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

Background How the prevalence of atrial fibrillation (AF) has changed over time in various demographic subgroups of patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT) in the United States is unknown. Whether in‐hospital outcomes differ between patients with AF versus patients without AF after MT remains uncertain. Methods We conducted a serial cross‐sectional study using all primary AIS discharges in the 2010 to 2020 National Inpatient Sample. Discharges with MT codes were identified (n = 155 277), and the proportion with AF in various age, sex, and racial subgroups were computed. We used multivariable‐adjusted negative binomial regression to compare AF prevalence between demographic subgroups and joinpoint regression to evaluate trends over time. Multivariable‐adjusted generalized linear models were used to evaluate the association of AF with in‐hospital outcomes. Results Across the study period, 45.0% of AIS discharges with MT had AF, but prevalence varied by age, sex, and race or ethnicity. After multivariable adjustment, AF prevalence was 4% higher in women versus men (prevalence rate ratio, 1.04 [95% CI, 1.01–1.07]) and was lower in Black versus White (prevalence rate ratio, 0.80 [95% CI, 0.77–0.84]) but higher in Asian compared with White discharges (prevalence rate ratio, 1.11 [95% CI, 1.05–1.18]). Prevalence increased with age (prevalence rate ratio for ≥80 years versus 18–39 years, 5.23 [95% CI, 4.28–6.39]). Following joinpoint regression, prevalence increased by 3.2% (95% CI, 1.3%–5.2%) annually across the period 2010 to 2015 but declined by −2.2% (95% CI −2.9% to −1.4%) from 2015 to 2020. AF was associated with 22% lower odds of in‐hospital death (odds ratio, 0.78 [95% CI, 0.71–0.85]) and 13% greater odds of routine home discharge (odds ratio, 1.13 95% CI, 1.04–1.22]) compared with no AF. Conclusion AF prevalence in patients undergoing MT in the United States is approximately twice that of the general AIS population. AF prevalence in MT increased from 2010 to 2015 but declined from 2015 to 2020. In the subset of patients with AIS undergoing MT, AF is associated with reduced in‐hospital death.

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.

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 Cerebral angiography, essential in managing cerebrovascular disorders, exposes patients to ionizing radiation, with dose dependence on procedure complexity, patient's body habitus, and equipment used, raising safety concerns (1,2). Conversion from primary to secondary access site, influenced by anatomical variables, further increases procedure and fluoroscopy time (3). We propose using Computed Tomography Angiography (CTA) prior to DSA for anatomical insights, potentially reducing access site conversion, procedure time, and radiation dose/fluoroscopy time. This study evaluates the impact of pre‐procedural CTA on fluoroscopy time and access site conversion rates. Methods A retrospective chart review was conducted at a single center to collect data for this study. A total of 93 participants who received DSA were evaluated. Variables of interest included whether a CTA was performed prior to DSA, fluoroscopy time, fluoroscopy dose, time per vessel, dose per vessel, average number of vessels imaged, and the conversion rate from radial to femoral access. Descriptive statistics were used to summarize the data, and independent sample t‐tests were conducted to compare the means of continuous variables between the groups that received a CTA Neck prior to DSA and those that did not. All statistical analyses were performed using a significance level of 0.05. Results Out of 93 participants, 61 had a prior CTA neck and 32 did not. The non‐prior CTA group had slightly higher average fluoroscopy time (15.68 vs. 14.30 min, p=0.39) and dose (643.29 vs. 582.90, p=0.37), but lower time per vessel (3.42 vs. 3.65, p=0.58) and higher dose per vessel (162.80 vs. 145.01, p=0.63). They also imaged more vessels on average (4.81 vs. 4.33, p=0.09). Conversion percentage for non‐prior CTA was lower compared to the prior CTA group (6.25% vs. 6.56%) but not statistically significant. Standard deviation for all measures, except for time per vessel, was higher in the non‐prior CTA neck, indicating more variability in this group. Conclusion This retrospective analysis suggests that prior computed tomography angiography (CTA) might lead to reduced fluoroscopy times and dosage during procedures, but the results are not statistically significant at this stage. However, the study indicates that prior CTA cases had a higher percentage of access site conversions, though the sample size was small. Due to these findings, further investigation with a larger sample size is needed to explore these variables more thoroughly. If CTA before digital subtraction angiography (DSA) can indeed decrease procedure time, radiation exposure, and the need for access site conversion, it has the potential to significantly improve functional neurological outcomes. Moreover, it may reduce the occurrence of complications related to radiation exposure and decrease the overall costs associated with performing DSA and related neurointerventions.

Introduction Flow diverters have demonstrated reliable safety and effectiveness for the treatment of selected anterior circulation intracranial aneurysms. However, posterior circulation aneurysms comprise around 10‐15% of all aneurysms, and they frequently present atypical morphological and anatomical characteristics. Furthermore, these lesions have an increased risk of rupture (compared to those in the anterior circulation) with respect to size and higher treatment risks (regardless of the technique). Flow diversion in posterior circulation aneurysms has been described previously with inconsistent clinical and radiological results. Hence, we aimed to compare the safety and effectiveness of FDs in fusiform/dissecting vs. saccular aneurysms located in the vertebrobasilar vessels. Methods We performed a multicenter, retrospective cohort study including 9 centers. All patients treated with FDs for aneurysms located in the posterior circulation (vertebral and basilar arteries) between 2015 and 2022 were included. Patients were divided into two groups according to the morphology of the aneurysm (fusiform/dissecting vs. saccular). The effectiveness outcome was complete aneurysm occlusion (Raymond‐Roy Class 1) at the latest follow‐up. Safety outcomes included the incidence of ischemic/hemorrhagic and mortality. After adjusting for confounders multivariable logistic regressions were performed to compare outcomes of interest. Results A total of 147 patients with 147 aneurysms were included. The fusiform/dissecting group included 85 cases, while the saccular group 62. The saccular group had older patients (median age: fusiform/dissecting, 55 years [45‐64] vs. saccular, 63 years [51‐70.0]; p=.02). The number of female patients was not different between groups (fusiform/dissecting, 42% vs. saccular, 58%; p=.05). Clinical presentation, comorbidities, modified Fisher, and Hunt and Hess were similar. Baseline modified Rankin Score (mRS) was different (mRS 0‐2: fusiform/dissecting, 84% vs. saccular, 98%; p=.030). Previous endovascular treatment (p=.396) was similar. Aneurysm location (most were in the vertebral artery: fusiform/dissecting, 60% vs. saccular, 42%; p=.009) was different. Median aneurysm size (fusiform/dissecting, 10.0 mm [6.5‐18.8] vs. saccular, 5.9 [3.0‐10.0]; p=1 FD: fusiform/dissecting, 36% vs. saccular, 10%; p=

Introduction Prior research has demonstrated mechanical thrombectomy (MT) to be a safe and effective treatment for stroke patients with a large vessel occlusion (LVO).1 However, MT has generally only been studied in a time window of less than 24 hours.2 To the best of the authors' knowledge, this case report is the first publication of a MT done months after the initial stroke event, in a patient with recurrent strokes and an evolving occlusion visualized in the middle cerebral artery (MCA). Methods The patient is a 55‐year‐old man with a past medical history of a left‐sided MCA stroke 2 months prior to current admission with multiple transient ischemic attacks (TIAs) on dual antiplatelet therapy (DAPT), with no persistent residual deficits. His first stroke was preceded by about 1 week of intermittent confusion and right arm tingling. MRI at the time showed an acute embolic infarct in left MCA territory, and a CTA showed a sub‐occlusive thrombus vs. atherosclerotic plaque in the superior branch of the left MCA. He was discharged on DAPT, but his prior symptoms began to recur on a weekly basis, lasting for a few minutes each time. The patient eventually presented on this admission to the ED with persistent dysarthria and word finding difficulties. Within 4 hours, his exam improved to an NIHSS of 0. An MRI without contrast showed a new acute punctate infarct in the posterior left lateral temporal cortex. CT angiogram showed a persistent left M2 occlusion which was confirmed by the diagnostic cerebral angiogram. CT Perfusion also showed a large penumbra in the same region. The decision was made to perform MT, and complete recanalization was achieved. On 2‐month follow‐up, the patient continues to report no new symptoms since the time of MT. Results The patient’s positive outcome thus far at 60 day follow up indicates that MT can prove safe and efficacious even in significantly delayed time windows. This also shows that the decision to proceed with MT ought not to depend on time interval and degree of collaterals alone, but also on the pattern of symptoms the patient is exhibiting. The recurrent TIAs and strokes our patient was having indicates that, although collaterals had formed in response to his sub‐occlusive thrombus in the MCA, they were still unable to provide full compensation for this lost blood flow, leading to the patient’s intermittent symptoms. Conclusion This report demonstrates that MT can be safely and effectively utilized even in significantly delayed time windows in patients with recurrent TIAs or strokes.

Introduction Large vessel occlusions (LVO) account for approximately 15 to 30% of acute ischemic strokes, necessitating rapid clinical recognition to facilitate timely endovascular team activation and reduce door‐to‐reperfusion time for mechanical thrombectomy (MT). Existing clinical LVO scales, such as RACE, FASTED, and VAN, designed for utilization by Emergency Medical Services (EMS), lack reliability and have not been widely adopted for pre‐activation of endovascular teams. Typically, endovascular team activation occurs after LVO confirmation through neuroimaging, highlighting the need for improved methods to identify LVO during early assessments by neurologists. Methods A prospective observational study was conducted at University Hospital, involving all stroke codes activated by the Emergency Department (ED) or EMS. Neurology residents responding to the codes performed initial assessments, encompassing patient history, physical examination, and NIH Stroke Scale (NIHSS) evaluations. Based on the onset and severity of symptoms, presence of cortical signs, and NIHSS scores, patients were classified into four categories: A) probable LVO and stroke, B) possible LVO and stroke, C) not LVO but probable stroke, and D) probable stroke mimic. All assessments were completed before CT scanning. Results Over a ten‐month period, 159 stroke codes were evaluated by neurology residents. Among these, 27 patients were diagnosed with LVO, while 132 patients had no LVO. The neurology residents classified 18 patients into the probable stroke group, demonstrating a sensitivity of 48%, specificity of 96%, a positive predictive value (PPV) of 72%, and a negative predictive value (NPV) of 90%. Combining the probable and possible stroke groups, the residents identified 34 patients with a sensitivity of 74%, specificity of 89%, a PPV of 5%, and an NPV of 94%. Regrettably, seven patients with LVO were misclassified as either stroke mimics or non‐LVO strokes. Among these cases, five patients presented with low NIHSS scores, two had LVO in the posterior circulation, and one developed an in‐stent thrombus. Conclusion Our study revealed that neurology residents' ability to predict LVO was comparable to other LVO prediction scales in terms of sensitivity and specificity, but significantly improved in PPV. With a PPV exceeding 70%, the clinical prediction of LVO by neurology residents proves to be a valuable tool for activating the endovascular team promptly. This approach holds promise for enhancing stroke care in both the emergency department and pre‐hospital ambulance‐based settings. Nevertheless, larger studies are warranted to validate and further refine these findings. Implementing the neurology residents' clinical judgment in LVO identification can potentially optimize patient outcomes and treatment timelines in acute ischemic strokes.

Background For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry. Methods Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups. Results Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P

Introduction Transradial access (TRA) for neuroendovascular interventions has been associated with multiple benefits, including decreased risk of complications, faster recovery times, and improved overall patient satisfaction in comparison to transfemoral access (TFA). We sought to assess the safety and suitability of an 088 catheter, in this case the Infinity guide catheter, to understand the optimal patient population for utilization in neurointerventions. To our knowledge, this is the first prospective study to investigate procedural characteristics and complications associated with the use of an 088 catheter. Methods After obtaining approval from our Institutional Review Board, prospective patients undergoing neurointerventional procedures at our institution, beginning from December 2020 to present, were serially enrolled after evaluation for suitability for TRA by ultrasound visualization and measurement of vessel diameter. A prospective Excel database was generated on an encrypted and password‐protected computer, with variables including patient demographics, co‐morbidities, procedure type, catheter specifics, vessel diameter, procedural characteristics, TRA to TFA conversion, and complications. Results 78 patients were enrolled over a 1.5 year study period (Table 1). The average patient age was 62.4 ± 16.1 years, with a moderate male predilection (46/78 (59%)). Procedure subtypes for enrolled patients included 36 (46.2%) patients who underwent stroke intervention, 6 (7.7%) aneurysm coil embolization, 9 (11.5%) aneurysm flow diversion, 5 (6.4%) carotid stenting, 5 (6.4%) AVM/AVF embolization, 4 (5.1%) tumor embolization, and 13 other procedures (9 (11.5%) MMA embolization, 3 (3.8%) vessel embolization, 1 (1.3%) aneurysm Onyx embolization). All procedures were performed via right radial access under direct ultrasound visualization. Average radial diameter was 2.97 ± 0.46mm and average fluoroscopy time was 48.99 ± 23.54 minutes. Parent vessel spasm was noted in 25/78 (32.1%) of cases and guide catheter kinking was noted in 4/78 (5.1%). TRA to TFA conversion was noted in 14/78 (17.9%) patients, primarily due to vessel tortuosity (57.1%; 8/14 cases). Minor complications included post‐procedural hand/wrist pain in 14/78 (17.9%) patients, and hand bruising in 6/78 (7.7%). Post‐operative vessel patency was noted in 71/78 (91%) of cases via ultrasound, with 57/78 (73.1%) having good pulsation noted on reverse Barbeau testing. No serious radial artery complications were noted. The overall rate of major complications was 7.7%, with two cases of ischemic stroke, contrast extravasation/intracerebral hemorrhage, and vessel rupture noted. Conclusions This prospective pilot study demonstrates the safety and suitability of the 088 Infinity guide catheter via TRA radial approach for neuroendovascular interventions. Further studies will be needed to assess the efficacy of the 088 Infinity in comparison to other 088 catheters, as well as the optimal settings by which we can minimize rates of TFA conversion and TRA‐related complications.

Introduction Higher blood pressure (BP) is considered to be harmful in patients who undergo mechanical thrombectomy (MT), however, the impact of BP post‐MT based on comorbidities like anemia has not been well studied. We aim to determine the association of 24‐h post‐MT BP parameters with mortality depending on the anemia status. Methods We conducted a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. Patients were dichotomized into anemic and non‐anemic groups based on the World Health Organization’s definition of anemia [hemoglobin < 12.0 g/dL in women and < 13.0 g/dL in men]. We performed a binary logistic regression analysis controlling for baseline parameters, with the 24‐h post‐MT BP parameters as predictors. The primary outcome was 3‐month mortality. Results 220 patients met the inclusion criteria. The 3‐month mortality rate was 27.27%. In the multivariable analysis, the 24‐h parameters of a lower mean DBP (65.53±9.73 vs. 71.94±10.16; OR, 0.92; 95% CI, 0.86‐0.98; P 0.007), lower mean MAP (85.7±8.65 vs. 91.38±10; OR, 0.93; 95% CI, 0.86‐0.99; P 0.02), a lower minimum DBP (49.27±10.51 vs. 55.1±11.23; OR, 0.93; 95% CI, 0.88‐0.99; P 0.019), a lower minimum MAP (68.96±9.54 vs. 74.73±10.47; OR, 0.93; 95% CI, 0.87‐0.99; P 0.023) were significantly associated with mortality in patients with anemia. There was no association between 24‐hour BP Parameters post‐MT and mortality in non‐anemic patients. Conclusions In our study, lower BP parameters were associated with higher 3‐month mortality in anemic patients, however, this effect was not found in non‐anemic patients. Anemia induces a relative hypoxic state in target tissue in the event of an increase in metabolic demand such as stroke. Higher BP post‐MT can potentially promote perfusion and thus is not associated with worse outcomes in anemic patients post‐MT, whereas in non‐anemic patients it may potentially lead to reperfusion injury.

Introduction The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial published in 2010 showed aggressive medical therapy is superior to percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD). Following the pivotal positive mechanical thrombectomy (MT) trials in 2015, MT utilization in the United States (US) has increased. Rescue ICAD stenting may be needed in MT patients with underlying ICAD but it remains uncertain whether PTAS use for ICAD has changed over this time. The aim of this study is to describe national trends in the utilization of PTAS for ICAD in the US before and after SAMMPRIS and following the pivotal MT trials. Methods We used a constellation of International Classification of Diseases ninth and tenth revision diagnostic/procedural codes to identify all elective and non‐elective adult (> = 18 years) ICAD admissions with or without infarction containing concomitant codes for PTAS in the 2007–2019 National Inpatient Sample. Admissions containing codes for subarachnoid hemorrhage, unruptured intracranial aneurysms or benign intracranial hypertension were excluded. We combined weighted counts of PTAS admissions with annual US adult census data to obtain prevalence of PTAS. We used joinpoint regression to evaluate trends in PTAS use over time. Results Across the study period, there were 16,477 weighted admissions for ICAD undergoing PTAS in the US. 52.4% of these admissions were in patients 60–79years and 43.2% were in women. 74.3% of these admissions were non‐elective and this proportion increased over time (P = 0.019). 26.5% of all admissions had concurrent codes for MT but this proportion increased by almost ten‐fold over time from 4.3% in 2007 to 40.0% in 2019. On join point regression, PTAS utilization increased but insignificantly from 3.0/million population in 2007 to 5.7/million population in 2010 (Annualized percentage change, APC 11.2%, 95%CI ‐11.8 to 40.3, p = 0.290), declined also insignificantly from 2010–2013 (APC ‐13.2, 95%CI ‐48.4 to 45.8, p = 0.514) and increased significantly from 3.55/million in 2013 to 3.80/million in 2014 and exponentially across the rest of the period to 8.4 cases/million in 2019 (APC 15.4, 95%CI 9.2 to 22.0, p = 0.001). Upon stratification by admission type, most of the increase across the period 2013/2014 to 2019 occurred in non‐elective admissions (Figure 1). Utilization in elective admissions varied from 0.92 to 1.96 cases per million population but this did not change significantly across the study period. Conclusions PTAS utilization for ICAD declined in the US after SAMMPRIS but has increased following publication of pivotal MT trials mainly in non‐elective admissions. PTAS utilization increased significantly following publication of pivotal MT trials likely in ICAD patients who required rescue stenting.. Additional prospective studies are needed to determine the long‐term outcomes of concurrent PTAS and MT as this is not a group of patients that was studied in SAMMPRIS.

Introduction Continued advancements in the treatments for neurological disease have helped interventionalists to refine approaches that offer improved surgical efficacy and patient outcomes. Carotid‐artery stenting (CAS) is a safe and effective alternative to carotid endarterectomy (CEA), that allows for revascularization of the internal carotid artery (ICA) in a minimally‐invasive manner. Traditionally, the mainstay for CAS has been through the femoral artery; however, patients with carotid‐artery disease (CAD) often have concomitant peripheral artery disease which confer increased risk of significant life‐threatening access‐site complications, such as retroperitoneal hematoma and limb ischemia. Given this, CAS via the radial artery has become increasingly popular. This study seeks to investigate the safety and feasibility of the transradial approach (TRA), in comparison to the traditional transfemoral approach (TFA), for carotid‐artery stenting. Methods The authors conducted a retrospective analysis of all adult patients (age >18) who underwent carotid‐artery stenting via TRA or TFA over a 4‐year study period (2018‐2021) across 4 different international academic centers. Important variables, such as patient demographics, comorbidities, procedural details, results, and complications were collected. Statistical analysis was performed to assess the strength of association and correlation for these variables. Results A total of 313 patients were enrolled during the study period. CAS via TFA was attempted in 251 patients and via TRA in 62 patients, respectively. Overall, CAS via TRA was found to be successful in 48/62 (76%) patients, and via TFA in 246/251 (98%) patients. Baseline demographics were similar for the two groups, with a female gender predilection, median age of 69, and hypertension and hyperlipidemia serving as the most common medical comorbidities. 14/62 (22.6%) patients who underwent TRA were converted to TFA. Spasm of the radial artery, kinking of the catheter and severe tortuosity of the vessels were the primary reasons for access site conversion. A total of five major access site‐related complications, including two deaths, and seven minor complications were noted in the TFA cohort. No serious access related complications were noted in the TRA group. In the multivariate‐analysis, after adjusting for age, hyperlipidemia, chronic heart failure, combination of stent plus angioplasty and fluoroscopy times, there was no statistically significant difference observed among the 2 groups in terms of procedural (OR: 0.31; CI: 0.36‐2.69; P = 0.29) and overall access site complications (OR: 0.17, CI: 0.02‐1.98, P = 0.16). Conclusions TRA seems to be a safe alternative approach for carotid stenting. In our cohort, no serious access site‐related complications were noted with TRA in comparison to the TFA group. Continued improvements in terms of patient selection, sample size, as well as advances in technique and technology will help to further refine TRA for CAS. Further studies and analysis will need to be performed to delineate the crucial variables that contribute to improved functional outcomes for these patients.

Introduction Management of acute large vessel occlusion due to intracranial stenosis remains challenging with high complication and poor recanalization rates. Morbidity is also related to the intracranial exchange that is required for stent placement after the rescue angioplasty. We aim to present our initial experience of deployment of Neuroform Atlas stent through the lumen of a Gateway angioplasty balloon to avoid microcatheter exchange. Methods Patients were identified from prospectively collected mechanical thrombectomy stroke database from Feb 2019 to July 2021. Demographic and clinical information was collected. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0–3), and the rate of intracranial hemorrhage (ICH). Good angiographic recanalization (TICI ≥ 2b), and mortality at 30 days were other outcomes. Results We identified 5 patients treated with this approach [mean age 54 ± 14 years, all were men] who presented with large vessel occlusion of middle cerebral artery. Initial median NIHSS was 8 (range 6–16) with one patient received IV t‐PA. Patient initially underwent mechanical thrombectomy using the Solumbra technique. Due to reocclusion or impending occlusion with evidence of atherosclerotic plaque, rescue angioplasty with stent placement was performed. Patients were loaded with 650 mg of aspirin and 180 mg of ticagrelor through nasogastric tube prior. Balloon angioplasty was performed using the gateway balloon size ranging from 1.5 to 3 mm which was inflated to subnominal pressures over 1 minutes. This was followed by placing Neuroform atlas stent through the gateway balloon with size ranging from 3 to 4 mm diameter and length ranges from 21–24 mm. TICI ≥ 2b was achieved in 4 patients. Mean time from symptoms onset to revascularization was (336 ± 90) minutes. One patient had asymptomatic ICH. 2 patients had mRs 0–3 at the time of discharge and one patient was dead at 1 month Conclusions Our preliminary experience showed lower risk of guidewire perforation as well as potentially decreased operative time and early reperfusion by deploying the Neuroform stent through a compatible gateway balloon microcatheter. This should be investigated further in a large multicenter study

BackgroundCoronavirus disease 2019 (COVID-19) is an immunoinflammatory and hypercoagulable state that contributes to respiratory distress, multi-organ dysfunction, and mortality. Dipyridamole, by increasing extracellular adenosine, has been postulated to be protective for COVID-19 patients through its immunosuppressive, anti-inflammatory, anti-coagulant, vasodilatory, and anti-viral actions. Likewise, low-dose aspirin has also demonstrated protective effects for COVID-19 patients. This study evaluated the effect of these two drugs formulated together as Aggrenox in hospitalized COVID-19 patients.MethodsIn an open-label, single site randomized controlled trial (RCT), hospitalized COVID-19 patients were assigned to adjunctive Aggrenox (Dipyridamole ER 200mg/ Aspirin 25mg orally/enterally) with standard of care treatment compared to standard of care treatment alone. Primary endpoint was illness severity according to changes on the eight-point COVID ordinal scale, with levels of 1 to 8 where higher scores represent worse illness. Secondary endpoints included all-cause mortality and respiratory failure. Outcomes were measured through days 14, 28, and/or hospital discharge.ResultsFrom October 1, 2020 to April 30, 2021, a total of 98 patients, who had a median [IQR] age of 57 [47, 62] years and were 53.1% (n = 52) female, were randomized equally between study groups (n = 49 Aggrenox plus standard of care versus n = 49 standard of care alone). No clinically significant differences were found between those who received adjunctive Aggrenox and the control group in terms of illness severity (COVID ordinal scale) at days 14 and 28. The overall mortality through day 28 was 6.1% (3 patients, n = 49) in the Aggrenox group and 10.2% (5 patients, n = 49) in the control group (OR [95% CI]: 0.40 [0.04, 4.01], p = 0.44). Respiratory failure through day 28 occurred in 4 (8.3%, n = 48) patients in the Aggrenox group and 7 (14.6%, n = 48) patients in the standard of care group (OR [95% CI]: 0.21 [0.02, 2.56], p = 0.22). A larger decrease in the platelet count and blood glucose levels, and larger increase in creatinine and sodium levels within the first 7 days of hospital admission were each independent predictors of 28-day mortality (p < 0.05).ConclusionIn this study of hospitalized patients with COVID-19, while the outcomes of COVID illness severity, odds of mortality, and chance of respiratory failure were better in the Aggrenox group compared to standard of care alone, the data did not reach statistical significance to support the standard use of adjuvant Aggrenox in such patients.

OBJECTIVES: As hospitals rapidly implement mechanical thrombectomy (MT) into stroke protocols following the pivotal trials in 2015, access to and outcomes from MT may be poorer for weekend-admitted patients. We sought to investigate whether a “weekend effect” influences MT outcomes nationally. MATERIALS AND METHODS: We identified stroke patients from 2010–2014 (pre-trials) to 2015–2017 (posttrials) using the Nationwide Readmissions Database. On multivariate analyses, we determined factors independently associated with receiving MT. Among MT patients, we then determined whether weekend admission was independently associated with inpatient mortality and unfavorable discharge. RESULTS: We identified 2,121,462 patients from 2010 to 2014, of whom 1.11% of weekday-admitted and 1.08% of weekend-admitted patients underwent MT. Of the 1,286,501 patients identified from 2015 to 2017, MT was performed in 2.82% and 2.91%, respectively. In the earlier cohort, weekend admission was independently associated with reduced odds of MT (odds ratio [OR] = 0.92, 95% confidence interval [CI]: 0.89–0.95, P < 0.0001), although this was not statistically significant in the later cohort. During both periods, age >80 years was independently associated with a reduced likelihood of receiving MT, and status as a teaching or large bed-size hospital was associated with a greater likelihood. Weekend admission was independently associated with unfavorable discharge only in the 2015–2017 cohort (OR = 1.11, 95% CI: 1.02–1.22, P = 0.02). CONCLUSIONS: While nationwide access to MT has improved for weekend-admitted patients, the elderly and those at smaller, nonteaching hospitals remain underserved. Although we found no effect of weekend admission on inpatient mortality, since the major shift in practice, an emerging “weekend effect” may influence discharge outcomes. Data suggest that some hospitals are being challenged to provide this new standard of care efficiently and equitably.

Background The COVID‐19 pandemic has disproportionately affected Black and Hispanic communities, whose stroke care has been previously shown to experience existing disparities. We sought to evaluate how these disparities in stroke care and in‐hospital mortality have been affected by the COVID‐19 pandemic. Methods In this retrospective observational cohort study, we evaluated stroke hospitalizations in the Society of Vascular and Interventional Neurology COVID‐19 registry. We compared stroke characteristics between non‐Hispanic White, non‐Hispanic Black, and Hispanic patients pre–COVID‐19 and post–COVID‐19 (March–July 2019 versus March–July 2020) and evaluated whether racial and ethnic differences present before the pandemic were exacerbated during the pandemic. Our primary outcome was in‐hospital mortality/discharge to hospice, and secondary outcomes were acute treatment use. Results Of the 4908 included patients, numerically fewer non‐Hispanic White and Hispanic patients were evaluated during COVID‐19. Non‐Hispanic White and non‐Hispanic Black patients with large‐vessel occlusion were more likely to undergo thrombectomy (P

Background Compared with non‐Hispanic White patients, non‐Hispanic Black (NHB) and Hispanic populations are less likely to receive acute treatment for ischemic stroke, and when they do, it can be delayed. We evaluated the interaction between arrival method and race or ethnicity on door‐to‐arterial puncture (DTAP) time in thrombectomy. Methods We conducted a retrospective observational cohort study of consecutive adults who underwent endovascular thrombectomy from 14 US Comprehensive Stroke Centers (January 1, 2019–July 31, 2020). DTAP was assessed in a linear mixed model including an interaction term for race or ethnicity and arrival method. Results Of the 1908 included patients, 356 of whom were Hispanic, Hispanic and NHB patients experienced significant delays in DTAP compared with non‐Hispanic White patients (adjusted βHisp=0.32, 95% CI, 0.08–0.55; βNHB=0.23; 95% CI, 0.04–0.41). More severe deficits were associated with shorter DTAP (βNIHSS per point −0.03; 95% CI −0.04 to −0.03), and arrival via emergency medical services or private vehicle versus transfer were associated with longer delays (βEMS=0.57; 95% CI, 0.41–0.74; βPV=1.27; 95% CI, 0.85–1.70). There was a significant interaction between Hispanic ethnicity and emergency medical services (P=0.03) or private vehicle arrival (P=0.04) in a direction favoring shorter treatment delays. Sites that treated a minority population of Hispanic patients (

BACKGROUND: The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS: There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS: While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.

Patients with COVID-19 may suffer from hemorrhagic complications. Our article highlights two cases of COVID-19-infected patients, who suffered severe epistaxis after initiation of intravenous recombinant tissue plasminogen activator (IV-rtPA) for acute ischemic stroke, followed by a sudden decline in their clinical status and ultimately leading to death within days. Given the global impact and mortality of COVID-19, it is essential to be aware of its unusual presentation and improve therapeutic strategies. We present two cases of individuals who suffered from a large vessel occlusion of and were candidates for both IV-rtPA and mechanical thrombectomy. They received IV-rtPA but had epistaxis so severe that they were not able to receive MT and died within the next few days. There are many potential mechanisms by which epistaxis can happen in an individual with COVID-19 who received IV-rtPA including invasion of the nasal mucosa and endothelium through angiotensin-converting enzyme 2 receptors by the virus. We also hypothesize that the coagulation abnormality seen in COVID-19 patients can be potentiated by the use of treatments such as IV-rtPA. We review these issues with a diagram illustrating the possible mechanisms.

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

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

Background COVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19.Methods We reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19.Results We identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests.Interpretation LVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.