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This manuscript provides a comprehensive review of intracranial atherosclerosis (ICAS)‐related large‐vessel occlusion (ICAS‐LVO) and its mimics, focusing on the challenges in diagnosis and the need for precise diagnostic methodologies, particularly in the context of endovascular therapy. ICAS‐LVO is a significant contributor to acute ischemic stroke, with varying prevalence rates across regions. ICAS‐LVO is characterized by the presence of residual focal fixed stenosis or reocclusion following endovascular treatment or evidence of distal hypoperfusion or watershed infarction on follow‐up imaging. Despite digital subtraction angiography being the gold standard, diagnosing ICAS‐LVO is complicated by similarities with other occlusive conditions, leading to misdiagnosis and inappropriate interventions. The review explores angiographic mimics of ICAS‐LVO, such as intracranial vasospasm, intracranial dissection, partially occlusive thrombus, and rare vasculopathies like Moyamoya disease, reversible cerebral vasoconstriction syndrome, and vasculitis. Each mimic is meticulously examined, providing insights into their distinctive features, diagnostic considerations, and potential interventions. The manuscript emphasizes the importance of early identification of these mimics to guide appropriate interventions and prevent complications. Future perspectives include the incorporation of advanced imaging tools such as integration of artificial intelligence for automated image analysis, and deployment of advanced imaging techniques such as intravascular ultrasound and optical coherence tomography for a more comprehensive radiographical characterization of ICAS‐LVO. Improved diagnostic criteria and ongoing research will play a pivotal role in addressing the challenges of distinguishing ICAS‐LVO from its mimics.

Background: Chordomas are rare, slow growing, locally aggressive malignant bone tumors that arise from remnants of the embryonic notochord with variable presenting symptoms depending on tumor location. Methods: All patients with craniospinal chordoma managed at our institution between 1982 and 2023 were retrospectively reviewed. Demographics, tumor characteristics, clinical course and treatment, and long-term neurological and survival outcomes were collected. Adjuvant radiotherapy (RT) was stratified into standard dose fractionated radiotherapy (standard XRT) for doses of 50 to 60 Gy at 1.8 Gy fractions or high dose hyperfractionated stereotactic radiotherapy (HD-FSRT) for doses of 60 to 81 Gy at 1.2-1.5 Gy fractions per treatment. Descriptive statistics, univariate analysis, Log-rank test, and Kaplan-Meier survival analysis were performed. Results: A total of 37 patients were included in our cohort (mean age 46.0 ± 20.8 years; 22 male). Clival chordomas accounted for the majority of patients (56.8%), followed by vertebral (27%) and sacral (10.8%) chordomas. Thirty-five patients (94.6%) underwent gross total resection (GTR) or subtotal resection (STR), and 2 patients underwent excisional biopsy only. Postoperatively, functional status trended towards improvement (KPS: Preop- 80 [range 40–100] vs. Post op- 90 [60–100], p = .0911) and all patients either maintained or improved their neurological function. Median overall survival (OS) after diagnosis was 16.5 years. Age < 65, clival tumor location, post-operative Frankel grade E, and administration of adjuvant RT following initial STR significantly improved OS. OS of GTR patients was not significantly affected by adjuvant RT treatment. Conclusions: Our results show the best long-term survival outcomes for chordoma patients undergoing GTR of tumor tissue. Higher postoperative neurological function was significantly associated with OS, highlighting the importance of maximal but safe total tumor resection. Moreover, adjuvant RT improved long-term survival for patients that underwent STR but had no effect on survival outcomes for patients that underwent GTR.

Background Flow diversion has revolutionized the management of wide‐necked intracranial aneurysms (IAs). We aimed to assess the effectiveness and safety of the new generation 64‐wire Surpass Evolve for the treatment of unruptured small/medium‐sized IAs. Methods and Results This is a subanalysis from the SEASE (Safety and Effectiveness Assessment of the Surpass Evolve) registry, an observational cohort study including 15 academic institutions in North America and Europe between July 2020 and October 2022. Patients with wide‐necked saccular IAs, measuring

Background The presence of an incorporated branch as well as its anatomical relationship to the intracranial aneurysms (IAs) and the parent artery may affect the occlusion outcome following flow diversion. This study evaluated the safety and effectiveness of the cobalt‐chromium Surpass Evolve (Stryker), a 64‐wire flow diversion device for the treatment of IAs with incorporated branches. Methods This subanalysis uses data from the SEASE (Safety and Effectiveness Assessment of Surpass Evolve) registry to retrieve data related to IAs with incorporated branches. Those IAs were classified by a core lab into 4 categories based on their anatomical relationship to the parent artery and branch: (A) sidewall anatomic, (B) sidewall hemodynamic, (C) neck branch, and (D) dome branch. We compared the outcomes based on their incorporated branch's relation to the dome (A–C versus D). Results This study included 67 patients and IAs. Most IAs were in the posterior communicating artery (46.3%), with a median size of 4.35 mm. Age, sex, comorbidities, baseline functional‐status, and IA features were similar between the 2 groups. Among those, 53 (79.1%) had branches emerging from the dome, and 14 (20.9%) had branches originating from other locations (A = 7, B = 2, and C = 5). At a median imaging follow‐up of 10.5 months, complete occlusion was lower in IAs with a branch from the sac compared with those with the neck (60.8% versus 92.9%; P = 0.026), with an overall occlusion of 67.7%. Thromboembolic and hemorrhagic complications, as well as retreatment, were reported in 1.6% and 3.1% of cases, respectively, with no significant differences between groups. Conclusion Our analysis underscores the influence of branch origin on occlusion rates, with the neck‐originating branch demonstrating higher occlusion rates. These insights emphasize the role of anatomical considerations in treatment strategies, follow‐up timelines, and designing future clinical trials. Further studies are warranted to explore these variations across different flow diversion technologies.

Background Flow diversion (FD) has emerged as an effective treatment option for intracranial aneurysms. However, there is limited evidence regarding its safety and efficacy specifically for distal and small‐artery aneurysms of the posterior circulation. This study aimed to investigate the outcomes of FD for aneurysms arising from the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and the P2 and P3 segments of the posterior cerebral artery. Methods This is a subanalysis of the Post‐FD (Posterior Circulation Aneurysms Treated With Flow Diversion) registry, highlighting distal aneurysms in the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and the P2 and P3 segments of the posterior cerebral artery treated with FD. Aneurysm characteristics and patient outcomes were described for the total series, and a more focused analysis comparing fusiform/dissecting versus saccular aneurysms was performed. The primary treatment outcome was complete aneurysm occlusion (Raymond–Roy class 1). Primary safety outcome was major ischemic/hemorrhagic stroke following FD. Secondary outcomes included functional outcome, aneurysm retreatment, and in‐stent stenosis. Results Overall, 36 patients with 36 aneurysms were treated with FD, with a median age of 60.0 years (interquartile range [IQR], 52.8—65.3 years). Of those, 13 were fusiform/dissecting, while 23 were saccular aneurysms. Complete occlusion was achieved in 78.1% for all aneurysms at a median follow‐up of 14.0 months (IQR, 9.3–48.6 months). There was a nonsignificant trend in rates of complete occlusion between fusiform/dissecting (91.7%) and saccular aneurysms (70%; P = 0.151). Major stroke was reported in 2 cases (5.6%) and in‐stent stenosis in 4 (11.1%), and retreatment was required for 4 aneurysms (11.4%) There was no difference in rates of major stroke, in‐stent stenosis, or retreatment between fusiform/dissecting and saccular aneurysms. Conclusion This study suggests the safety and feasibility of FD for distal aneurysms of the posterior circulation, particularly fusiform/dissecting aneurysms. Further larger‐scale studies are warranted to confirm these findings.

Background The available evidence supporting the use of endovascular thrombectomy (EVT) in acute ischemic stroke patients with large core has increased with the recent release of the Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Efficacy and Safety of Thrombectomy In Stroke with Extended Lesion and Extended Time Window (TENSION), and Large Stroke Therapy Evaluation (LASTE) trials, providing critical information on additional subgroups not included in initial trials. We aimed to study the efficacy and safety of EVT in patients with acute ischemic stroke with large core and stratify by several subgroups including core infarct at presentation, using a comprehensive meta‐analysis of aggregate data. Methods We executed a systematic search to identify randomized controlled trials that compared EVT to medical management (MM) for the treatment of patients with acute ischemic stroke with large core, defined as Alberta Stroke Program Early CT [Computed Tomography] Score ≤5 on noncontrast CT and/or estimated ischemic core ≥50 mL on CT‐perfusion/MR diffusion. The primary outcome was the shift analysis in the 90‐day modified Rankin scale (mRS) score. Secondary outcomes included functional independence (mRS score 0–2), independent ambulation (mRS score 0–3), 90‐day mortality, and symptomatic intracranial hemorrhage. Pooled odds ratios were calculated for shift mRS score through the random‐effects meta‐analyses, and risk ratios (RRs) were used for the other outcomes, comparing EVT with MM alone. Results Out of 3402 titles and abstracts screened, 6 randomized controlled trials with 1886 patients were included. The EVT group had a higher shift toward a lower mRS than MM alone (odds ratio [OR], 1.49 [95% CI, 1.24–1.79]). Furthermore, the use of EVT was associated with higher rates of functional independence (19.5% versus 7.5%, RR, 2.49 [95% CI, 1.92–3.24]), independent ambulation (36.5% versus 19.9%, RR, 1.91 [95% CI, 1.51–2.43]), and symptomatic intracranial hemorrhage (5.5% versus 3.2%, RR, 1.73 [95% CI, 1.01–2.95]) compared with MM. There was no difference between the 2 groups regarding mortality (31.5% versus 36.8%, RR, 0.86 [95% CI, 0.72–1.02]). Importantly, EVT was consistently associated with a shift toward a lower mRS score in both Alberta Stroke Program Early CT Score 3–5 (OR, 1.60 [95% CI, 1.10–2.32]) and Alberta Stroke Program Early CT Score 0–2 (OR, 1.45 [95% CI, 1.17–1.80]) when compared with MM alone. Conclusion Our results confirm the efficacy of EVT for acute ischemic stroke with large core and suggest a consistent benefit across all Alberta Stroke Program Early CT Score categories. These results represent an important shift in the current large vessel occlusion selection paradigm that currently considers core as an effect modifier for EVT selection.

Background Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large‐bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large‐bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN [Society of Vascular Interventional Neurology] Registry) treated with stand‐alone contact aspiration for the first pass in the middle cerebral artery M1 or intracranial internal carotid artery occlusions from 2012 to 2021. Catheters were stratified on the basis of construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first‐pass effect (first‐pass eTICI 2c–3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first‐pass technique. First‐pass effect was observed in 34% and associated with age (odds ratio [OR], 1.02 [95% CI, 1.01–1.03]), cardioembolic stroke pathogenesis (OR, 1.69 [95% CI, 1.77–2.41]), middle cerebral artery M1 (OR, 2.74 [95% CI, 1.09–1.87]), nongeneral anesthesia (OR, 0.55 [95% CI, 0.39–0.767]), as well as with 0.070‐inch (OR, 2.04 95% CI, 1.01–3.78]), and 0.088‐inch (OR, 3.90 [95% CI, 1.58–9.61]) distal catheter inner diameter in the adjusted analysis. Mean time from arterial access to clot contact was 17 minutes, with faster times observed in younger patients (OR, 0.99 [95% CI, 0.98–0.996]) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18–30 cm) on multivariable regression (OR, 0.30 [95% CI, 0.11–0.82]). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of first‐pass effect. Aspiration catheter construction components were found to influence times from arterial access to clot contact.

Background The optimal endovascular approach for acutely ruptured wide‐neck intracranial aneurysms remains uncertain, and the use of stent‐assisted coiling or flow diversion is controversial due to antiplatelet therapy requirements and potential risks. Various techniques have been developed to address these challenges, including balloon‐assisted coiling (BAC) and intrasaccular flow‐disruption. The Woven EndoBridge (WEB) is an intrasaccular device that has shown a favorable efficacy and safety profile for ruptured aneurysms with minimal rebleeding rates. We aimed to compare the clinical and radiological outcomes between WEB and BAC in a cohort of patients with ruptured wide‐necked intracranial aneurysms. Methods In this international multicenter cohort study, we included consecutive patients treated for ruptured wide‐neck intracranial aneurysms with either WEB or BAC at 4 neurovascular centers. The primary effectiveness outcome was complete aneurysm occlusion at the final imaging follow‐up using the Raymond–Roy scale. Secondary outcomes included a composite of periprocedural hemorrhagic/ischemia‐related complications and favorable functional outcome. Results The study included 104 patients treated with WEB and 107 patients treated with BAC. Of the patients, 60.5% in the WEB group and 53% in the BAC group achieved complete occlusion, with no significant difference between the 2 groups after adjusting for covariates (adjusted odds ratio [OR] = 1.02; 95% CI 0.46–2.25; P = 0.964). The odds of favorable functional outcome did not significantly differ between the WEB (74.8%) and BAC groups (77.4%, adjusted OR = 1.45; 95% CI 0.65–3.24; P = 0.368). Procedure‐related complications were similar in both groups (WEB: 9.6%, BAC: 10.3%, P = 0.872), with no significant difference observed in the rates of ischemic events (WEB: 6.7% versus BAC: 2.8%; P = 0.180) and hemorrhagic events (WEB: 3.8% versus BAC: 7.5%; P = 0.255) between the 2 groups. Conclusion In conclusion, both WEB and BAC techniques showed similar effectiveness and safety outcomes in treating ruptured wide‐neck intracranial aneurysms. Further prospective comparative studies are needed to better guide treatment decisions for this patient population.

Abstract Background Malignant peripheral nerve sheath tumor (MPNST) is an exceedingly rare and aggressive tumor, with limited literature on its management. Herein, we present our series of surgically managed craniospinal MPNSTs, analyze their outcomes, and review the literature. Methods We retrospectively reviewed surgically managed primary craniospinal MPNSTs treated at our institution between January 2005 and May 2023. Patient demographics, tumor features, and treatment outcomes were assessed. Neurological function was quantified using the Frankel grade and Karnofsky performance scores. Descriptive statistics, rank-sum tests, and Kaplan–Meier survival analyses were performed. Results Eight patients satisfied the inclusion criteria (4 male, 4 female). The median age at presentation was 38 years (range 15–67). Most tumors were localized to the spine (75%), and 3 patients had neurofibromatosis type 1. The most common presenting symptoms were paresthesia (50%) and visual changes (13%). The median tumor size was 3 cm, and most tumors were oval-shaped (50%) with well-defined borders (75%). Six tumors were high grade (75%), and gross total resection was achieved in 5 patients, with subtotal resection in the remaining 3 patients. Postoperative radiotherapy and chemotherapy were performed in 6 (75%) and 4 (50%) cases, respectively. Local recurrence occurred in 5 (63%) cases, and distant metastases occurred in 2 (25%). The median overall survival was 26.7 months. Five (63%) patients died due to recurrence. Conclusions Primary craniospinal MPNSTs are rare and have an aggressive clinical course. Early diagnosis and treatment are essential for managing these tumors. In this single-center study with a small cohort, maximal resection, low-grade pathology, young age (

Background and Purpose Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours. Methods This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (

Background Carotid artery stenting (CAS) has emerged as a viable alternative to carotid endarterectomy for managing carotid artery stenosis in high‐risk patients. Although transfemoral arterial access remains the preferred method, it is associated with inherent limitations and potential complications. Consequently, exploring transradial artery access as a potential option becomes crucial in optimizing patient outcomes and procedural success rates. There are limited data comparing the outcomes of the transradial with the transfemoral approach for CAS. This study aimed to systematically review and meta‐analyze the outcomes and complication rates between transradial and transfemoral access for CAS. Methods A systematic electronic search was conducted in 4 databases. Studies with randomized or nonrandomized designs, involving CAS by the transradial or transfemoral approach, were included. Outcomes of interest were stroke, transient ischemic attack, death, myocardial infarction, and access site complications. A meta‐analysis was performed, analyzing pooled odds ratios (ORs) and 95% CIs to assess the effect size. Results Six studies with a total of 6917 patients were included, of whom 602 (8.7%) underwent the transradial approach and 6315 (91.3%) the transfemoral approach. The meta‐analysis showed no significant difference in stroke occurrence between the transradial and transfemoral groups (transradial:1.7% versus transfemoral:1.9%; OR = 0.98 [95% CI, 0.49–1.96]; I2 = 0%). Similarly, no significant difference was found in death (TR:1% versus transfemoral:0.9%; OR = 0.95 [95% CI, 0.38–2.37]; I2 = 0%), myocardial infarction (transradial:0.2% versus transfemoral:0.3%; OR = 1.53 [95% CI, 0.20–11.61]; I2 = 0%), transient ischemic attack (transradial:0.4% versus transfemoral:1%; OR = 0.46 [95% CI, 0.11–1.95]; I2 = 0%), or access site complications (transradial:2.2% versus transfemoral:1%; OR = 0.97 [95% CI, 0.48–1.98]; I2 = 0%). Conclusion No significant differences were observed in stroke, death, myocardial infarction, transient ischemic attack, or access site complications on comparing thetransradial and transfemoral approaches for CAS. The transradial approach shows promise as an alternative method for CAS, offering potential benefits without increased risk of complications. However, further studies are needed to confirm these findings.

Background We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. Methods We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. Conclusions The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.

ImportanceStroke-to-recanalization time is a strong predictor of outcomes in anterior circulation large-vessel occlusion (LVO). The authors aimed to evaluate functional outcomes in early (

Background Chronic symptomatic internal carotid artery occlusion is an important cause of ischemic strokes. Medical management alone remains suboptimal for secondary prevention, and randomized controlled trials failed to demonstrate the efficacy and safety of extracranial‐intracranial vascular bypass. Carotid occlusion endovascular surgery (COES) is a promising technique, yet its efficacy and safety remain unclear. Methods This systematic review and meta‐analysis included studies in which patients with chronic symptomatic internal carotid artery occlusion underwent treatment with COES and medical management. Primary outcomes included successful reperfusion rates and periprocedural ischemic and hemorrhagic events rates. Secondary outcomes included rates of ischemic events recurrence, other periprocedural events, and mortality. Studies contained at least one of the treatment groups and outcomes of interest. Results Twenty‐two studies were selected for systematic review, with 18 of them for meta‐analysis. From 14 studies (N=561) the rate of successful recanalization was achieved in 74% of all patients undergoing COES. Thirteen studies (N=534) showed that the rate of COES was 2% both for periprocedural ischemic and hemorrhagic events. At long‐term follow‐up, the COES cohort included a total of 10 studies (N=311) and had a 12% rate of ischemic events, while the medical management group, which included 5 studies (N=313), showed a rate of 19%, with nonsignificant subgroup differences (P=0.09, I2, 12%). Rates of other periprocedural mortality were 4% and 1%, respectively. Conclusion This meta‐analysis supports the use of COES as a promising and innovative technique for the secondary prevention of symptomatic internal carotid artery occlusion. Our findings suggest that COES may be superior to medical management alone, although further research is needed to fully evaluate its efficacy and safety.

Middle meningeal artery embolization is an increasingly common procedure involved in the treatment of chronic subdural hematoma (cSDH) that can be an adjuvant intervention or an alternative to traditional medical or surgical therapies. Our review aims to summarize the mechanism, properties, and available clinical data for current and investigative embolic agents used for the treatment of cSDH. Pubmed, Scopus, and clinicaltrials.gov were searched for relevant studies and ongoing trials that examine middle meningeal artery embolization for cSDH. Particle agents, liquid embolic agents, and coil embolization are the common classes of embolic materials used in clinical practice and in ongoing trials. These embolic agents are not only mechanical occlusive materials; they have unique properties that address the angiogenic and proinflammatory mechanisms that propagate and sustain cSDH. Particle agents, such as polyvinyl alcohol and Embosphere (tris‐acryl gelatin microspheres) have been the most commonly used embolic agents given the long‐term evidence base regarding efficacy and established safety record. Liquid embolic agents such as cyanoacrylate glues and copolymer agents such as Onyx, Squid, and PHIL are increasingly common in clinical settings due to improved visualization on imaging, durable embolization, and better control of distal embolization. Coil embolization is used in conjunction with other embolic agents or as monotherapy in the setting of dangerous middle meningeal artery anastomoses. There are several ongoing randomized clinical trials and prospective cohort studies that will clarify the safety, efficacy, and use cases of particle agents, liquid embolic agents, and coil embolization for the treatment of cSDH.

Background Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. Methods and Results A systematic review and meta‐analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90‐day functional independence (modified Rankin scale score 0–2). Additionally, rates were compared between patients receiving IVT using DOAC and non‐DOAC by a random effect meta‐analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non‐DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3–4) symptomatic intracranial hemorrhage, 12% (95% CI, 7–19) any ICH, and 0.7% (95%CI, 0–1) serious systemic bleeding, and 90‐day functional independence was achieved in 57% (95% CI, 43–70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67–1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61–2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79–2.02]), and 90‐day modified Rankin scale score 0–2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400–3.67]) did not differ between DOAC and non‐DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. Conclusions Patients with acute ischemic stroke treated with IVT in recent DOAC versus non‐DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Background Procedural intravenous cangrelor has been proposed as an effective platelet inhibition strategy for stenting in acute ischemic stroke. We aimed to compare the safety profile of low‐dose intravenous cangrelor versus dual oral antiplatelet therapy (DAPT) loading in patients with acute cervical tandem lesions. Methods We retrospectively identified cases from an international multicenter cohort who underwent intraprocedural administration of intravenous cangrelor (15 μg/kg followed by an infusion of 2 μg/kg per min) or DAPT loading during acute tandem lesions intervention. Safety outcomes included rates of symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, and in‐stent thrombosis. Inverse probability of treatment weighting matching was used to reduce confounding. Results From 691 patients, we included 195 patients, 30 of whom received intravenous cangrelor and 165 DAPT. The DAPT regimens were aspirin+clopidogrel (93.3%) or aspirin+ticagrelor (6.6%). After inverse probability of treatment weighting, the patients treated with cangrelor were not at greater odds of symptomatic intracranial hemorrhage (odds ratio [OR], 1.30 [95% CI, 0.09–17.3]; P=0.837), symptomatic intracranial hemorrhage–parenchymal hematoma type 2 (OR, 0.54 [95% CI, 0.05–4.98]; P=0.589), or petechial hemorrhage (OR, 1.11 [95% CI, 0.38–3.28]; P=0.836). Similarly, the rate of in‐stent thrombosis was not significantly different between the 2 groups (1.8% versus 0%; P=0.911). Conclusion Cangrelor at the half dose of the myocardial infarction protocol showed a similar safety profile compared with the commonly used DAPT loading protocols in patients with acute tandem lesions. Further studies with larger samples are warranted to elucidate the safety of antiplatelet therapy in tandem lesions.

Introduction Flow diversion (FD) has emerged as an effective treatment option for intracranial aneurysms (IAs). However, there is limited evidence regarding its safety and efficacy specifically for distal aneurysms of the posterior circulation including posterior inferior cerebellar artery (PICA), anterior inferior cerebellar artery (AICA), superior cerebellar artery (SCA), and the P2 and P3 segment of the posterior cerebral artery (PCA). This study aimed to investigate the outcomes of FD for these aneurysms. Methods A retrospective analysis of a multicentric observational registry was performed between 2014 and 2022. Patients harboring distal aneurysms of the posterior circulation including the PICA, AICA, SCA, and PCA P2‐3 treated with FD were included. Aneurysms characteristics and outcomes were calculated for the total series and a comparison was performed between fusiform/dissecting versus saccular aneurysms. The primary outcome was complete occlusion at last imaging follow up which was defined as per the Raymond Roy occlusion scale. Additional outcomes included the retreatment rate, and thromboembolic and hemorrhagic complications Results Overall, 36 patients with 36 aneurysms were treated with FD with a median age in years of 60.0 (interquartile range [IQR]: 52.8‐65.3 years). Of those, 13 were fusiform/dissecting while 23 were saccular IAs. Complete occlusion was achieved in 78.1% for all IAs at a median follow‐up of 14.0 months (IQR: 9.3‐48.6 months). There was no significant difference in rates of complete occlusion between fusiform/dissecting (91.7%) and saccular aneurysms (70%, p=0.151). Thromboembolic and hemorrhagic complications were observed in four cases (11.1%), and retreatment was required for four IAs (11.4%). There was no significant difference in rates of thromboembolic and hemorrhagic complications, or retreatment between fusiform/dissecting and saccular IAs Conclusion This study suggests the safety and efficacy of FD for distal aneurysms of the posterior circulation. Further larger‐scale studies are warranted to confirm these findings and to explore the long‐term safety and efficacy of FD in this specific aneurysm population.

Introduction Intracranial atherosclerosis‐related large vessel occlusion (ICAS‐LVO) is a common cause of failed mechanical thrombectomy (MT) in acute ischemic stroke (AIS) [1]. Treatment of ICAS‐LVO with rescue stenting and/or angioplasty has shown promising outcomes, but diagnosing ICAS‐LVO during MT can be challenging [2, 3]. There are uncertainties regarding optimal approaches, techniques, and timing for treating ICAS‐LVO. To understand current practice patterns and address these uncertainties, we conducted a survey among neurointerventional practitioners experienced in ICAS‐LVO management during MT. Methods We conducted an international online survey of neurointerventionalist members of the Society of Neurointerventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN). The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results 168 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 40.6% reported an incidence of 6–10% of ICAS‐LVO during MT. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis (FFS) after multiple MT attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS) +/‐ angioplasty. However, in patients who achieved recanalization with a severe FFS, the majority (44%) recommended maximal medical management only. The preferred medication during acute RS was intravenous antiplatelet therapy (69%), and after acute RS was dual oral antiplatelet therapy (58%). Fear of hemorrhagic complications (70%) was the most compelling reason not to perform RS +/‐ angioplasty. Twenty‐five percent of respondents were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before MT treatment. Conclusion Our survey highlights the significant variability and uncertainty in the diagnosis and management of ICAS‐LVO during MT among neurointerventional practitioners. There is no equipoise regarding the optimal treatment strategy, and the fear of hemorrhagic complications associated with antithrombotic medications contributes to the variation in practice. Our survey underscores the need for future research and randomized clinical trials to address the uncertainties in the management of ICAS‐LVO during MT. Improved imaging biomarkers and consensus guidelines are essential to guide clinical decision‐making and optimize patient outcomes in this challenging population of AIS patients.

Introduction Tandem Lesions (TLs) pose unique challenges in the endovascular management of acute ischemic stroke.(1) The absence of anterograde blood flow in the carotid occluded segment may limit the effectiveness of endovascular interventions, resulting in delayed reperfusion or suboptimal recanalization.(2,3) Thus, the presence of unpaired blood flow through the ICA in the context of TLs is believed to exacerbate the extension of ischemic lesions. (4,5) This study compared the clinical and procedural outcomes of patients with TLs and extracranial internal carotid artery occlusion versus those with stenosis. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups: those with extracranial ICA stenosis and those with occlusion. Clinical outcomes, including functional independence, hemorrhagic events, and procedural time metrics including puncture to reperfusion time were assessed. Sensitivity analyses were conducted to evaluate these differences segregating patients according to varying degrees of stenosis, and in pre‐specified subgroups. Results A total of 513 patients with TLs were included in the study. 281 (54.8%) presented with ICA occlusion, and 232 (45.2%) presented stenosis >=70% (Table 1). The comparison between the stenosis and occlusion groups revealed no significant differences in the main outcomes, including mTICI 2c‐3 (47.5% vs. 50.6%, aOR 1.07, 95% CI 0.70‐1.64, p=.751) (Figure 1), mRS 0‐2 at 90 days (43.6% vs. 48.9%, aOR 0.79, 95% CI 0.52‐1.20, p=.271), sICH rates (4.7% vs. 5.6%, aOR 0.72, 95% CI 0.31‐1.71, p=.458), and puncture to reperfusion time (58 [40‐80.5] vs. 52.5 [35.2‐80], ratio 1.04, 95% CI 0.88‐1.23, p=.64). Similar analyses performed comparing different degrees of stenosis and occlusion, and in patients treated with the antegrade approach only, did not show significant differences either. Conclusion Our findings indicate that although more severe degrees of stenosis or occlusion of the ICA prolong the time from puncture to reperfusion, no significant differences in clinical outcomes exist. The clinical implications of these findings need to be further evaluated to fully comprehend the specific needs of patients affected by TLs.

Introduction Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN Registry) treated with stand‐alone contact aspiration for the first pass in the MCA M1 or intracranial ICA occlusions from 2012‐2021. Catheters were stratified based on construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first pass effect (FPE ‐ first‐pass eTICI2c‐3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first pass technique. FPE was observed in 34% and associated with age (OR:1.016;95%CI:1.006‐1.027), cardioembolic stroke etiology (OR:1.685;95%CI:1.77 ‐2.41), MCA M1(OR:2.737;95%CI:1.091 ‐1.867), non‐general anesthesia (OR:0.546;95%CI:0.389 ‐0.767), as well as with 0.070” (OR:2.038;95%CI:1.099 ‐3.779) and 0.088” (OR:3.899;95%CI:1.582 ‐9.606) distal catheter inner diameter in the adjusted analysis. Median time from arterial access to clot contact was 17 minutes with faster times observed in younger patients (OR:0.986;95%CI:0.975 ‐0.996) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18‐30cm) on multivariable regression (OR:0.303; 95%CI:0.113‐0.816). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of FPE. Aspiration catheters with reduced distal tip hydrophilic coating were associated with faster arterial access to clot contact time.

Introduction The optimal endovascular approach for wide‐neck intracranial aneurysms (IAs) during the acute phase of bleeding remains uncertain, and the use of stent‐assisted coiling or flow diversion is controversial due to antiplatelet therapy requirements and potential risks (1, 2). Various techniques have been developed to address these challenges, including balloon‐assisted coiling (BAC) and intrasaccular flow‐disruption. The Woven EndoBridge (WEB) is a flow disrupter that has gained popularity in treating ruptured IAs due to its effectiveness in occluding aneurysms with minimal rebleeding (3, 4). The aim of this study is to provide outcome comparisons between WEB and BAC in a specific cohort of patients with ruptured wide‐necked IAs. Methods In this international cohort study, we included consecutive patients treated for ruptured wide‐neck IAs with either WEB or BAC at three neurovascular centers. The primary effectiveness outcome was complete aneurysm occlusion at the final imaging follow‐up using the Raymond‐Roy (RR) occlusion classification. Secondary outcomes included favorable functional outcome and periprocedural hemorrhagic/ischemia‐related complications. Comparisons were performed using multivariable logistic and ordinal regressions. Results One hundred four patients treated with WEB and 107 patients treated with BAC were included. The mean length of imaging follow‐up was 17.5 (± 17.6) months in the WEB group and 11.8 (± 10.3) months in the BAC group (p = 0.142). Of the patients, 60.5% in the WEB group and 53% in the BAC group achieved complete occlusion, with no significant difference between the two groups after adjusting for covariates (adjusted OR [aOR] = 1.02; 95% CI 0.46 – 2.25; p = 0.964). The odds of favorable functional outcome did not significantly differ between the WEB (74.8%) and BAC groups (77.4%, aOR = 1.45; 95% CI 0.65 – 3.24; p = 0.368). Procedure‐related complications were similar in both groups (WEB: 9.6%, BAC: 10.3%, p = 0.872). There was no statistically significant difference observed in the rates of ischemic events (WEB: 6.7% vs. BAC: 2.8%, p = 0.180) and hemorrhagic events (WEB: 3.8% vs. BAC: 7.5%, p = 0.255) between the two groups. Conclusion In conclusion, both WEB and BAC techniques showed similar effectiveness and safety outcomes in treating ruptured wide‐neck IAs. Further research and direct comparative studies are needed to better guide treatment decisions for this patient population.

Introduction Flow diverters (FD) have become a revolutionary approach in the endovascular treatment of intracranial aneurysms (IAs), supplanting traditional methods (1). Despite their demonstrated efficacy and safety, unforeseeable device‐related technical complications, such as fish‐mouthing, device braid narrowing, deformation, ovalization, and collapsing have been reported during implantation and follow‐up (2,3,4). However, the definitions and reporting of these complications remain inconsistent. We conducted a systematic review and meta‐analysis to assess overall device‐related technical complication rates associated with flow diversion and provide an overview of the current reported definitions. Methods We searched six databases up to April 4th, 2023, and included studies that reported device‐related technical complications related to FD treatment for IAs. We considered five main outcome measures as device‐related technical complications: (1) fish‐mouthing, (2) device braid collapsing, (3) device braid narrowing, (4) device braid deformation, and (5) device braid ovalization. The data from these studies were pooled using a random‐effects model. Results We included 48 studies involving 3,572 patients and 3,939 aneurysms. Among them, 14 studies (39%) provided definitions for fish‐mouthing. However, none of the included studies offered specific definitions for device braid collapsing, narrowing, or deformation, despite reporting rates for these complications in five, six, and three studies, respectively. The pooled rates for device‐related technical complications were as follows: 3% (95% CI 2 – 4%; I2 = 27%) for fish‐mouthing, 1% (95% CI 0 – 3%; I2 = 0%) for collapsing, 7% (95% CI 2 – 20%; I2 = 85%) for narrowing, and 1% (95% CI 1 – 4%; I2 = 0%) for deformation. Device braid ovalization data were not available. Conclusion The findings of this study suggest that FD treatment for IAs generally exhibits low rates of fish‐mouthing, device braid narrowing, collapsing, and deformation. However, the lack of standardized definitions hinders the ability to objectively compare device outcomes, emphasizing the need for uniform device‐related complication definitions in future prospective studies on FD.

Introduction Tandem lesions (TLs) are present in up to 15% of patients with stroke due to acute large vessel occlusions.(1) Nevertheless, published research on endovascular treatment outcomes in this population is scarce. Although TLs are most commonly of atherosclerotic etiology, some patients present with dissection of the ICA.(2, 3) In this study, we compared the clinical outcomes of TL patients with the two etiologies. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups according to the etiology of the ICA lesion: atherosclerosis and dissection. Patients were matched by baseline characteristics. Clinical outcomes, including recanalization success, functional independence and hemorrhagic events were assessed with multivariable analyses. Results Of 691 patients from the database, 526 met the inclusion criteria of this study. 467 (88.8%) patients presented with atherosclerosis of the ICA, and 59 (11.2%) patients presented dissection. Univariable differences were found in median age (69 y. [IQR 61 ‐ 76] vs. 52 y. [IQR 44 ‐ 63], p

Introduction Mechanical thrombectomy (MT) often fails to achieve successful reperfusion in up to 20% of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) [1, 2]. Rescue strategies options, including balloon angioplasty alone, rescue stenting (RS) alone, or stent with balloon angioplasty, have shown promise in observational studies and meta‐analyses [3, 4]. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in anterior circulation LVO‐AIS patients who underwent failed MT. Methods This retrospective cohort study utilized prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry, including adult patients with AIS who experienced a failed MT at 14 comprehensive stroke centers. A failed MT was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 0 to 2a after multiple attempts to clot retrieval. The patients were divided into two groups: those who received RS and those who only received MM. The primary efficacy outcome was the shift in the degree of disability, as measured by the modified Rankin Scale (mRS), at 90 days. Additional outcomes included functional independence (defined as a 90‐day mRS score of 0‐2), symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. These outcomes were assessed using uni‐ and multivariable logistic regression models. Results A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b‐3 was achieved in 242/293 (82.6%) patients in the RS group. Compared to the MM group, the RS showed a favorable shift in the overall 90‐day mRS distribution (adjusted common odds ratio [OR]=1.97, 95% CI 1.36–2.85, 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 When mechanical thrombectomy (MT) fails to achieve successful reperfusion, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess clinical outcomes. We aimed to compare the safety and efficacy of RS versus routine medical management in patients with failed MT using an aggregated meta‐analysis. Methods A systematic review was performed from inception to July 2022 of all studies using RS after failed MT. Outcomes of interest included a modified Rankin scale score of 0–2 at 90 days, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3) after RS and symptomatic intracranial hemorrhage. A random‐effects meta‐analysis between the RS and medical treatment arms was performed to calculate pooled odds ratios (OR) for each outcome. We assessed the certainty of evidence using the Grading of Recommendation, Assessment, Development, and Evaluation approach. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 12 studies included 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a significantly higher proportion of patients with a modified Rankin scale score of 0–2 at 90 days (RS: 41% versus 21%; OR,3.27; [95% CI 2.08–5.16]; I2=64%; moderate‐certainty evidence) and a decreased risk of mortality at 90 days (RS: 22.5% versus 33.8%; OR, 0.47; [95% CI 0.32–0.69]; I2=45%; low‐certainty evidence), compared with medical treatment after failed MT. The pooled rate of successful reperfusion after RS was 87% (95% CI 82–91; I2=57%; low‐certainty evidence). The rate of symptomatic intracranial hemorrhage did not differ between groups (RS: 8.5% versus 11.7%; OR, 0.85; [95% CI 0.59–1.20]; I2=7%; low‐certainty evidence). Conclusion RS is a promising strategy for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, randomized trials using a standardized approach/technique and MT failure definition are warranted to confirm these results.

Background Clinical and radiographic outcomes after mechanical thrombectomy in the setting of COVID‐19 infection remain poorly characterized. We sought to determine how COVID‐19 status affects mechanical thrombectomy outcomes in the real‐world setting in the United States. Methods The prospectively maintained multicenter mechanical thrombectomy registry from the Society of Vascular and Interventional Neurology was queried for baseline clinical characteristics among patients with and without COVID‐19 who underwent mechanical thrombectomy between March 1 and December 31, 2020 at 12 sites. Primary outcome was the likelihood of good neurological outcomes (90 day modified Rankin scale 0–2) among patients with COVID‐19 treated with endovascular thrombectomy, which was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b, 2c, and 3). Secondary outcomes included National Institutes of Health Stroke Scale at 24 hours. Results Among 915 patients who underwent mechanical thrombectomy during the study period, 51 patients were positive for COVID‐19 (5.6%). Univariate analysis revealed that compared with patients who were COVID‐19 negative, patients who were positive for COVID‐19 were more likely to be male, nonsmokers, have lower Alberta Stroke Program Early CT Score, and present with intracranial internal carotid artery occlusions (Table 1). They were also less likely to achieve successful reperfusion. Multivariable analysis, however, failed to identify any independent associations with COVID‐19 positive status. Conclusion In our cohort, patients postive for COVID‐19 with acute ischemic stroke who undergo mechanical thrombectomy have similar baseline characteristics, imaging features, procedural, and clinical outcomes compared to patients who are negative for COVID‐19 in multivariate analysis. Further analyses are warranted.

Introduction The management of wide‐necked bifurcation aneurysms can be challenging due to multiple factors. Intrasaccular flow disruption with the Woven EndoBridge (WEB) has demonstrated a safe and effective profile. Current microemboli data after the WEB device placement is non‐existent. We evaluated the rate of embolic signals (MES) after WEB device implantation. Methods We performed a retrospective analysis of a prospectively maintained database including patients who underwent WEB device implantation for the treatment of unruptured intracranial aneurysms between 2021 and 2022. Variables studied included patient demographics, modified Rankin Scale (mRS) before and 3 months post‐treatment, comorbidities, aneurysm characteristics, platelet inhibition tests, and activated clotting time. All patients were on aspirin and a P2Y12 inhibitor and had therapeutic levels on platelet aggregation assays. Intraoperative heparin was given in all cases to keep a therapeutic ACT. P2Y12 drugs were stopped after the procedure. In all patients, MES monitoring was performed in the immediate postoperative period and >12 hours after the procedure. Results 34 patients with 34 aneurysms were analyzed. Mean age was 67.4 years and 85% were females. Mean aneurysm size was 13.1 ± 2.0 mm and mean neck size 4.4 ± 1.5 mm. Locations were middle cerebral artery bifurcation and M1‐M2 segment (n = 13), basilar artery tip (n = 10), anterior communicating artery (n = 8), internal carotid artery terminus (n = 2) and pericallosal artery (n = 1). A single WEB was implanted in 100% of the cases. MES were negative in all cases. 3‐month mRS remained stable or improved in all cases. No procedure‐related complications were seen. Conclusions Our findings reinforce the safety profile of intrasaccular flow disruption. These findings differ from a previous analysis of unruptured aneurysms in our institution where a 7.7% incidence of MES was reported after endovascular treatment of unruptured aneurysms with primary or assisted coiling.

Introduction Actual guidelines offer little guidance for endovascular treatment of patients with acute ischemic stroke (AIS) and pre‐morbid disability (PMD). Often, patients with a mRS >2 are not considered for mechanical thrombectomy (MT) and might not be given the best chance of achieving recovery. Three recent meta‐analysis have showed conflicting results regarding the benefit of MT, while persistently showing a significant increase in mortality. Methods We conducted a systematic search in Embase, Medline, and Web of Science for studies of patients with AIS and PMD who were treated with MT or MM. We included all definitions of PMD, main outcomes were favorable functionality at 90‐days (mRS 0–2 or return to baseline mRS), symptomatic ICH, and mortality. We performed meta‐analyses using a random‐effect model, and I2 to evaluate heterogeneity. Subgroup analyses were used when appropriate. Results 2 studies contained data comparing PMD patients treated with MT versus MM, 14 studies contained data only of patients treated with MT, and 10 only of patients treated with MM; they provided data of 1071 patients in the MT group and 4547 in the MM group. Pooled rates in the MT group were 28% (95% CI 0.24‐0.32) for favorable functionality, 7% (95% CI 0.04‐0.12) for sICH, 43% (95% CI 0.36‐0.51) for 90‐days mortality, 18% (95% CI 0.14‐0.23) for intra‐hospital mortality, and pooled reperfusion rate (mTICI 0–2) of 80% (95% CI 0.72‐0.86). In a meta‐analysis of proportion with the treatments modalities as subgroups, including only studies with a similar definition of PMD, we obtained: for favorable functionality, MT = 26% (95% CI 0.23‐0.30) vs. MM = 35% (95% CI 0.22‐0.51); for sICH, MT = 6% (95% CI 0.05‐0.08) vs. MM = 6% (95% CI 0.05‐0.08); for 90‐days mortality, MT = 48% (95% CI 0.44‐0.52) vs. MM = 34% (95% CI 0.27‐0.41); and for in‐hospital mortality, MT = 18% (95% CI 0.14‐0.23) vs. MM = 22% (95% CI 0.17‐0.28). Additionally, meta‐analysis for 90‐days mortality in MT studies, showed a pooled rate of 49% (95% CI 0.45‐0.53) for the high tPA rate subgroup, and 30% (95% CI 0.19‐0.44) for the low tPA rate subgroup. Conclusions Up to one third of PMD patients who undergo MT might achieve favorable functionality, without increasing the risk of sICH and with rates similar to those obtained with MM. Furthermore, we observed a high 90‐day mortality rate, in both MT and MM groups. In subgroups exploration, there is trend of high tPA rates to be associated with the increased mortality. It is urgent to identify PMD patients who will benefit from MT and factors associated with poor outcomes.

Introduction Improvements in the safety and efficacy of curative embolization for brain arteriovenous malformations (bAVMs) have allowed to achieve comparable results to microsurgical resection and radiosurgery, especially for low‐grade bAVMs (Spetzler Martin [SM] grade I and II). However, whether this treatment modality is beneficial in the pediatric population remains unknown. Hence, we assessed the safety and efficacy of curative embolization for low‐grade bAVMs in children. In addition, we determined predictors of intraprocedural complications and predictors of complete occlusion in one embolization session. Methods Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for low‐grade bAVMs was conducted at two institutions. Demographic data, clinical presentation, SM grade, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Multivariable logistic regression analysis was performed to identify potential predictive factors of intraprocedural complications and complete occlusion in one session. For selected variables, odds ratios (OR) with 95% confidence intervals (CI) and p value of the likelihood‐ratio test were presented. Results Sixty‐eight patients (41 females; mean age 12.9 ± 3.6 years) underwent a total of 102 embolization sessions. Fifty‐one bAVMs (75%) presented ruptured, and headache was the most common clinical presentation (50%). There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Onyx was the most used embolic agent (33%) and the transarterial approach was the most common (93%). The mean volume of embolic agents in each patient was 2.4 ml (range 0.2 to 7.5 ml). Fourteen intraprocedural complications (14% of procedures) were observed and no deaths were reported. The most common complication was microcatheter‐related vessel perforation (6%). Single venous drainage decreased the risk of intraprocedural complications (OR = 0.19; 95% CI 0.04 – 0.78). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (52%) the bAVM was occluded with a single session. A small bAVM size was predictor of complete occlusion in one session (OR = 0.42; 95% CI 0.21 – 0.73). Conclusions Curative embolization in pediatric low‐grade bAVMs can be performed with an acceptable complete occlusion rate but with a high rate of intraprocedural complications. The risk of intraprocedural complications was low in bAVMs with a single venous drainage. The odds of complete occlusion in one session are high in small bAVMs. Curative embolization should be selected on an individual basis in order to achieve optimal results.

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 Posterior communicating artery (PComA) aneurysms are common and have a high risk of rupture. Flow diverters (FD) have demonstrated a safe and effective profile. However, the use of FD in PComA aneurysms has shown controversial results with high rates of recurrence and a high risk of potential ischemic complications. There, we aimed to evaluate the safety and efficacy of flow diversion for the treatment of PComA aneurysms with a meta‐analysis of the literature. Methods We performed a systematic search in Scopus, Embase, Medline, and Web of Science from inception until May 2022 for all the studies that reported the safety and effectiveness of FD for the treatment of intracranial aneurysms located in the posterior communicating artery. The primary effectiveness endpoint was a complete aneurysm occlusion rate at final follow‐up. The primary safety endpoint was a composite measure of cumulative events that occurred during and after the procedure. Events included death and ischemic/hemorrhagic complications. Random‐effects meta‐analysis was used to calculate proportions. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 13 studies with 397 patients harboring 403 aneurysms were included in our analysis. Mean age was 48 years and mean aneurysm size was 5.3 mm. Complete aneurysm occlusion at final follow‐up was 74% (95% CI 66–81%; I2 = 54%). The primary safety composite outcome was 5% (95% CI 3–9%; I2 = 0%). The mortality rate was 1% (95% CI 0–2%; I2 = 0%). Subgroup analysis showed that patients with a non‐fetal PComA had a higher rate (76%; 95% CI 62%‐86%; I2 = 53%) of complete aneurysm occlusion compared to those with a fetal PComA (36%; 95% CI 21%‐54%; I2 = 0%). Conclusions Our findings show that flow diversion for the treatment of aneurysms located in the PComA is effective and safe. However, the same treatment for aneurysms located in a fetal‐type PComA did not show the same efficacy profile suggesting that these cases might require an alternative treatment to achieve permanent occlusion rates.

Introduction Following the favorable clinical and radiographical results of flow diversion, its use has continually expanded for the treatment of complex intracranial aneurysms. The high metal surface of flow diverters (FD) increases the risk of thromboembolic complications. Current emboli monitoring data after FD placement is limited. Transcranial doppler (TCD) offers a non‐invasive evaluation of microembolic signals and might be a valuable tool to prevent ischemic complications. We evaluated the rate of embolic signals and their management after FD implantation. Methods We performed a retrospective, single‐center evaluation of adult patients who underwent a FD procedure with the Pipeline Embolization Device (PED) for unruptured intracranial aneurysms between 2012 and 2016. Covariates included patient demographics, comorbidities, aneurysm characteristics, procedure characteristics, and post‐procedure TCD emboli monitoring (immediate and >12 hours post‐operative). TCD emboli signals were classified as positive (< 15 microembolic signals) and strongly positive (>15 signals). The primary outcome was the rate of symptomatic stroke at 2 and 12 weeks in these patients. Results 105 patients with 132 aneurysms were analyzed. Mean age was 59.7 years, and 78% were females. Mean aneurysm size was 7.8 ± 6.4 mm. Most of them were located in the paraclinoid region (40%). Two PEDs were implanted in 12 (11%) cases and adjunctive coiling was performed in 15 (14%) cases. Microemboli were detected in 11.4% of cases (12/105 patients) after PED deployment. In 5/12 patients, the emboli resolved upon repeat testing with no intervention. In 6/12 patients, further heparinization, additional clopidogrel administration, or change in antiplatelet agents were needed. These treatments reduced the microembolic events. In 1 patient who was clopidogrel‐resistant and a ticagrelor super‐responder, mechanical thrombectomy was necessary due to acute in‐stent thrombosis. There were no symptomatic strokes at 2 and 12 weeks. Conclusions TCD emboli monitoring can be a powerful non‐invasive tool for the early identification and prevention of thromboembolic events after FD implantation. Early detection of microembolic signals offers the possibility to modify postoperative management, avoid silent emboli, and potentially avoid symptomatic strokes.

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = < 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Introduction Paraclinoid aneurysms (PAs) have traditionally been treated with clipping. However, with the emergence of new techniques, endovascular treatment (EVT) has supplanted surgical treatment in recent years. We aimed to determine the safety and efficacy of EVT and microsurgical clipping for PAs. Methods A systematic review was performed in Scopus, Embase, Medline, Web of Science, and Cochrane from inception to March 2022 for all studies that tested the safety and efficacy of EVT or microsurgical clipping of PAs. Efficacy outcomes included complete aneurysm occlusion at last follow‐up, immediate complete occlusion, and an mRS 0–2 at last follow‐up. Safety outcomes included mortality, intraoperative and postoperative complications. We performed a random‐effects meta‐analysis of proportions and assessed the statistical heterogeneity across studies with I2 statistics. Results Eighty‐nine studies included 6496 patients, 3682 treated with EVT and 2814 with microsurgical clipping. Immediate complete occlusion rates were 92% (95% CI 88 – 96%; I2 = 60%) and 46% (95% CI 34 – 59%; I2 = 93%) for clipping and EVT, respectively. The rate of complete occlusion at last follow‐up was 94% (95% CI 91 – 96%; I2 = 0%) and 69% (95% CI 63 – 74%; I2 = 79%) for microsurgical clipping and EVT, respectively. Among EVT studies, the rate of complete occlusion was 54% (95% CI 48 – 59%; I2 = 50%), 52% (95% CI 39 – 64%; I2 = 73%), and 77% (95% CI 54 – 91%; I2 = 91%) for primary coiling, stent‐assisted coiling, and flow diversion, respectively. Among clipping studies, the rate of last follow‐up mRS 0–2 was 86% (95% CI 76 – 92%; I2 = 72%). Among EVT studies, the rate of last follow‐up mRS 0–2 was 94% (95% CI 86 – 98%; I2 = 93%). Mortality rate was 4% (95% CI 3 – 7%; I2 = 57%) and 1% (95% CI 0 – 3%; I2 = 0%) for clipping and EVT, respectively. Among EVT studies, the mortality rate was 3% (95% CI 1 – 6%; I2 = 0%) and 3% (95% CI 1 – 9%; I2 = 39%) for primary coiling and flow diversion, respectively. Intraoperative and postoperative complications were present in 9% (95% CI 6 – 14%; I2 = 68%) and 21% (95% CI 17 – 26%; I2 = 87%) among clipping studies, respectively. Intraoperative and postoperative complications were present in 6% (95% CI 4 – 9%; I2 = 64%) and 9% (95% CI 6 – 13%; I2 = 72%) among EVT studies, respectively. Conclusions In conclusion, microsurgical clipping and EVT for PAs are both safe and effective treatment modalities. Treatment via either approach should be determined on a case‐by‐case basis and according to institutional experience and resources.

Introduction The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature. Methods We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion. Results Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion. Conclusions The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.

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 Despite the irrefutable benefit of mechanical thrombectomy for patients with isolated intracranial large vessel occlusions (LVO), the effect of endovascular treatment in patients with tandem lesions remains unclear. In this study from the multi‐center PICASSO registry, we compare efficacy and safety outcomes in TLs patients treated in the early versus late window. Methods In this study, we used the data from the multi‐center PICASSO (Proximal Internal Carotid Artery Acute Stroke Secondary to Tandem Occlusion Thrombectomy) registry. PICASSO collaboration is a retrospective observational registry from 17 stroke centers. We compared efficacy and safety outcomes in TLs patients treated in the early versus late window. Patients were divided into two groups depending on last known well (LKW) to puncture time: Early time‐window group (

Introduction The incidence of ruptured cerebral arteriovenous malformations (AVMs) has increased as a consequence of the publication of the ARUBA trial. In the setting of ruptured AVMs, target embolization of high‐risk features can be considered to decrease the risk for recurrent hemorrhage. However, embolization with the intention to cure has not been well studied in ruptured AVMs. Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization for ruptured AVMs in pediatric patients. Methods Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for ruptured AVMs was conducted in two institutions. Demographic data, clinical presentation, Spetzler‐Martin (SM) grade, associated high‐risk vascular structures, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Results Sixty‐eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. The most frequent clinical presentation was headache (79%). There were 15 (22%) SM grade I lesions, 34 (51%) grade II, 14 (21%) grade III, and 4 (6%) grade IV. In 21 patients, twenty‐three high‐risk structures were observed (3 prenidal aneurysms, 12 intranidal aneurysms, 3 venous aneurysms, 2 varicose veins, 3 arteriovenous fistulae). Decompressive craniectomy with intracerebral hemorrhage evacuation was performed in 15 patients (22%). The mean number of sessions per patient was 1.6 (range 1 to 6) and n‐butyl cyanoacrylate was the most used embolic agent (30%). The transarterial approach was the most common (91%). The mean volume of embolic agents in each patient was 2.1 ml (range 0.1 to 6 ml). Seventeen intraprocedural complications (16% of procedures) were observed and no deaths were reported. In patients with high‐risk structures the rate of intraprocedural complications was 24%. The most common complication was microcatheter‐related vessel perforation (7%). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. The rate of complete obliteration in patients with high‐risk structures was 62%. Conclusions Curative embolization of ruptured pediatric AVMs shows a high rate of intraprocedural complications, especially when high‐risk associated vascular structures are present. In addition, acceptable complete obliteration rates were found. Appropriate long‐term follow‐up in prospective studies tailored to the pediatric population are required to determine the best therapeutic approach.

Introduction There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Methods Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. Results 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR = 0.57, 95%CI: 0.25‐1.29, p = 0.18), parenchymal hematoma type 2 (OR = 0.61, 95%CI: 0.3‐1.22, p = 0.16), and all‐cause mortality at 90 days (OR = 1.22, 95%CI: 0.66‐2.26, p = 0.52). However, the median puncture‐to‐reperfusion time was higher in AA compared with RA [59 minutes (IQR: 38–92) vs 53.5 minuntes (IQR: 37–87)]. Conclusions The AA and RA approaches for the treatment of tandem occlusions seem to achieve similar efficacy and safety outcomes. These results are consistent with those of a previous multi‐center study. Additionally, and in line with previous research, there is a puncture‐to‐reperfusion time difference between both approaches, which suggests a potential benefit when using the RA. However, further prospective randomized studies are needed to elucidate its benefit in achieving better clinical outcomes.

Background Current evidence comparing flow diverters (FDs) for the treatment of intracranial aneurysms is limited to single‐arm head‐to‐head retrospective and prospective studies. Herein, we aimed to compare the efficacy and safety of four FDs for the treatment of intracranial aneurysms. Methods We performed a retrospective, multicenter international cohort study of adult patients treated with FDs (Pipeline embolization device, Surpass Streamline, Flow Redirection Endoluminal Device, and Silk) for intracranial aneurysms between 2015 and 2021. Efficacy was determined by aneurysm occlusion at final follow‐up. Safety was determined by ischemic/hemorrhagic events and mortality. Secondary safety was assessed by technical complications. A mixed‐effect multivariable ordinal and logistic regression were performed to evaluate variables that predicted the outcomes of interest. Results We included 235 patients with 274 aneurysms. Treatment was performed with either the Pipeline embolization device (92), Surpass Streamline (56), Flow Redirection Endoluminal Device (47), and Silk (40). Median age was 57 (47–65) years. Most patients were asymptomatic (76%), and 8% had previous rupture. Most aneurysms were saccular (85%) and anterior (94%). The Pipeline embolization device subgroup had the largest aneurysms (6 mm, P=0.005). Median follow‐up time was 9 (6–14) months. Final overall complete occlusion was 72% without significant differences between FDs (P=0.5). Total ischemic (5%) and hemorrhagic (3%) events were also similar (P=0.1 and P=0.06). One patient expired (0.4%, P=0.6). In multivariable analysis, device diameter predicted aneurysm persistence and ≥50% in‐stent stenosis predicted ischemic/hemorrhagic complications. Conclusions Our findings comparing 4commonly used FDs in a heterogeneous population with mainly small‐sized aneurysms confirmed a similar safety and efficacy profile between devices.

Background Balloon‐assisted coiling (BAC) and stent‐assisted coiling (SAC) have been established as feasible approaches to manage ruptured wide‐necked intracranial aneurysms. Antiplatelet medications used with SAC theoretically increase risk of thrombotic and hemorrhagic complications. This study aims to evaluate safety and efficacy of SAC versus BAC for acutely ruptured wide‐necked intracranial aneurysms. Methods We performed a 2‐center retrospective observational study of consecutive patients treated with SAC or BAC for ruptured wide‐necked intracranial aneurysms from 2015 to 2020. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow‐up and functional status at 3 months. Safety outcomes included periprocedural hemorrhagic/ischemic complications and symptomatic ventriculostomy tract and cerebrospinal shunt hemorrhage rates. Univariable and multivariable analyses with multiple imputations to account for follow‐up loss were performed. Results A total of 112 and 109 patients underwent SAC and BAC, respectively. Median cohort age was 56 years, and 72% were female. Baseline characteristics were similar. Hydrocephalus rate was higher in the SAC group (78% versus 64%; P=0.02). Median aneurysm size was 5.1 mm. Anterior circulation aneurysms were most common (81%). Aneurysm and neck size were different, more aneurysms measuring

Flow diversion is an evolving endovascular modality for treating intracranial aneurysms. Although rare, serious adverse events following flow diversion may include ischemic stroke, intracranial hemorrhage, or delayed rupture of the treated aneurysm. This dataset describes 141 flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, or Surpass Streamline on 126 subjects with intracranial aneurysms [1]. The retrospective data were collected from electronic medical records at two large tertiary centers. Baseline patient data included age, sex, and medical comorbidities. The dataset also describes aneurysm characteristics including laterality, anatomic location, morphology, dome height, and neck width. In addition, digital subtraction images showing the internal carotid artery tortuosity were included for aneurysms in the anterior cerebral circulation [2]. Procedural data include case duration, radiation exposure, number of flow diverters deployed, and complications encountered during deployment. In addition, data related to the duration of hospitalization and postoperative adverse events are included. Finally, time to follow up and rates of total aneurysm obliteration at first and second postoperative visits are included. This data is propensity score matching are included. This data is presented as a starting point for future prospective comparisons in the safety and efficacy of flow diverters as more devices become approved and commercially available.

In stroke care, the extent of irreversible brain injury, termed infarct core, plays a key role in determining eligibility for acute treatments, such as intravenous thrombolysis and endovascular reperfusion therapies. Many of the pivotal randomized clinical trials testing those therapies used MRI Diffusion-Weighted Imaging (DWI) or CT Perfusion (CTP) to define infarct core. Unfortunately, these modalities are not available 24/7 outside of large stroke centers. As such, there is a need for accurate infarct core determination using faster and more widely available imaging modalities including Non-Contrast CT (NCCT) and CT Angiography (CTA).Prior studies have suggested that CTA provides improved predictions of infarct core relative to NCCT; however, this assertion has never been numerically quantified by automatic medical image computing pipelines using acquisition protocols not confounded by different scanner manufacturers, or other protocol settings such as exposure times, kilovoltage peak, or imprecision due to contrast bolus delays. In addition, single-phase CTA protocols are at present designed to optimize contrast opacification in the arterial phase. This approach works well to maximize the sensitivity to detect vessel occlusions, however, it may not be the ideal timing to enhance the ischemic infarct core signal (ICS).In this work, we propose an image analysis pipeline on CT-based images of 88 acute ischemic stroke (AIS) patients drawn from a single dynamic acquisition protocol acquired at the acute ischemic phase. We use the first scan at the time of the dynamic acquisition as a proxy for NCCT, and the rest of the scans as a proxy for CTA scans, with bolus imaged at different brain enhancement phases. Thus, we use the terms “NCCT” and “CTA” to refer to them. This pipeline enables us to answer the questions “Does the injection of bolus enhance the infarct core signal?” and “What is the ideal bolus timing to enhance the infarct core signal?” without being influenced by aforementioned factors such as scanner model, acquisition settings, contrast bolus delay, and human reader errors. We use reference MRI DWI images acquired after successful recanalization acting as our gold standard for infarct core.The ICS is quantified by calculating the difference in intensity distribution between the infarct core region and its symmetrical healthy counterpart on the contralateral hemisphere of the brain using a metric derived from information theory, the Kullback-Leibler divergence (KL divergence). We compare the ICS provided by NCCT and CTA and retrieve the optimal timing of CTA bolus to maximize the ICS.In our experiments, we numerically confirm that CTAs provide greater ICS compared to NCCT. Then, we find that, on average, the ideal CTA acquisition time to maximize the ICS is not the current target of standard CTA protocols, i.e., during the peak of arterial enhancement, but a few seconds afterward (median of 3 s; 95% CI [1.5, 3.0]). While there are other studies comparing the prediction potential of ischemic infarct core from NCCT and CTA images, to the best of our knowledge, this analysis is the first to perform a quantitative comparison of the ICS among CT based scans, with and without bolus injection, acquired using the same scanning sequence and a precise characterization of the bolus uptake, hence, reducing potential confounding factors.

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.

Introduction: Chronic internal carotid occlusion is responsible for 10–15% ischemic strokes or transit ischemic attacks (TIA). Subsequent ipsilateral ischemic stroke rate is 5.9% per year. However, this risk can increase up to 23% in two years in a subgroup of patients with poor collaterals regardless of medical therapy with antiplatelet or anticoagulant agents. Prevention of subsequent stroke in patients with carotid artery occlusion remains a difficult challenge. Carotid artery stenting (CAS) has recently been considered in its management. However, there is ambiguity on its safety. We aim to evaluate the safety and feasibility of CAS and compared it with medical management. Methods: We performed a systematic review and meta‐analysis to compare long‐term outcome (stroke recurrence) of current carotid occlusion treatments (CAS vs medical therapy). Two independent reviewers performed the screening, data extraction, and quality assessment. A random effects model was used for analysis. Results: A total of 5720 studies were screened. Of these, 11 studies were included in our systematic review and meta‐analysis of proportions. The CAS group has lower proportions of recurrent strokes (5% vs 30%,) after 30 days than medical therapy alone. Additionally, the proportion of periprocedural intracranial hemorrhage was 4.4% (95% CI 2.5 to 6.8) in the CAS group. Conclusions: CAS of the chronically occluded cervical ICA seems to be a safe procedure with lower rates of recurrent stroke in clinical follow up. Future randomized studies are warranted to guide the optimal management of this complex disease.

Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P=0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P