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Background: Death certification is an integral part of physician practice, yet common errors are being encountered from this vital source of health information. Most medical training programs lack formal curricula for this important skill. Accurate information from DC will help in improve our mortality data which can be use public health purposes Objectives: This study evaluated the effect of a multifaceted educational intervention on accuracy of completing death certification in a tertiary-based paediatric residency program Method: A pre-post intervention and control cohort study over 12- month period to assess the effect of our multifaceted intervention accuracy rate of completed DC was conducted. The intervention consisted of a 3-part program (distribution of educational material, presentation by a skilled instructor, skills workshop, and clinical mortality/auditing feedback sessions). Primary outcome was the difference in scores preand post-intervention and also the rate of accuracy on the MAHI death certificate scoring system. Results: The mean score before the intervention was 6.8±2.7 and 7.1±2.3 in both the intervention and control cohorts respectively. The mean score after the intervention was 16.3±2.5 and 7.3±2.8 in both the intervention and control cohorts respectively indicating an increase in scores. The mean difference in pre- and post-tutorial scores was significant (t=20.39, p=0.0001). Conclusions: We found that using a multifaceted educational intervention to train junior physicians on how to correctly complete a DC was effective in a residency-based pediatric program

Abu-Zaied MA, Loutfy SA, Hassan AE, Elgemeie GH. Drug Des Devel Ther. 2019;13:2437–2457. The Editor and Publisher of Drug Design, Development and Therapy wish to retract the published article. Concerns were raised regarding the duplication of images in Figure 5. Specifically, Figure 5A, image for compound 4, appears to have been duplicated with Figure 5A, image for compound 8a. Figure 5B, image for compound 4, appears to have been duplicated with Figure 5B, image for compound 8a. In addition, the article was also found to contain a significant amount of overlap with a previously published and unreferenced article by the same authors: Elgemeie GH, Abu-Zaied MA, Loutfy SA. 4-Aminoantipyrine in carbohydrate research: Design, synthesis and anticancer activity of thioglycosides of a novel class of 4-aminoantipyrines and their corresponding pyrazolopyrimidine and pyrazolopyridine thioglycosides. Tetrahedron. 2017;73(40):5853-5861 (https://doi.org/10.1016/j.tet.2017.08.024). The authors did respond to our queries but were unable to provide a satisfactory explanation for the alleged image duplication or the overlap with the previously published article. The decision was made to retract the article and the authors were notified of this. Our decision-making was informed by our policy on publishing ethics and integrity and the COPE guidelines on retraction. The retracted article will remain online to maintain the scholarly record, but it will be digitally watermarked on each page as “Retracted”. This retraction relates to this paper

Mamdouh A Abu-Zaied,1 Samah A Loutfy,2,3 Ashraf E Hassan,2,4 Galal H Elgemeie41Green Chemistry Department, National Research Centre, Dokki, Giza, Egypt; 2Virology & Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt; 3Nanotechnology Research Center, British University, Cairo, Egypt; 4Chemistry Department, Faculty of Science, Helwan University, Helwan, Cairo, EgyptBackground: A series of novel pyrazolopyrimidine and pyrazololpyridine thioglycosides were synthesized and confirmed via their spectral analyses.Purpose: To evaluate the effect of these anti-metabolic compounds against proliferation of Huh-7 and Mcf-7 as in vitro models of human liver and breast cancers, respectively. Vero cells were used as an example of normal green monkey kidney cells.Methods: The most promising compound was subjected to a nanoformulation by its encapsulation into chitosan nanoparticles to increase its anti-cancerous activity. Nanoformulation was confirmed by TEM and FT-IR to ensure encapsulation and screened for their cytotoxicity against Huh-7 and Mcf-7 cells using MTT colorimetric assay and morphological examination. Genotoxic effect was performed by cellular DNA fragmentation assay. Simulated CompuSyn software (linear interaction effect) was conducted to predict the possible synergistic effect of nanocomposite as anticancerous activity. Apoptotic effect was further analyzed by detection of apoptotic proteins using ELISA assay.Results: The nano preparation was successfully prepared by encapsulation of compound 14 into chitosan nanoparticles, controlled to a size at 105 nm and zeta charges at 40.2 mV. Treatment of Huh-7 and Mcf-7 showed that compound 14 was the most cytotoxic compound on both cancer cell lines where IC50 was 24.59 (9.836 μg/mL) and 12.203 (4.8812 μg/mL) on Huh-7 and Mcf-7 respectively. But IC50 of the nano preparation was 37.19 and 30.68 μg/mL on Huh-7 and Mcf-7, respectively, indicating its aggressiveness on human breast cancer cells as confirmed by DNA fragmentation assay and theoretically by CompuSyn tool.Conclusion: A novel series of pyrazolopyrimidine thioglycosides and pyrazolopyridine thioglycosides were synthesized. Nanoformulation of compound 14 into chitosan nanoparticles demonstrated anticancer activity and can be used as a drug delivery system, but further studies are still required.Keywords: purine thioglycoside analogs, chitosan nanoparticles, human breast cancer cells, human liver cancer cells, anticancer agents, antimetabolites

Background: Recent trials confirmed the efficacy and safety of endovascular thrombectomy in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS); however, evidence in tandem lesions is limited. This study evaluates endovascular thrombectomy safety and efficacy in patients with acute large-vessel occlusion with tandem lesions, stratified by baseline ASPECTS., Methods and Results: We conducted a retrospective analysis of data from 16 centers. Inclusion criteria included the following: age ≥18 years, anterior circulation tandem lesions, endovascular thrombectomy <24 hours of symptom onset, and ≥70% internal carotid artery stenosis/occlusion. Patients were categorized into low (0-5) and high (6-10) ASPECTS. Inverse probability of treatment weighting matching was used to balance the groups. Primary outcomes included the following: 90-day modified Rankin Scale (mRS) score 0 to 2 and symptomatic intracranial hemorrhage. Secondary outcomes included the following: ordinal mRS, mRS 0 to 3, modified Thrombolysis in Cerebral Infarction ≥2b and 2c-3, petechial hemorrhage, parenchymal hematoma (1/2), early neurologic improvement, and mortality. Of 691 patients, 44 had ASPECTS 0 to 5 and 505 had ASPECTS 6 to 10. Patients with low ASPECTS had lower odds of 90-day mRS 0 to 2 (adjusted odds ratio [OR], 0.48; P =0.036) and higher odds of symptomatic intracranial hemorrhage (adjusted OR, 3.78; P =0.014). Additional significant differences were found in mRS shift, mRS 0 to 3, parenchymal hematoma 2, and mortality. In interaction analysis, the association between low ASPECTS and functional outcome persisted only in the internal carotid artery occlusion subgroup, with no significant interaction indicating no reason to suppose a difference between the effect of both subgroups., Conclusions: Endovascular thrombectomy in patients with tandem lesions with low ASPECTS is associated with reduced odds of functional recovery and increased symptomatic intracranial hemorrhage risk, when compared with patients with high ASPECTS. However, 30% of patients with low ASPECTS achieved 90-day functional independence, suggesting potential benefit for a nonnegligible proportion of patients.

Background: The volume of mechanical thrombectomy (MT) performed at hospitals is used as one of the criteria for advanced-level designation for stroke care., Objective: Our study sought to determine the relationship between annual MT procedural volume and in-hospital outcomes in acute ischemic stroke patients undergoing MT in the United States., Methods: We analyzed the National Inpatient Sample from 2016 to 2020. The hospitals were grouped into quartiles based on the volume of MT procedures performed within the calendar year. We compared the rates of routine discharge/home health care; in-hospital mortality, and post-treatment intracranial hemorrhage (ICH) between the quartiles after adjusting for potential confounders., Results: Patients undergoing MT ranged from 15,395 in quartile 1 to 78,510 MT in quartile 4. There were lower rates of discharge home/self-care of 22.5%, 20.8%, and 20.8% for quartiles 2, 3, and 4, respectively, compared with 34.9% in quartile 1. The odds of ICH increased to 1.81 ( p  < 0.001), 1.84 ( p  < 0.001), and 1.98 ( p  < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of home discharge/self-care decreased to 0.66 ( p  < 0.001), 0.60 ( p  < 0.001), and 0.63 ( p  < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of in-hospital mortality increased to 1.92 ( p  < 0.001), 1.99 ( p  < 0.001), and 1.84 ( p  < 0.001) among the quartiles from lowest to highest procedural volumes., Conclusions: We observed a paradoxical relationship between adverse outcomes and the annual procedural volume of MT at the hospital presumably due to the higher severity of acute ischemic stroke treated at high-volume hospitals., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The value of thrombectomy in patients with acute ischemic stroke cannot be understated. As such, whether these patients get access to this treatment can significantly impact their disease outcomes. We analyzed the trends in thrombectomy adoption between teaching and non-teaching hospitals in the United States, and their impact on overall patient care., Materials and Methods: We conducted a retrospective analysis of hospital admissions in the Nationwide Inpatient Sample with a diagnosis of acute ischemic stroke between 2012 and 2020. We compared the annual total number and proportion of patients undergoing thrombectomy between teaching and non-teaching hospitals, and their corresponding outcomes., Results: A total of 3,823,490 and 1,875,705 patients were admitted to teaching and non-teaching hospitals during the study duration, respectively. The proportion of patients who underwent thrombectomy increased from 1.60 % to 7.02 % (p-value for trend p < 0.001) in teaching hospitals and from 0.32 % to 2.20 % (p-value trend p < 0.001) in non-teaching hospitals. The absolute increase in the number of acute ischemic stroke patients undergoing thrombectomy was highest in teaching hospitals particularly those with large bed size, an increase from 3635 patients in 2012 to 24,730 patients in 2020. Higher rates of intravenous thrombolysis and patient transfer prior to thrombectomy were seen in teaching hospitals compared with non-teaching hospitals., Conclusions: The study highlights disparities between teaching and non-teaching hospitals, with teaching hospitals showing a disproportionately higher rate of thrombectomy adoption in acute ischemic stroke patients. Further studies are needed to understand the barriers to the adoption of thrombectomy in non-teaching hospitals., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Thanh Nguyen serves on the advisory boards for Aruna Bio and Brainomix, while also holding the position of Associate Editor at Stroke. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Endovascular thrombectomy (EVT) safety and efficacy in patients with large core infarcts receiving oral anticoagulants (OAC) are unknown. In the SELECT2 trial (NCT03876457), 29 of 180 (16%; vitamin K antagonists 15, direct OACs 14) EVT, and 18 of 172 (10%; vitamin K antagonists 3, direct OACs 15) medical management (MM) patients reported OAC use at baseline. EVT was not associated with better clinical outcomes in the OAC group (EVT 6 [4-6] vs MM 5 [4-6], adjusted generalized odds ratio 0.89 [0.53-1.50]), but demonstrated significantly better outcomes in patients without OAC (EVT 4 [3-6] vs MM 5 [4-6], adjusted generalized odds ratio 1.87 [1.45-2.40], p = 0.02). The OAC group had higher comorbidities, including atrial fibrillation (70% vs 17%), congestive heart failure (28% vs 10%), and hypertension (87% vs 72%), suggesting increased frailty. However, the results were consistent after adjustment for these comorbidities, and was similar regardless of the type of OACs used. Whereas any hemorrhage rates were higher in the OAC group receiving EVT (86% in OAC vs 70% in no OAC), no parenchymal hemorrhage or symptomatic intracranial hemorrhage were observed with OAC use in both the EVT and MM arms. Although we did not find evidence that the effect was due to excess hemorrhage or confounded by underlying cardiac disease or older age, OAC use alone should not exclude patients from receiving EVT. Baseline comorbidities and ischemic injury extent should be considered while making individualized treatment decisions. ANN NEUROL 2024;96:887-894., (© 2024 American Neurological Association.)

Objectives: Whereas highly cost-effective and cost-saving for patients with small infarcts, whether endovascular thrombectomy (EVT) remains cost-effective in patients with extensive ischemic injury is uncertain., Methods: We conducted a model-based cost-effectiveness analysis from the United States, Australian, and Spanish societal perspectives, using a 7-state Markov model, with each state defined by the modified Rankin Scale (mRS) score. Initial probabilities at 3 months were derived from the SELECT2 trial. All other model inputs, including transition probabilities, health care and non-health care costs, and utility weights, were sourced from published literature and government websites. Our analysis included extensive sensitivity and subgroup analyses., Results: EVT in patients with large ischemic stroke improved health outcomes and was associated with lower costs from a societal viewpoint. EVT was cost-effective with a mean between-group difference of 1.24 quality-adjusted life years (QALYs), and a cost-saving of $23,409 in the United States, $10,691 in Australia, and $30,036 in Spain, in addition to uncosted benefits in productivity for patients and carers. Subgroup analyses were directionally consistent with the overall population, notably with preserved cost-effectiveness in older patients (≥ 70 years) and those with more severe strokes (National Institutes of Health Stroke Scale [NIHSS] ≥ 20). Sensitivity analyses were largely consistent with the base-case results., Interpretation: EVT demonstrated cost-effectiveness in patients with large core across different settings in the United States, Australia, and Spain, including older patients and those with more severe strokes. These results further support adaptation of systems of care to accommodate the expansion of thrombectomy eligibility to patients with large cores and maximize EVT benefits. ANN NEUROL 2024., (© 2024 American Neurological Association.)

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

Background and Purpose: Intraarterial thrombolysis as an adjunct to mechanical thrombectomy is increasingly being considered to enhance reperfusion in acute ischemic stroke patients. Intraarterial thrombolysis may increase the risk of post-thrombectomy intracerebral hemorrhage (ICH) in certain patient subgroups., Methods: We analyzed acute ischemic stroke patients treated with mechanical thrombectomy in a multicenter registry. The occurrence of any (asymptomatic and symptomatic) post-thrombectomy ICH was ascertained using standard definition requiring serial neurological examinations and computed tomographic scans acquired within 48 hours of the thrombectomy. We determined the risk of ICH in subgroups defined by clinical characteristics and the use of intravenous (IV) thrombolysis., Results: A total of 146 (7.5%) patients received intraarterial thrombolysis among 1953 acute ischemic stroke patients who underwent mechanical thrombectomy. The proportion of patients who developed any ICH was 26 (17.8%) and 510 (28.2%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .006). The proportion of patients who developed symptomatic ICH was 4 (2.7%) and 30 (1.7%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .34). Among patients who received IV thrombolysis (n = 1042), the proportion of patients who developed any ICH was 9 (16.7%) and 294 (30.7%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .028). The risk was not different in strata defined by age, gender, location of occlusion, preprocedure National Institutes of Health Stroke Scale score, time interval between symptom onset and thrombectomy, Alberta Stroke Program Early CT Score, systolic blood pressure, and serum glucose concentrations., Conclusions: In patients undergoing mechanical thrombectomy, the risk of any ICH and symptomatic ICH was not increased with intraarterial thrombolysis, including in those who had already received IV thrombolytics., (© 2024 American Society of Neuroimaging.)

Background: Neuroblastoma is a highly lethal malignancy of young children. Mesenchymal stromal cells (MSCs) may represent a novel cellular delivery vehicle due to their innate tumor-homing properties. We compared in vivo homing abilities of placental-derived MSCs (PMSCs) and bone marrow-derived MSCs (BM-MSCs) in an orthotopic neuroblastoma xenograft., Methods: 28 mice underwent direct implantation of neuroblastoma cells (cell line NB1643) into the adrenal gland followed by intraperitoneal injection of 5 × 10 6 MSCs (PMSC n = 13, BM-MSC n = 13, PBS controls n = 2). MSC migration was monitored with in vivo imaging system (IVIS) radiance measurements at multiple timepoints post-MSC injection. Necropsy timepoints were 72 h (n = 10) and 7 days (n = 16). Ex vivo imaging was performed on all adrenal masses and select organ tissues. Immunohistochemistry (IHC) assessed the presence of MSCs in tumors., Results: IVIS demonstrated initial diffuse signal that migrated to the left abdomen. Radiance decreased over time, but MSC signal persisted at day 7 in all animals. Ex vivo IVIS demonstrated signal in the adrenal tumor but not other organs. There was no significant difference in average ex vivo adrenal mass radiance between MSC groups (p = 0.74). IHC confirmed presence of both MSC types within the tumor., Conclusion: PMSCs and BM-MSCs successfully migrated to neuroblastoma tumor tissues in vivo without evidence of migration to other organs. MSCs migrate within 72 h and persisted within the tumor up to 7 days. There was no significant difference in homing capabilities of PMSCs compared to BM-MSCs, indicating that either cell type has potential as a drug delivery vehicle., Type of Study: Original Research., Level of Evidence: n/a., (Copyright © 2024 Elsevier Inc. All rights reserved.)

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

Background: Intracranial atherosclerotic disease (ICAD) is one of the most prevalent causes of stroke across the world. Endovascular treatment has gained prominence but remains a challenge with unfavorable results. Recent literature has demonstrated that the Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) is a technically safe option with low complication rates along with 30-day outcomes associated with intracranial stent placement for ICAD with RO-ZES compared to results from the Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Here, we aim to compare outcomes at one year with the SAMMPRIS trial with a multicenter longitudinal study., Materials and Methods: Prospectively maintained databases across seven stroke centers were analyzed for adult patients undergoing RO-ZES placement for ICAD between January 2019 and May 2023. The primary endpoint was composite of one-year stroke, ICH, and/or death. These data were propensity score matched using age, sex, hypertension, diabetes mellitus, smoking status, and impacted vessel for comparison between RO-ZES and the SAMMPRIS percutaneous angioplasty and stenting groups (S-PTAS)., Results: A total of 104 patients were included, mean age ± SD: 64.9 ± 10.9 years, 25.5% female. Propensity score match analysis of the 104 patients with S-PTAS demonstrated one-year stroke, ICH, and/or death rate of 11.5% in the RO-ZES group and 28.1% in the S-PTAS group (odds ratio 4.17, 95% CI 2.06-8.96, p = 0.001)., Conclusion: The RO-ZES system demonstrates strong potential to reduce long-term complications at one year compared with the S-PTAS group. Further prospective multicenter studies are needed to corroborate and build upon these findings., Competing Interests: Declaration of conflicting interestsDr Burkhardt is a consultant for Stryker, Microvention, Q'Apel, Longeviti, Cerenovus, Phenox, and Medtronic. Dr Jabbour is a consultant for Medtronic, Microvention, and Cerus Endovascular. Stavropoula I. Tjoumakaris is a consultant for Medtronic/Microvention. Dr Siddiqui has the following disclosures: Financial Interest/Investor/Stock Options/Ownership: Adona Medical, Inc, Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc, Cerebrotech Medical Systems, Inc, CerevatechMedical, Inc, CognitionMedical, CVAID Ltd, E8, Inc, Endostream Medical, Ltd, Galaxy Therapeutics, Inc, Imperative Care, Inc, InspireMD, Ltd, Instylla, Inc, International Medical Distribution Partners, Launch NY, Inc, Neurolutions, Inc, NeuroRadial Technologies, Inc, NeuroTechnology Investors, Neurovascular Diagnostics, Inc, Peijia Medical, PerFlow Medical, Ltd, Q'Apel Medical, Inc, QAS.ai, Inc, Radical Catheter Technologies, Inc, Rebound Therapeutics Corp (purchased in 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc (purchased in 2020 by Medtronic), Sense Diagnostics, Inc, Serenity Medical, Inc, Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, Inc, StimMed, LLC, Synchron, Inc, Three Rivers Medical, Inc, Truvic Medical, Inc, Tulavi Therapeutics, Inc, Vastrax, LLC, VICIS, Inc, Viseon, Inc; Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc, Boston Scientific, Canon Medical Systems USA, Inc, Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc, Cerenovus, Cerevatech Medical, Inc, Cordis, Corindus, Inc, Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc, Peijia Medical, Penumbra, Q'Apel Medical, Inc, Rapid Medical, Serenity Medical, Inc, Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc, VasSol, Viz.ai, Inc; National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFTDIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial. Dr Grandhi is a consultant for Balt, Medtronic Neurovascular, and Cerenovus. Dr Qureshi received consultation fees from AstraZeneca. Dr Hassan is a consultant/speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, RapidMedical, Imperative Care, and Galaxy Therapeutics; is the principal investigator for the COMPLETE study—Penumbra, and LVOSYNCHRONISE—Viz.ai; is a member of the steering committee/publication committee for SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI; and DSMB for the COMAND trial. Other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Background and Objectives: Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs., Methods: This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion., Results: A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome., Discussion: In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.

Background: Endovascular treatment with the woven endobridge (WEB) device has been widely utilized for managing intracranial aneurysms. However, predicting the probability of achieving adequate occlusion (Raymond-Roy classification 1 or 2) remains challenging., Objective: Our study sought to develop and validate a predictive calculator for adequate occlusion using the WEB device via data from a large multi-institutional retrospective cohort., Methods: We used data from the WorldWide WEB Consortium, encompassing 356 patients from 30 centers across North America, South America, and Europe. Bivariate and multivariate regression analyses were performed on a variety of demographic and clinical factors, from which predictive factors were selected. Calibration and validation were conducted, with variance inflation factor (VIF) parameters checked for collinearity., Results: A total of 356 patients were included: 124 (34.8%) were male, 108 (30.3%) were elderly (≥65 years), and 118 (33.1%) were current smokers. Mean maximum aneurysm diameter was 7.09 mm (SD 2.71), with 112 (31.5%) having a daughter sac. In the multivariate regression, increasing aneurysm neck size (OR 0.706 [95% CI: 0.535-0.929], p  = 0.13) and partial aneurysm thrombosis (OR 0.135 [95% CI: 0.024-0.681], p  = 0.016) were found to be the only statistically significant variables associated with poorer likelihood of achieving occlusion. The predictive calculator shows a c -statistic of 0.744. Hosmer-Lemeshow goodness-of-fit test indicated a satisfactory model fit with a p -value of 0.431. The calculator is available at: https://neurodx.shinyapps.io/WEBDEVICE/., Conclusion: The predictive calculator offers a substantial contribution to the clinical toolkit for estimating the likelihood of adequate intracranial aneurysm occlusion by WEB device embolization., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: We aimed to assess the impact of time to endovascular thrombectomy (EVT) on clinical outcomes in the DAWN trial, while also exploring the potential effect modification of mode of stroke onset on this relationship., Methods: The association between every 1-h treatment delay with 90-day functional independence (modified Rankin Scale [mRS] score 0-2), symptomatic intracranial hemorrhage, and 90-day mortality was explored in the overall population and in three modes of onset subgroups (wake-up vs. witnessed vs. unwitnessed)., Results: Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6 to 12 hours and 12 to 24 hours time window, respectively. Considering all three modes of onset together, there was no statistically significant association between time last seen well to randomization with either functional independence or mortality at 90 days in either the endovascular thrombectomy (mRS 0-2 1-hour delay OR 1.07; 95% CI 0.93-1.24; mRS 6 OR 0.84; 95% CI 0.65-1.03) or medical management (mRS 0-2 1-hour delay OR 0.98; 95% CI 0.80-1.14; mRS 6 1-hour delay OR 0.94; 95% CI 0.79-1.09) groups. Moreover, there was no significant interaction between treatment effect and time (p = 0.439 and p = 0.421 for mRS 0-2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between time last seen well to successful reperfusion (modified Treatment in Cerebral Infarction ≥2b) and 90-day functional independence showed a significant interaction with mode of presentation (p = 0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p = 0.018) negative slope in wake-up patients. There was no association between treatment times and symptomatic intracranial hemorrhage., Interpretation: Mode of onset modifies the effect of time to reperfusion on thrombectomy outcomes, and should be considered when exploring different treatment paradigms in the extended window. ANN NEUROL 2024;96:356-364., (© 2024 American Neurological Association.)

Objective: We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT)., Methods: This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality., Results: Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009)., Interpretation: Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355., (© 2024 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: Neuroblastoma is a common pediatric malignancy with poor survival for high-risk disease. Mesenchymal stromal cells (MSCs) have innate tumor-homing properties, enabling them to serve as a cellular delivery vehicle, but MSCs have demonstrated variable effects on tumor growth. We compared how placental MSCs (PMSCs) and bone marrow-derived MSCs (BM-MSCs) affect proliferation of neuroblastoma (NB) cells in vitro., Methods: Indirect co-culture assessed proliferative effects of 18 MSCs (early-gestation PMSCs (n = 9), term PMSCs (n = 5), BM-MSCs (n = 4) on three high-risk NB cell lines (NB1643, SH-SY5Y, and CHLA90). Controls were NB cells cultured in media alone. Proliferation was assessed using MTS assay and measured by fold change (fc) over controls. PMSCs were sub-grouped by neuroprotective effect: strong (n = 7), intermediate (n = 3), and weak (n = 4). The relationship between MSC type, PMSC neuroprotection, and PMSC gestational age on NB cell proliferation was assessed., Results: NB cell proliferation varied between MSC groups. BM-MSCs demonstrated lower proliferative effects than PMSCs (fc 1.18 vs 1.44, p < 0.001). Neither gestational age nor neuroprotection significantly predicted degree of proliferation. Proliferative effects of MSCs varied among NB cell lines. BM-MSCs had less effect on CHLA90 (fc 1.01) compared to NB1643 (fc 1.33) and SH-SY5Y (fc 1.20). Only NB1643 showed a difference between early and term PMSCs (p = 0.04)., Conclusion: Effects of MSCs on NB cell proliferation vary by MSC source and NB cell line. BM-MSCs demonstrated lower proliferative effects than most PMSCs. MSC neuroprotection was not correlated with proliferation. Improved understanding of MSC proliferation-promoting mechanisms may provide valuable insight into selection of cells best suited as drug delivery vehicles., Level of Evidence: N/A., Type of Study: Original Research., (Published by Elsevier Inc.)

Objective: Symptomatic intracerebral hemorrhage (sICH) after stroke is a devastating neurological complication. Current guidelines support a "possible benefit" of decompressive craniectomy (DC) for large supratentorial sICH with significant mass effect., Methods: The authors conducted a retrospective study of 8 comprehensive stroke centers. They included all patients who sustained an sICH after acute ischemic stroke (AIS), as defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), from January 2016 to December 2020. They compared patients who underwent DC to those who were treated with standard medical treatment to measure functional outcome at 90 days, primarily as defined by the modified Rankin Scale (mRS) and secondarily by the Glasgow Outcome Scale-Extended (GOS-E)., Results: Eighty-five patients were identified, 26 of whom (30.5%) underwent DC. Patients who underwent DC were younger (58 years [DC] vs 76 years [no DC], p < 0.001). No patient with a previous history of cancer underwent DC (n = 14, p = 0.004). Twenty-five patients (96.2%) in the DC group underwent thrombectomy versus 54 (91.5%) in the non-DC group (p = 0.443). Patients who underwent DC had a longer ICU stay (median [IQR] 240 [38-408] hours vs 24 [5-96] hours in non-DC patients, p = 0.002). At 90 days, 3 patients (4.1%) had obtained an mRS score of 0-2 and 10 patients (11.7%) an mRS score of 0-3. Patients who had improved functional outcome were younger (mRS score, OR 1.06, 95% CI 1.01-1.10, p = 0.012). Patients with a history of cancer had worse 90-day mRS scores (OR 8.49, 95% CI 1.54-159, p = 0.046). The rate of in-hospital mortality or discharge to hospice was significantly higher in the non-DC cohort (10 [38.5%] patients in the DC cohort vs 38 [64.4%] in the non-DC cohort, p = 0.026). Ninety days later, patients who underwent DC were more likely to have improved outcome (mRS mean rank 30.0 vs 40.0, p = 0.027). In multivariable analysis, history of cancer (OR 12.2, 95% CI 1.26-118, p = 0.031) and older age (OR 1.07, 95% CI 1.02-1.13, p = 0.011) increased the odds of worse mRS outcomes while DC did not (OR 1.34, 95% CI 0.357-5.03, p = 0.665)., Conclusions: DC after sICH did not improve functional outcome at 90 days according to multivariable analysis, although younger age and absence of previous cancer history were associated with improved outcomes.

Background Irritable bowel syndrome (IBS) continues to pose significant healthcare challenges due to its broad differential diagnosis and the often extensive yet inconclusive workup. We investigated the rates and characteristics of unplanned 30-day readmissions in adult patients hospitalized with IBS. In addition, we identified factors that predict readmission within 30 days of initial discharge. Methods We analyzed the 2020 Nationwide Readmission Database. Using the International Classification of Diseases, Tenth Revision, Clinical Modification code, we identified hospitalizations in adult patients with IBS. We excluded hospitalizations for minors and planned or elective readmissions. To compare baseline characteristics between readmissions and index hospitalizations, χ2 tests were employed. We used multivariate Cox regression analyses to identify independent predictors of readmissions. Results A total of 5,729 adult hospitalizations with IBS as the primary diagnosis were discharged alive, and 638 (11.1%) readmissions occurred within 30 days. The most common diagnoses associated with readmission were noninfective gastroenteritis and colitis, sepsis, enterocolitis due to Clostridium difficile , and irritable bowel syndrome with or without diarrhea. Patients in readmissions had a mean age of 56.3 years, similar to index hospitalizations (54.5 years, p=0.093). Readmissions had a higher burden of comorbidity (Charlson comorbidity index (CMI) scores ≥3: 26.7%, 170 cases vs. 16.6%, 953 cases; p<0.001) and were mostly Medicare beneficiaries (49.5%, 316% vs. 44.9%, 2,578) compared with index hospitalizations. Readmissions had a longer mean length of stay (LOS) (5.2 vs. 3.6 days, p<0.0001), higher inpatient mortality (0.8%, 5% vs. 0.2%, 11; p=0.032), and higher mean hospital costs ($47,852 vs. $34,592; p<0.0001) compared with index admissions. Secondary diagnoses of ulcerative colitis (adjusted hazard ratio (AHR), 2.82; p<0.0001), interstitial cystitis (AHR, 5.37; p=0.007), peripheral vascular disease (AHR, 1.59; p=0.027), and discharge to short-term hospitals (AHR, 1.03; p<0.0001) were significantly associated with a higher likelihood of readmission within 30 days. Conclusion IBS readmissions have poorer outcomes than index hospitalizations. Patients with an existing history of ulcerative colitis, interstitial cystitis, and peripheral vascular disease and those discharged to short-term hospitals following index hospitalization are more likely to be readmitted within 30 days., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ugboke et al.)

Purpose: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA., Methods: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability., Results: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac., Conclusions: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background and Purpose: Automated CTP postprocessing packages have been developed for managing acute ischemic stroke. These packages use image processing techniques to identify the ischemic core and penumbra. This study aimed to investigate the agreement of decision-making rules and output derived from RapidAI and Viz.ai software packages in early and late time windows and to identify predictors of inadequate quality CTP studies., Materials and Methods: One hundred twenty-nine patients with acute ischemic stroke who had CTP performed on presentation were analyzed by RapidAI and Viz.ai. Volumetric outputs were compared between packages by performing Spearman rank-order correlation and Wilcoxon signed-rank tests with subanalysis performed at early (<6 hours) and extended (>6 hours) time windows. The concordance of selecting patients on the basis of DAWN and DEFUSE 3 eligibility criteria was assessed using the McNemar test., Results: One hundred eight of 129 patients were found to have adequate-quality studies. Spearman rank-order correlation coefficients were calculated on time-to-maximum >6-second volume, time-to-maximum >10-second volume, CBF <30% volume, mismatch volume, and mismatch ratio between both software packages with correlation coefficients of 0.82, 0.65, 0.77, 0.78, 0.59, respectively. The Wilcoxon signed-rank test was also performed on time-to-maximum >6-second volume, time-to-maximum >10-second volume, CBF <30% volume, mismatch volume, and mismatch ratio with P values of .30, .016, <.001, .03, <.001, respectively. In a 1-sided test, CBF <30% was greater in Viz.ai ( P  < .001). Although this finding resulted in statistically significant differences, it did not cause clinically significant differences when applied to the DAWN and DEFUSE 3 criteria. A lower ejection fraction predicted an inadequate study in both software packages ( P  = .018; 95% CI, 0.01-0.113) and ( P  = .024; 95% CI, 0.008-0.109) for RapidAI and Viz.ai, respectively., Conclusions: Penumbra and infarct core predictions between Rapid and Viz.ai correlated but were statistically different and resulted in equivalent triage using DAWN and DEFUSE3 criteria. Viz.ai predicted higher ischemic core volumes than RapidAI. Viz.ai predicted lower combined core and penumbra values than RapidAI at lower volumes and higher estimates than RapidAI at higher volumes. Clinicians should be cautious when using different software packages for clinical decision-making., (© 2024 by American Journal of Neuroradiology.)

Background and Purpose: Despite the numerous studies evaluating the occlusion rates of aneurysms following WEB embolization, there are limited studies identifying predictors of occlusion. Our purpose was to identify predictors of aneurysm occlusion and the need for retreatment., Materials and Methods: This is a review of a prospectively maintained database across 30 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB who had available intraprocedural data and long-term follow-up., Results: We studied 763 patients with a mean age of 59.9 (SD, 11.7) years. Complete aneurysm occlusion was observed in 212/726 (29.2%) cases, and contrast stasis was observed in 485/537 (90.3%) of nonoccluded aneurysms. At the final follow-up, complete occlusion was achieved in 497/763 (65.1%) patients, and retreatment was required for 56/763 (7.3%) patients. On multivariable analysis, history of smoking, maximal aneurysm diameter, and the presence of an aneurysm wall branch were negative predictors of complete occlusion (OR, 0.5, 0.8, and 0.4, respectively). Maximal aneurysm diameter, the presence of an aneurysm wall branch, posterior circulation location, and male sex increase the chances of retreatment (OR, 1.2, 3.8, 3.0, and 2.3 respectively). Intraprocedural occlusion resulted in a 3-fold increase in the long-term occlusion rate and a 5-fold decrease in the retreatment rate ( P < .001), offering a specificity of 87% and a positive predictive value of 85% for long-term occlusion., Conclusions: Intraprocedural occlusion can be used to predict the chance of long-term aneurysm occlusion and the need for retreatment after embolization with a WEB device. Smoking, aneurysm size, and the presence of an aneurysm wall branch are associated with decreased chances of successful treatment., (© 2024 by American Journal of Neuroradiology.)

Background: Tandem lesions consist of cervical internal carotid artery (ICA) stenosis or occlusion, most commonly of atherosclerosis or dissection etiology, plus a large vessel occlusion. In this study, we compare outcomes in patients with atherosclerosis versus dissection of the cervical ICA., Methods: This multicenter retrospective cohort study includes data from tandem lesion patients who underwent endovascular treatment from 2015 to 2020. Atherosclerosis was defined as ICA stenosis/occlusion associated with a calcified lesion and dissection by the presence of a tapered or flame-shaped lesion and intramural hematoma. Primary outcome: 90-day functional independence (modified Rankin Scale score, 0-2); secondary outcomes: 90-day favorable shift in the modified Rankin Scale score, modified Thrombolysis in Cerebral Infarction score 2b-3, modified Thrombolysis in Cerebral Infarction score 2c-3, symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, distal embolization, early neurological improvement, and mortality. Analysis was performed with matching by inverse probability of treatment weighting., Results: We included 526 patients (68 [59-76] years; 31% females); 11.2% presented dissection and 88.8%, atherosclerosis. Patients with dissection were younger, had lower rates of hypertension, hyperlipidemia, diabetes, and smoking history. They also exhibited higher rates of ICA occlusion, multiple stents (>1), and lower rates of carotid self-expanding stents. After matching and adjusting for covariates, there were no differences in 90-day functional independence. The rate of successful recanalization was significantly lower in the dissection group (adjusted odds ratio, 0.38 [95% CI, 0.16-0.91]; P =0.031), which also had significantly higher rates of distal emboli (adjusted odds ratio, 2.53 [95% CI, 1.15-5.55]; P =0.021). There were no differences in other outcomes. Acute ICA stenting seemed to increase the effect of atherosclerosis in successful recanalization., Conclusions: This study reveals that among patients with acute stroke with tandem lesions, cervical ICA dissection is associated with higher rates of distal embolism and lower rates of successful recanalization than atherosclerotic lesions. Using techniques to minimize the risk of distal embolism may mitigate this contrast. Further prospective randomized trials are warranted to fully understand these associations., Competing Interests: Disclosures A.E. Hassan reports compensation from Penumbra, Inc, for consultant services; employment by Valley Baptist Medical Center; compensation from Cerenovus for consultant services; compensation from Medtronic for consultant services; compensation from viz AI for consultant services; compensation from MicroVention, Inc, for consultant services; compensation from Stryker Corporation for consultant services; and compensation from GE Healthcare for consultant services. Dr Divani reports employment by the University of New Mexico. Dr Abraham reports compensation from Penumbra, Inc, for consultant services; compensation from Stryker Corporation for consultant services; and compensation from Q’Apel for consultant services. Dr Fifi reports compensation from Cerenovus for consultant services; compensation from Mivi for data and safety monitoring services; employment by Mount Sinai Health System; compensation from MicroVention, Inc, for consultant services; compensation from Stryker Corporation for consultant services; grants from viz AI; stock holdings in Imperitive Care; compensation from Penumbra, Inc, for consultant services; and compensation from Medtronic for consultant services. Dr Siegler reports grants from Philips and viz AI. Dr Nguyen reports compensation from Brainomix for consultant services; compensation from Aruna for consultant services; and compensation from the American Stroke Association for other services. Dr Sheth reports compensation from viz AI for consultant services; compensation from Imperative Care, Inc, for consultant services; employment by UTHealth McGovern Medical School; compensation from Motif Neurosciences for other services; compensation from Penumbra, Inc, for consultant services; and grants from the National Institutes of Health. Dr Yoo reports compensation from Vesalio for consultant services; grants from Genentech USA, Inc, to other services; compensation from the National Institutes of Health for data and safety monitoring services; compensation from Rapid Medical, Ltd, for consultant services; stock holdings in Galaxy Therapeutics; compensation from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. for consultant services; compensation from ZOLL Circulation, Inc, for consultant services; grants from Medtronic to other services; employment by HCA Healthcare; grants from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. to other services; grants from Penumbra, Inc, to other services; stock holdings in Insera; compensation from Nicolab for consultant services; compensation from Penumbra, Inc, for consultant services; grants from Stryker to other services; stock options in Nicolab; compensation from Philips for consultant services; compensation from the American Heart Association for other services. Dr De Leacy reports compensation from Stryker Corporation for consultant services; stock holdings in endostream; stock holdings in Spartan Micro; stock holdings in Synchron; stock holdings in Q’Apel; compensation from Imperative Care, Inc, for consultant services; stock holdings in Vastrax; and compensation from Johnson & Johnson for consultant services. Dr Mokin reports stock holdings in QAS.AI; compensation from MicroVention, Inc, for consultant services; compensation from Balt USA, LLC for consultant services; stock holdings in Serenity Medical; stock holdings in Bendit Technology; compensation from Medtronic for consultant services; compensation from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. for consultant services; stock holdings in Borvo Medical; stock holdings in BrainQ; stock holdings in Quantanosis.AI; compensation from Rapid Pulse for consultant services; stock holdings in Sim&Cure; stock holdings in Synchrone; stock holdings in Radical Catheter Technologies; and stock holdings in Endostream. Dr Yavagal reports stock options in Rapid Medical; compensation from Stryker Corporation for consultant services; compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; stock holdings in Athersys; compensation from Poseydon for consultant services; compensation from Gravity Medical Technology for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Athersys for consultant services; compensation from Vascular Dynamics for consultant services; and stock options in Poseydon. Dr Ribo reports stock holdings in Methinks; stock holdings in Anaconda Biomed; compensation from Philips for consultant services; compensation from Stryker Corporation for consultant services; stock holdings in Nora; compensation from Cerenovus for consultant services; compensation from AptaTargets for consultant services; and compensation from Medtronic MiniMed, Inc, for consultant services. Dr Jovin reports employment by Cooper University Healthcare; stock options in Gravity; compensation from Johnson & Johnson Cerenovus for data and safety monitoring services; stock options in Anaconda; stock options in Route92; stock options in Galaxy; stock options in Methinks; stock options in viz AI; stock options in StataDx; stock options in Basking; compensation from Contego Medical, Inc, for consultant services; stock options in Freeox Biotech; stock options in Kandu; grants from Stryker Corporation; and grants from Medtronic USA, Inc. Dr Ortega-Gutierrez reports grants from MicroVention, Inc; grants from Siemens; grants from the National Institutes of Health; compensation from Medtronic for consultant services; compensation from Stryker for consultant services; compensation from MicroVention, Inc, for consultant services; grants from Methinks; grants from the National Institutes of Health; grants from Stryker; and employment by Carver College of Medicine–University of Iowa. The other authors report no conflicts.

Background: While mechanical thrombectomy (MT) is proven to be lifesaving and disability sparing, there remains a disparity in its access in low- to middle-income countries. We hypothesized that team-based MT workshops would improve MT knowledge and skills., Methods: We designed a 22-hour MT workshop, conducted as 2 identical events: in English (Jamaica, January 2022) and in Spanish (Dominican Republic, May 2022). The workshops included participating neurointerventional teams (practicing neurointerventionalists, neurointerventional nurses, and technicians) focused on acute stroke due to large vessel occlusion. The course faculty led didactic and hands-on components, covering topics from case selection and postoperative management to device technology and MT surgical techniques. Attendees were evaluated on stroke knowledge and MT skills before and after the course using a multiple choice exam and simulated procedures utilizing flow models under fluoroscopy, respectively. Press conferences for public education with invited government officials were included to raise stroke awareness., Results: Twenty-two physicians and their teams from 8 countries across the Caribbean completed the didactic and hands-on training. Overall test scores (n=18) improved from 67% to 85% ( P <0.002). Precourse and postcourse hands-on assessments demonstrated reduced time to completion from 36.5 to 21.1 minutes ( P <0.001). All teams showed an improvement in measures of good MT techniques, with 39% improvement in complete reperfusion. Eight teams achieved a Thrombolysis in Cerebral Infarction score of 3 on pre-course versus 15 of 18 teams on post-course. There was a significant reduction in total potentially dangerous maneuvers (70% pre versus 20% post; P <0.002). Universally, the workshop was rated as satisfactory and likely to change practice in 93% Dominican Republic and 75% Jamaica., Conclusions: A team-based hands-on simulation approach to MT training is novel, feasible, and effective in improving procedural skills. Participants viewed these workshops as practice-changing and instrumental in creating a pathway for increasing access to MT in low- to middle-income countries., Competing Interests: Disclosures Dr Inoa reports compensation from MicroVention, Inc, for consultant services; compensation from Medtronic for consultant services; compensation from Cerenovus for consultant services; employment by Semmes Murphey Clinic; compensation from Siemens for consultant services; compensation from Vizai for consultant services; compensation from Penumbra, Inc, for consultant services; and grants from Medtronic. Dr Fraser reports compensation from Penumbra, Inc, for consultant services; an ownership stake in Fawkes Biotechnology; employment by University of Kentucky; compensation from Medtronic for consultant services; compensation from Imperative Care, Inc, for data and safety monitoring services; an ownership stake in Cerelux; compensation from CereVasc, Inc, for consultant services; and compensation from Stream Biomedical for consultant services. Dr Martins reports compensation from Novo Nordisk for other services; compensation from Novartis for other services; compensation from Boehringer Ingelheim for other services; compensation from Daiichi Sankyo Company for other services; compensation from Penumbra, Inc, for other services; compensation from Servier Affaires Medicales for other services; compensation from Pfizer for other services; compensation from Medtronic for other services; and compensation from Bayer for other services. Dr Elijovich reports compensation from MIVI for consultant services; compensation from Corindus, Inc, for consultant services; compensation from Balt USA, LLC for consultant services; compensation from Vizai for consultant services; compensation from Stryker Corporation for consultant services; compensation from Medtronic MiniMed, Inc, for consultant services; compensation from MicroVention, Inc, for consultant services; compensation from Cerenovus for consultant services; and compensation from Scientia Vascular for consultant services. A.E. Hassan reports compensation from Medtronic for consultant services; employment by Valley Baptist Medical Center; compensation from MicroVention, Inc, for consultant services; compensation from Cerenovus for consultant services; compensation from Stryker Corporation for consultant services; compensation from GE Healthcare for consultant services; compensation from Penumbra, Inc, for consultant services; and compensation from Vizai for consultant services. Dr Ortega-Gutierrez reports compensation from Medtronic for consultant services; compensation from Stryker for consultant services; grants from MicroVention, Inc; grants from Stryker; grants from Siemens; grants from methinks; grants from National Institutes of Health; compensation from MicroVention, Inc, for consultant services; grants from the National Institutes of Health; and employment by Carver College of Medicine–University of Iowa. Dr Yavagal reports compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; compensation from Stryker Corporation for consultant services; stock options in Rapid Medical; compensation from Poseydon for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Athersys for consultant services; compensation from Vascular Dynamics for consultant services; stock holdings in Athersys; compensation from Gravity Medical Technology for consultant services; and stock options in Poseydon. The other authors report no conflicts.

Importance: Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH., Objective: To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis., Design, Setting, and Participants: This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021., Exposures: Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke., Main Outcome Measures: sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages., Results: Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P < .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86)., Conclusions and Relevance: Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.

Introduction: This study is the first multicentric report on the safety, efficacy, and technical performance of utilizing a large bore (0.081″ inner diameter) access catheter in neurovascular interventions., Methods: Data were retrospectively collected from seven sites in the United States for neurovascular procedures via large bore 0.081″ inner diameter access catheter (Benchmark BMX81, Penumbra, Inc.). The primary outcome was technical success, defined as the access catheter reaching its target vessel. Safety outcomes included periprocedural device-related and access site complications., Results: There were 90 consecutive patients included. The median age of the patients was 63 years (IQR: 53, 68); 53% were female. The most common interventions were aneurysm embolization (33.3%), carotid stenting (12.2%), and arteriovenous malformation embolization (11.1%). The transradial approach was most used (56.7%), followed by transfemoral (41.1%). Challenging anatomic variations included severe vessel tortuosity (8/90, 8.9%), type 2 aortic arch (7/90, 7.8%), type 3 aortic arch (2/90, 2.2%), bovine arch (2/90, 2.2%), and severe angle (<30°) between the subclavian artery and target vessel (1/90, 1.1%). Technical success was achieved in 98.9% of the cases (89/90), with six cases requiring a switch from radial to femoral (6.7%) and one case from femoral to radial (1.1%). There were no access site complications or complications related to the 0.081″ catheter. Two postprocedural complications occurred (2.2%), unrelated to the access catheter., Conclusion: The BMX™ 81 large-bore access catheters was safe and effective in both radial and femoral access across a wide range of neurovascular procedures, achieving high technical success without any access site or device-related complications., Competing Interests: Declaration of conflicting interestsThe author(s) have disclosed any potential conflicts of interest regarding the research, authorship, and publication of this article in the disclosure section.

Background: Vasospasm and delayed cerebral ischemia (DCI) are the leading causes of morbidity and mortality after intracranial aneurysmal subarachnoid hemorrhage (aSAH). Vasospasm detection, prevention and management, especially endovascular management varies from center to center and lacks standardization. We aimed to evaluate this variability via an international survey of how neurointerventionalists approach vasospasm diagnosis and endovascular management., Methods: We designed an anonymous online survey with 100 questions to evaluate practice patterns between December 2021 and September 2022. We contacted endovascular neurosurgeons, neuroradiologists and neurologists via email and via two professional societies - the Society of NeuroInterventional Surgery (SNIS) and the European Society of Minimally Invasive Neurological Therapy (ESMINT). We recorded the physicians' responses to the survey questions., Results: A total of 201 physicians (25% [50/201] USA and 75% non-USA) completed the survey over 10 months, 42% had >7 years of experience, 92% were male, median age was 40 (IQR 35-46). Both high-volume and low-volume centers were represented. Daily transcranial Doppler was the most common screening method (75%) for vasospasm. In cases of symptomatic vasospasm despite optimal medical management, endovascular treatment was directly considered by 58% of physicians. The most common reason to initiate endovascular treatment was clinical deficits associated with proven vasospasm/DCI in 89%. The choice of endovascular treatment and its efficacy was highly variable. Nimodipine was the most common first-line intra-arterial therapy (40%). Mechanical angioplasty was considered the most effective endovascular treatment by 65% of neurointerventionalists., Conclusion: Our study highlights the considerable heterogeneity among the neurointerventional community regarding vasospasm diagnosis and endovascular management. Randomized trials and guidelines are needed to improve standard of care, determine optimal management approaches and track outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The purpose of this study was to report our initial experience of using a large-bore (0.096″ inner diameter) access catheter in neurovascular interventions., Methods: Data were retrospectively collected from 5 sites in the US for neurovascular procedures performed using a large-bore access catheter. The effectiveness outcome was technical success, defined as the access catheter's successfully reaching its target vessel without conversion to direct carotid puncture or to a smaller-bore access catheter and successfully completing the intended neurointervention., Results: One hundred and thirteen procedures performed in 112 patients were included in this study. The mean age of the patients was 67.5 years (SD 16.2), and about half (49.1%) were female. The most common primary access sites were the femoral (64.6%) or radial (32.7%) artery. Challenging anatomic variations included severe vessel tortuosity (26/81, 32.1%), type II aortic arch (17/88, 19.3%), type III aortic arch (14/88, 15.9%), bovine arch (16/104, 15.4%), severe angle (<30°) between the subclavian and target vessel (11/74, 14.9%), and subclavian loop (7/79, 8.9%). The median access time to branch view was 18 min (IQR 11-28, N = 75). The technical success rate was 94.7%. Two dissections (1.8%) were related to the large-bore access catheter. Access site complications occurred in 2 patients (1.8%). Four additional symptomatic periprocedural complications not related to the large-bore access catheter occurred (7.1%)., Conclusion: For neurovascular interventions, a 0.096″ inner diameter access catheter could be used with both femoral and radial arterial approaches, had a high technical success rate, and had a low rate of periprocedural complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Robert M Starke: Research supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Unrestricted research grant from Medtronic. Consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, and Optimize Vascular. Isaac Josh Abecassis: Consulting agreements with IschemaView (Rapid) and Remedy Robotics. Equity with Remedy Robotics. Vasu Saini: Nothing to disclose. Charles C Matouk: Consultant for Penumbra, Stryker, Microvention-Terumo, and Silk Road Medical. Paid speaker for Penumbra and Silk Road Medical. Ameer E Hassan: Consultant/Speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera Therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care and Galaxy Therapeutics. Principal Investigator for COMPLETE study (Penumbra) and LVO SYNCHRONISE (Viz.ai). Steering Committee/Publication committee member for SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, and DELPHI. Data and Safety Monitoring Board for COMAND trial Adnan H Siddiqui: Current Research Grants: Co-investigator for NIH - 1R01EB030092-01, Project Title: High Speed Angiography at 1000 frames per second; Mentor for Brain Aneurysm Foundation Carol W. Harvey Chair of Research, Sharon Epperson Chair of Research, Project Title: A Whole Blood RNA Diagnostic for Unruptured Brain Aneurysm: Risk Assessment Prototype Development and Testing. Financial Interest/Investor/Stock Options/Ownership: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd., BlinkTBI, Inc, Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd., E8, Inc., Endostream Medical, Ltd, Galaxy Therapeutics, Inc., Imperative Care, Inc., InspireMD, Ltd., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., Neurolutions, Inc., NeuroRadial Technologies, Inc., NeuroTechnology Investors, Neurovascular Diagnostics, Inc., Peijia Medical, PerFlow Medical, Ltd., Q'Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (Purchased 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc. (Purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd., Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Q'Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc. National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial. Donald F Frei: Consultant and speakers bureau for Penumbra.

Objective: The placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive improvement of aneurysm occlusion after treatment-with low complication and rupture rates-has led to a dilemma regarding the management of aneurysms in which occlusion has not occurred within 6-24 months. The authors aimed to identify clinical consensus regarding management of intracranial aneurysms displaying persistent filling 6-24 months after flow diversion and to ascertain questions that may drive future investigation., Methods: An international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion., Results: Of the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter., Conclusions: The authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.

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

Background: Endovascular thrombectomy improves outcomes and reduces mortality for large vessel occlusion (LVO) and is time-sensitive. Computer automation may aid in the early detection of LVOs, but false values may lead to alarm desensitization. We compared Viz LVO and Rapid LVO for automated LVO detection., Methods: Data were retrospectively extracted from Rapid LVO and Viz LVO running concurrently from January 2022 to January 2023 on CT angiography (CTA) images compared with a radiologist interpretation. We calculated diagnostic accuracy measures and performed a McNemar test to look for a difference between the algorithms' errors. We collected demographic data, comorbidities, ejection fraction (EF), and imaging features and performed a multiple logistic regression to determine if any of these variables predicted the incorrect classification of LVO on CTA., Results: 360 participants were included, with 47 large vessel occlusions. Viz LVO and Rapid LVO had a specificity of 0.96 and 0.85, a sensitivity of 0.87 and 0.87, a positive predictive value of 0.75 and 0.46, and a negative predictive value of 0.98 and 0.97, respectively. A McNemar test on correct and incorrect classifications showed a statistically significant difference between the two algorithms' errors (P=0.00000031). A multiple logistic regression showed that low EF (Viz P=0.00125, Rapid P=0.0286) and Modified Woodcock Score >1 (Viz P=0.000198, Rapid P=0.000000975) were significant predictors of incorrect classification., Conclusion: Rapid LVO produced a significantly larger number of false positive values that may contribute to alarm desensitization, leading to missed alarms or delayed responses. EF and intracranial atherosclerosis were significant predictors of incorrect predictions., Competing Interests: Competing interests: HCA Healthcare has a minority equity stake in VIZ.ai and also purchases products from the company for use in its facilities. AH is a consultant and a speaker for Viz.ai, which develops the Viz LVO algorithm that we tested, and he is also involved in a study sponsored by Viz.ai called the LVO Synchronise Study, which looks at the impact of a Viz LVO implementation on patient timing and outcomes. Our other authors do not have any direct conflicts of interest. In the interest of full disclosure, here is a list of conflicts of related companies that are in a related field that we do not believe directly impact this study. YA has stock in Sanavention inc. ME has stock in Galaxy therapeutics. AH is a Consultant/Speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care and Galaxy Therapeutics. AH is also a principal investigator of COMPLETE study – Penumbra, LVO SYNCHRONISE – Viz.ai, Millipede Stroke Trial - Perfuze, RESCUE - ICAD - Medtronic. AH is also on the Steering Committee/Publication Committee of SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, and DISTALS. He is also DSMB of the COMAND trial., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)