpose of this study is to evaluate the impact multiple overlapping flow‐diverting stents have on aneurysm occlusion rates and iatrogenic complications relative to single flow‐diverting stents. Methods A retrospective review of a multicenter aneurysm database from 2012 to 2020 was performed to identify saccular aneurysms treated initially with single and multiple flow‐diverting stents with ≥12‐month angiographic and clinical follow‐up. Aneurysm occlusion rates as a function of stent number served as a primary outcome measure with iatrogenic complications serving as a secondary outcome measure. Results A total of 250 patients were initially treated with a single Pipeline embolization device (PED), and 48 patients were initially treated with multiple PEDs. There was no significant difference in aneurysm size, morphology, or dual‐antiplatelet therapy regimen used between groups. There was no significant difference in the aneurysm occlusion (single, 83.6%, versus multiple, 83.4%; P=0.65) or retreatment rates (single, 8.0%, versus multiple, 10.4%; P=0.58) between groups. There was no significant difference in the number of procedure‐related complications between groups (single, 8.0%, versus multiple, 4.2%; P=0.42), with 0.8% of patients treated with a single PED and 2.1% of patients treated with multiple PEDs experiencing a procedure‐related ischemic stroke. Conclusions There is no significant difference in overall aneurysm occlusion rates between aneurysms treated initially with single versus multiple overlapping PEDs nor are there significant differences in procedure‐related complications. Single PED flow diversion may be preferred whenever possible, with multiple PED constructs reserved for extenuating clinical circumstances as may be encountered with giant aneurysms.

Abstract Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric, acceptable in-hospital glucose ranges, or suitable insulin regimens in this population. In this single-center retrospective cohort study of aSAH patients, admission glucose, and hospital glucose mean (MHG), minimum (MinG), maximum (MaxG), and variability were compared. Primary endpoints (mortality, complications, and vasospasm) were assessed using multivariate logistic regressions. Of the 217 patients included, complications occurred in 83 (38.2%), 124 (57.1%) had vasospasm, and 41 (18.9%) died. MHG was independently associated with (p

INTRODUCTION: Anterior cerebral artery (ACA) aneurysms are commonly encountered in clinical practice but can be challenging to treat. Flow diversion is a viable treatment in this population. METHODS: We retrospectively evaluated patients treated at our center from May 2017 to December 2020 who underwent flow diversion for an ACA aneurysm at or distal to the anterior communicating artery (ACOM). We defined ACA aneurysms as any aneurysm involving the ACOM itself, at the junction of the ACA with the ACOM (A1/A2), or in distal A2/A3 branches; both ruptured and unruptured aneurysms were included. Baseline and follow-up clinical and angiographic data were collected; the primary measure was elimination of the aneurysm on follow-up angiogram. Patients underwent flow diversion with a Pipeline stent. A single flow diverting stent was placed in the dominant ACA spanning from the A2 segment extending into the A1 segment; two patients required H-pipe technique. Distal aneurysms were treated with a single Pipeline device deployed across the parent vessel, covering the aneurysm. RESULTS: Two-seven patients underwent a total of 28 flow diversion procedures; median age was 57 and 16 (59.3%) were male. Thirteen (48.2%) patients presented with subarachnoid hemorrhage; of these, four were treated within 6 weeks of the index hemorrhage. Most patients (22; 81.5%) had significant ACA asymmetry. There was one postoperative intracerebral hemorrhage and one groin complication. Follow-up data were available for 19 patients, 15 (78.9%) of which showed no residual aneurysm and 17 (89.5%) had protection of the dome. CONCLUSION: Flow diversion of ACA aneurysms can be a primary treatment modality in an unruptured aneurysm or a complement to initial coil protection of a ruptured aneurysm. Further studies are needed to confirm these results.

Background The rapidly changing treatment landscape for large vessel occlusion acute ischemic stroke, now more than ever, has added to the complexity of emergent decision making and the demand for neurointerventionists. Ensuring exposure of neurology trainees to neurointervention and the availability of well‐defined pathways for those interested in this career is crucial. Here we report the results from our large survey of neurology trainee attitudes toward neurointervention training. Methods An online survey targeting trainee impressions on the current state of vascular neurology, neurocritical care, and neurointervention training was conducted as a mandatory requirement for trainee registration in the Society for Vascular and Interventional Neurology Break meeting in April 2020. Quantitative results are reported in proportions, and qualitative results are described. Chi‐square test was used to determine association between categorical variables. Results Of the 725 respondents from 49 countries who participated in this conference, 450 (62%) were trainees. A total of 30% of trainees did not have access to neurointervention training, and 40% believed that neurology residency, vascular neurology, or neurocritical care fellowship do not adequately prepare them for a career in neurointervention. A total of 237/321 (73%) trainees whose institutional neurointervention practice included neurologists or a mix of subspecialty backgrounds including a neurologist had an opportunity to spend elective time in a neurology–angiography suite compared with 49/89 (55%) if the institutional neurointervention practice consisted of neurosurgeons or radiologists alone (P=0.001). A total of 49% of trainees each preferred the introduction of a mandatory or an elective neurointervention module during residency. A total of 60% of trainees preferred no to minimal exposure at the medical student level. Conclusions This international survey of trainees reinforces the existing gap in neurointervention exposure for neurology trainees. Inclusion of neurointervention faculty that come from a neurology training background and exposure to neurointervention will be crucial to support trainees interested in a neurointervention career pathway.

Background After MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) demonstrated that endovascular therapy improved outcomes in patients with stroke, the number of endovascular procedures has risen sharply. We describe acute transient contrast‐induced neurological deficit (ATCIND), a group of neurological syndromes associated with arterial contrast administration during angiography. Our goal is to elucidate the incidence, risk factors, outcomes, pathogenesis, and diagnostic characteristics of ATCIND. Our primary objective is to elucidate the incidence of ATCIND in the setting of coronary or cerebral angiography. Secondary outcomes include potential risk factors, demographics, treatment modalities, and patient recovery. Methods The data that support the findings of this study are available from the corresponding author on reasonable request. The databases of the Cochrane Library, MEDLINE, Web of Science, and Embase were queried, yielding studies from 1974 to 2021. Inclusion criteria for articles were the following: (1) contrast‐induced encephalopathy, contrast‐induced neurotoxicity, or cortical blindness after contrast administration during angiography were the focus of the article; (2) incidence was reported; (3) studies included ≥3 cases; and (4) follow‐up tests were described to rule out other causes. Exclusion criteria included the following: (1) incidence was not reported; (2) unavailable in the English language; (3) abstracts and unpublished studies; and (4) did not exclude other possible causes, or findings suggested other possible causes, such as worsening ischemic injury. Of 627 articles, 7 were retained. This systematic review with meta‐analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and the Meta‐Analysis of Observational Studies in Epidemiology (MOOSE) checklists. Independent extraction by multiple reviewers was performed. Data were pooled using a random‐effects model. Results The primary study outcome was incidence of ATCIND, which was formulated before data collection began. We hypothesized that the pooled incidence of ATCIND would be similar to that of individual studies. A total of 70 of 21007 patients had the diagnosis of contrast‐induced encephalopathy, contrast‐induced neurotoxicity or angiography‐associated cortical blindness, and ATCIND. The incidence rate of ATCIND is estimated to be 0.51% (CI, 0.3%–1.0%; P150 mL was a positive, significant predictor of visual disturbance (OR, 7.083; CI, 1.1742–42.793 [P=0.033]). Full recovery is estimated at 89.5% (95% CI, 76.9%–95.6%; P

Background Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. Methods We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. Results There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. Conclusions Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

Introduction: Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion (LVO) stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety and outcome of mechanical thrombectomy (MT) in acute FPCA occlusions. Methods: We performed a multi‐center retrospective review of consecutive patients who underwent MT of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure CT angiogram or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different LVO. Demographics, clinical presentation, imaging findings, endovascular treatment and outcome were reviewed. Results: There were twenty‐five patients with acute FPCA occlusion who underwent MT, distributed across 14 centers. Median NIHSS on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial CTA in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. TICI 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intra‐procedural complications. At 90 days, 48% (12/25) were functionally independent as defined by mRS≤2. Conclusions: Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the fetal posterior cerebral artery in patients presenting with anterior circulation stroke syndrome and patent anterior circulation.

Introduction: Comprehensive stroke centers require resource‐intensive patient care and supportive divisions. Resource underutilization can include: traditional beliefs about etiology of stroke, transportation barriers, or an inability to recognize early symptoms of stroke. We explore the available literature to determine region‐specific social and cultural barriers to obtaining stroke care. Methods: A literature review was performed to identify studies that described stroke care in low‐income and middle‐income countries (LMICs). We used the search term “stroke” along with the following terms: “burden”, “incidence”, “prevalence”, “awareness”, “transportation”, “stroke services”, “rehabilitation” “tissue plasminogen activator”, “acute stroke”, “emergency care”, “infrastructure”, “stroke services”, “quality improvement”, and “stroke units”, between January 1st, 2015 and August 1st, 2021. Forty‐five articles were identified. Results: We identified two broad limitations to expanding stroke care across the globe: infrastructure and education/ culture. We subdivided stroke care regionally into Middle East and North Africa (MENA), Europe, Asia, Latin America, and Subsaharan Africa. In MENA, religious health fatalism scores on questionnaires are negatively correlated with adherence to rehabilitative protocols and stroke outcome. Increased faith engagement conversely is strongly correlated with improved psychiatric outcome following stroke, indicating a role in properly educating Middle Eastern citizens regarding stroke etiology and urgency of treatment. In Europe stroke mortality and incidence is greater in rural areas in the region, likely indicating transit‐related difficulties in obtaining stroke care or deficits in education regarding lifestyle‐based measures to reduce vascular disease. Low per capita numbers of stroke‐specific care units in southern and eastern countries indicate a significant care access need in rural and low‐resource regions. For Asia, a lack of major infrastructure obstacles to wider accessibility of EVT, especially among developing countries. Only 6.5% in a nationwide survey in China were aware that there was a therapeutic window for thrombolytic therapy in 2016, increased to 32.8% after a 2 year nationwide campaign. The adept use of social media to target high‐risk populations can improve awareness of therapeutic windows. Ethnic and socioeconomic disparities are especially pronounced in this region. The RESILIENT trial demonstrated the effectiveness of EVT in Brazilian public hospitals, which helped convince the government to change policy and promote the use of EVT. Similar trials could be used to convince other governments to shift policy and promote the use of EVT as standard of care in public hospital systems. Some African communities consider stroke to be an illness of debilitating/ paralytic, ghost, or shivering etiology. Many communities rely on non medical means of care. A survey at Ignance Deen Neurology ward in 2014 revealed that only 2% of stroke patients arrived in an ambulance while 46% came by public transport and 27% arrived by personal car. Conclusions: Social and cultural barriers to obtaining stroke care are based on lack of availability and patient trust. Trust in care and compliance with preventive/rehabilitative measures may be helped by connecting NGOs such as Stroke Angels and Mission Thrombectomy 2020 with community‐based/ religious leaders to correct assumptions about origin and treatment. Targeted, culturally‐relevant messaging may help to increase awareness about symptoms, risk factors, and etiology.

Introduction: Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, there remain cases where recanalization fails due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transbrachial or transcarotid access may be considered as alternatives to the transfemoral or increasingly popular transradial route. Of these approaches, the transcarotid route has not gained prominence due to safety concerns despite its prior routine use in angiography. In this study, we conducted a systematic review and meta‐analysis of the literature in order to better summate the data on transcarotid access. Methods: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were used in order to perform a systematic review of articles published from 2010–2020 summarizing pre‐intervention characteristics of patients undergoing mechanical thrombectomy via transcarotid puncture. We performed a meta‐analysis focused on clinical outcomes, reperfusion times (in minutes), and overall complication rates of transcarotid access for mechanical thrombectomy. Pooled analyses were performed to examine predictors of complications and outcomes. Results: Six studies describing 72 patients, out of 80 attempts at carotid access (90% success rate), were included. Age ranged from the 5th to 9th decade (median 7.5). Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 4 to 28 (median 17). Direct carotid puncture was most often used as a rescue technique (86% of patients) secondary to failed femoral access. Successful recanalization was achieved in 85% of patients. Good 90‐day outcome (modified Rankin Scale ≤2) was achieved in 27% of patients. Median carotid puncture‐to‐reperfusion time was 32 minutes (CI = 24–40, p < 0.001). Cervical complications occurred at a rate of 23% (CI = 14– 35%, p < 0.001). Only one complication resulted in a fatal outcome and only one required an intervention (each 1.4%). Use of IV thrombolysis did not significantly predict better mTICI outcome. Complications were not predicted by use of IV thrombolysis or closure method. Carotid puncture as the primary access route was associated with significantly shorter procedure times and carotid puncture as a rescue route was associated with comparable procedure times to the classic femoral access route. Conclusions: Our results suggest that, despite current concerns about the use of transcarotid access, this technique can be considered a viable backup route in cases of failed transfemoral or transradial access. Though this method requires further research to better understand the variables that might play into clinical decision‐making for its use in acute stroke management, it is a promising area of study that could allow for thrombectomy in patients where it would otherwise be aborted.

Introduction: Flow diversion has established itself as standard treatment of wide complex intracranial aneurysms (IA). Its recognition has been validated with positive occlusion rates and favorable clinical outcomes. The Surpass Streamline (SS) flow diverter (FD) is a braided cobalt/chromium alloy implant with 72 or 96 wires approved by the FDA in 2018. The aim of this study is to determine the safety and efficacy of the SS in a post‐marketing large US cohort. Methods: We performed a multicenter, retrospective study for consecutive patients treated with the SS FD for IA between January 2018 and June 2021 in the United States. Inclusion criteria for participants were: 1. Adults (≥ 18 years) and 2. Treatment with SS FD for IA. Primary safety end point was a major ipsilateral stroke (increase in National Institutes of Health Stroke Scale Score of ≥ 4) or neurological death within 12 months. Primary efficacy was assessed using the 3‐point Raymond‐Roy (RR) occlusion scale on digital subtraction angiography (DSA) at 6‐12‐month follow‐up. Results: A total of 276 patients with 313 aneurysms were enrolled. The median age was 59 years and 199 (72%) were females. The most common comorbidities included hypertension in 156 (57%) subjects followed by hyperlipidemia in 76 (28%) patients. One hundred and twenty‐two (44%) patients were asymptomatic while subarachnoid hemorrhage was present in only 10 (4%) patients. A total of 143 (46%) aneurysms were left‐sided. Aneurysms were located as follows: 274 (88%) were in the anterior circulation with paraophthalmic being the most common in 120 (38%) followed by petrocavernous ICA in 81 (26%); 33 (11%) aneurysms were located in the posterior circulation with basilar trunk being the most common in 14 (5%). The mean maximum aneurysm dome width was 5.77 ± 4.7 mm, neck width 4.22 ± 3.8 mm and dome to neck ratio was 1.63 ± 1.3 mm. The mean number of SS FD implanted per aneurysm was 1.06 (range 1–3) with more than one SS FD implanted in 21 (7%) aneurysms. Modified Rankin Scale (mRS) of 0–2 was present in 206/213 (97%) patients at 6–12 month follow‐up. The complete aneurysm occlusion (RR 1) rate was 145/175 (83%) among subjects who had angiographic follow‐up at 6–12 months. Major stroke and death was encountered in 7 (2%) and 5 (1.8%) of the patients respectively. Conclusions: Our data represent the largest real‐world study using SS FD. These results corroborate its post‐marketing safety and efficacy for the treatment of intracranial aneurysms showing more favorable rates to the initial experience during SCENT trial.