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Background: The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75–3mm. We report our first clinical experiences. Methods: Between March 2018–January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29–73 years). Results: In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9–34.2%) and mortality was 4.5% (1 of 22, 95%CI <0.01–23.5%). Most complications were procedure-related and not device-specific. Of 22 patients with 25 aneurysms treated with p48, 18 patients with 20 aneurysms had angiographic follow-up after 5–18 months. Of 19 aneurysms, 10 were occluded and 7 showed a remnant. Two aneurysms were open after 6 months. Three aneurysms were still not occluded after 12, 14, and 18 months and these 3 were retreated. Retreatment rate was 16% (3 of 19) and the adequate occlusion rate was 90% (17 of 19). Conclusions: Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately. [ABSTRACT FROM AUTHOR]

Background and purpose: Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. Materials and methods: We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. Results: Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1–6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. Conclusion: The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern. [ABSTRACT FROM AUTHOR]

Background: The MR CLEAN NO-IV trial showed neither superiority nor noninferiority of endovascular treatment (EVT) alone compared to intravenous thrombolysis (IVT; Alteplase) before EVT in acute ischemic stroke (AIS) patients with large vessel occlusion of the anterior circulation. Although the treatment effect is largely attributable to EVT, IVT may affect hypercoagulability during AIS., Aims: To investigate the association between activated coagulation and final infarct volume and clinical outcomes (modified Rankin Scale 3-6 and mortality 90 days post-EVT), and whether this effect is modified by IVT administration., Methods: Enzyme-linked immunosorbent assays were used to quantify activated coagulation markers (activated coagulation factor (F) XIIa-C1 esterase inhibitor (C1inh); FXIIa-antithrombin (AT), FXIa-C1inh, FXIa-AT, FIXa-AT, FXa-AT, T-AT, FVIIa-AT) in plasma samples obtained on admission (T 0 ), 1 h post-EVT (T 1 ) and 24 h post-EVT (T 2 ). Multivariable regressions were performed to investigate the associations and effect modification., Results: In the total cohort of 116 patients, a significant increase at T 1 was seen in FIXa-AT (p = .001), FXa-AT (p < .001), T-AT (p < .001), and FVIIa-AT (p = .012), while there was a significant increase at T 2 in FXIIa-C1inh (p < .001). Similar results were seen in the IVT+EVT subgroup. The EVT alone subgroup showed a significant temporary increase at T 1 in FXa-AT (p < .001) and T-AT (p = .014). Neither the enzyme:inhibitor complexes nor the interaction with IVT were significantly associated with the outcome measures., Conclusion: Despite temporary significant increases in enzyme:inhibitor complexes in the IVT+EVT group, but not in the EVT alone group, there were no significant associations with final infarct volume and clinical outcomes., Competing Interests: Declaration of competing interest Magdolna Nagy reports financial support was provided by Dutch Heart Foundation. Charles BLM Majoie reports a relationship with Dutch Heart Foundation that includes: funding grants. Charles BLM Majoie reports a relationship with Stryker that includes: funding grants. Charles BLM Majoie reports a relationship with Boehringer Ingelheim that includes: funding grants. Charles BLM Majoie reports a relationship with European Commission, Healthcare Evaluation Netherlands that includes: funding grants. Charles BLM Majoie reports a relationship with TWIN Foundation that includes: funding grants. Hugo ten Cate reports a relationship with Novostia that includes: consulting or advisory. Hugo ten Cate reports a relationship with Galapagos that includes: consulting or advisory. Hugo ten Cate reports a relationship with Astra Zeneca that includes: consulting or advisory. Hugo ten Cate reports a relationship with Alveron that includes: consulting or advisory. Hugo ten Cate reports a relationship with Coagulation Profile that includes: equity or stocks. Charles BLM Majoie reports a relationship with Nicolab that includes: equity or stocks. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Both CT angiography and CT perfusion involve the administration and tracking of a contrast medium bolus for different purposes. In this study, we aim to compare the diagnostic accuracy and subjective image quality of CTP-angiographic reconstructions with conventional CTA for occlusion detection in ischemic stroke patients., Methods: In this retrospective study, patients with a final diagnosis of ischemic stroke and who underwent both CTA and CTP from September 2020 up to and including September 2021 were included. CTP-AR was reconstructed from the 1 mm CTP series at the time of maximum arterial inflow. Three reviewers with different levels of experience assessed both CTA and CTP for occlusion detection, expressed certainty, and rated subjective image quality. The reference standard was set at the consensus meeting. Pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Differences in subjective and objective image quality and certainty were assessed using Kendall's tau correlation and paired samples t-tests., Results: In total, 107/210 included patients had an occlusion based on our reference standard. Pooled sensitivity and specificity for occlusion detection were 90% (95%CI 85-93) and 94% (95%CI 90-97) for CTA, and 89% (95%CI 84-93) and 93% (95%CI 89-96) for CTP-AR, respectively. The pooled certainty did not significantly differ between CTA and CTP-AR (P=.43). The pooled subjective image quality scores significantly differed between CTA and CTP-AR (τ = 0.3, P<.001), where one reviewer rated subjective image quality higher in CTA and two reviewer in CTP-AR., Conclusion: CTP-AR has comparable diagnostic accuracy to conventional CTA imaging for occlusion detection in ischemic stroke patients. Thus, using CTP-AR instead of CTA plus CTP may conserve contrast medium., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: WHZ reports speaker fees from Stryker, Cerenovus, Medtronic, Microvention and Nicolab, and consulting fees from Philips (all paid to institution); chaired the advisory boards of WeTrust (Philips) and ANAIS ([Advanced Neurovascular Access in Combination With a Stent Retriever in Patients With Acute Ischemic Stroke]; Anaconda) (all paid to institution); and chaired the advisory board of InExtremis (CHU Montpellier, Montpellier, France) for which no payments were received. AAP received an institutional grant from Siemens Healthineers and Bayer Healthcare. Other co-authors have nothing to disclose., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background and Aim: The clinical importance and management of vasospasm as a complication during endovascular stroke treatment (EVT) has not been well studied. We sought to investigate current expert opinions in neurointervention and therapeutic strategies of iatrogenic vasospasm during EVT., Methods: We conducted an anonymous international online survey (4 April 2023 to 15 May 2023) addressing treatment standards of neurointerventionalists (NIs) practising EVT. Several illustrative cases of patients with vasospasm during EVT were shown. Two study groups were compared according to the NI's opinion regarding the potential influence of vasospasm on patient outcome after EVT using descriptive analysis., Results: In total, 534 NI from 56 countries responded, of whom 51.5% had performed >200 EVT. Vasospasm was considered a complication potentially influencing the patient's outcome by 52.6% (group 1) whereas 47.4% did not (group 2). Physicians in group 1 more often added vasodilators to their catheter flushes during EVT routinely (43.7% vs 33.9%, p=0.033) and more often treated severe large-vessel vasospasm with vasodilators (75.3% vs 55.9%; p<0.001), as well as extracranial vasospasm (61.4% vs 36.5%, p<0.001) and intracranial medium-vessel vasospasm (27.1% vs 11.2%, p<0.001), compared with group 2. In case of a large-vessel vasospasm and residual and amenable medium-vessel occlusion during EVT, the study groups showed different treatment strategies. Group 2 continued the EVT immediately more often, without initiating therapy to treat the vasospasm first (9.6% vs 21.1%, p<0.001)., Conclusion: There is disagreement among NIs about the clinical relevance of vasospasm during EVT and its management. There was a higher likelihood of use of preventive and active vasodilator treatment in the group that perceived vasospasm as a relevant complication as well as differing interventional strategies for continuing an EVT in the presence of a large-vessel vasospasm., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Direct aspiration during endovascular treatment (EVT) for acute ischemic stroke (AIS) patients is safe and effective. The 'Soft torqueable catheter Optimized For Intracranial Access' (Sofia) catheter is commonly used. Data on differences between 5Fr and 6Fr Sofia is limited. Hence, we aimed to compare the clinical, technical, and safety outcomes between both Sofia catheters in AIS patients., Methods: Patients with an intracranial anterior circulation occlusion from the 'Maastricht Stroke Quality-registry' (MaSQ-registry), who underwent EVT for AIS from September 2020 to February 2023, and treated with the Sofia catheter in the first-line technique were included. Outcomes included a shift on the modified Rankin Scale (mRS) score at 90 days, favorable functional outcome (mRS 0-2), first-attempt recanalization rate, and per procedural complications. Multivariable regression analyses were performed with adjustments., Results: Out of 511 registered patients in the MaSQ-registry, 366 patients were included. 281 patients (77 %) were treated with the Sofia 6Fr. No shift towards better outcomes on the ordinal mRS score at 90 days was observed in the Sofia 6Fr group compared to the 5Fr (adjusted common[ac] OR:1.34, 95 %CI:0.70-2.56). Favorable functional outcome (aOR:1.24, 95 %CI:0.49-3.13), and per procedural complications (aOR:1.04, 95 %CI:0.41-2.64) did not differ significantly between Sofia 6Fr and 5Fr. The Sofia 6Fr achieved higher first-attempt successful recanalization rates (53 % versus 34 %; aOR:2.28, 95 %CI:1.11-4.69), and lower total thrombectomy attempts (median:1 versus 2; aβ:-0.63, 95 %CI:-1.21 to -0.05)., Conclusions: The use of 6Fr Sofia aspiration catheter leads in this single-center registry to higher first-attempt successful recanalization rates and fewer thrombectomy attempts compared to the 5Fr Sofia catheter. However, this did not reflect in better clinical outcomes., Competing Interests: Declaration of competing interest WHvZ reports speaker fees from Stryker, Cerenovus, and Nicolab, and consulting fees from Philips (all paid to institution); participated in the advisory boards of WeTrust (Philips) and ANAIS (Anaconda) (all paid to institution); and participated in the advisory boards of InEcxtremis (CHU Montpellier, Montpellier, France) and DISTAL (University Hospital Basel, Basel, Switzerland), studies for which no payments were received. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Pre- and post-endovascular treatment (EVT) imaging may aid in predicting functional outcomes in acute middle cerebral artery (MCA) ischemic stroke. Low post-EVT contrast extravasation (CE)-ASPECTS is associated with poor functional outcomes. Besides the MCA regions included in the ASPECTS score, CE may be seen in the mesial temporal (MT) region. In this study, we investigated the frequency and prognostic implication of MT-CE in acute ischemic stroke patients., Methods: Patients with an acute ischemic stroke due to anterior large vessel occlusion who received EVT and post-EVT DECT between 2010 and 2019 were included. Iodine overlay maps of DECT were assessed for the occurrence of CE, using the ASPECTS for occurrence in the MCA region and, calculating a CE-ASPECTS, for whether the MT region was involved. Multivariable linear and logistic regression were used to assess the relationship between involvement of MT-CE and 24-48h NIHSS, mRS, and mortality on a multiple imputed dataset. All models were adjusted significant variables in univariate analyses and for total CE-ASPECTS., Results: 501/651 patients met the inclusion criteria. MT-CE occurred in 97 (19 %) patients, and was more often present in patients with internal carotid artery occlusions. MT-CE was associated with higher NIHSS scores at 24-hours (aβ 2.2, 95 % CI 0.09-4.31), with increased risk of higher mRS scores (acOR 1.88, 95 % CI 1.16-3.06), and with increased risk of mortality (aOR 2.12, 95 % CI 1.16-3.86)., Conclusion: MT-CE is a common finding on post-EVT DECT and is an independent predictor for worse functional outcomes., Competing Interests: Declaration of competing interest W.Z reports consulting fees from Philips, and speaker fees from Stryker, Cerenovus, and Nicolab (all paid to the institution). Moreover, he is participating in the Safety Monitoring Board or Advisory Board of WeTrust (Philips), InEcxtremis (CHU Montpellier), ANAIS (Anaconda), and DISTAL (University of Hospital Basal) studies. A.P received an institutional grant from Siemens Healthineers and Bayer Healthcare. Other co-authors have nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

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

Background: CT perfusion angiographic reconstructions (CTP-AR), derived at the peak arterial inflow, have demonstrated similar diagnostic accuracy to CTA for occlusion detection in the anterior circulation. Colour-coded CTP maps may aid in localizing an occlusion. This study aim to assess the additional value of CTP maps for occlusion detection in ischemic stroke patients assessed with CTA or CTP-AR., Methods: In this single center retrospective study, ischemic stroke patients who underwent both CTA and CTP from September 2020 up to and including September 2021 were included. The 1 mm CTP series at peak arterial inflow corresponds to the CTP-AR. Following the initial assessment of CTA and CTP-AR for occlusion detection, three readers with varying levels of experienced, reassessed the CTA and CTP-AR with access to the color-coded CTP maps. Each CTA and CTP-AR was reviewed by two readers, and certainty of assessment was recorded. The reference standard was determined through a consensus meeting. Differences in certainty were assessed using a t-test for paired samples., Results: Out of 210 patients, 107 patients had an occlusion based on our reference standard. The addition of CTP maps resulted in the finding of 11 (2.6%) additional occlusions out of 420 CTA readings and 9 (2.1%) out of 420 CTP-AR readings, primarily involving distal occlusions. After addition of CTP maps, 7 (1.6%) initial assessments on CTA and 3 (0.7%) initial assessments on CTP-AR were deemed false positive. The overall certainty of all readers significantly (P < 0.001) increased after addition of CTP maps., Conclusion: The usage of CTP maps improved occlusion detection on both CTA and CTP-AR, especially for distal occlusions, and resulted in the increase of the overall level of certainty among readers with varying levels of experience., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Importance: Recent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset., Objective: To evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset., Design, Setting, and Participants: Open-label, blinded-end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023., Intervention: The intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone., Main Outcomes and Measures: The primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage., Results: The trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], -0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages., Conclusions and Relevance: Among patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study., Trial Registration: ClinicalTrials.gov Identifier: NCT03805308.

Background: The MR CLEAN-LATE trial provided evidence for the safety and efficacy of endovascular treatment for acute ischaemic stroke within the late window (after 6-24 h) in patients who were preselected based on the presence of collateral flow on CT angiography. We aimed to evaluate clinical outcomes 2 years after randomisation., Methods: MR CLEAN-LATE was a phase 3, multicentre, open-label, blinded-endpoint, randomised controlled trial conducted at 18 stroke intervention centres in the Netherlands. If endovascular treatment could be initiated within 6-24 h of symptom onset or last seen well, patients (aged 18 years or older) with an acute ischaemic stroke due to a large vessel occlusion in the anterior circulation and at least some collateral flow in the affected middle cerebral artery territory on CT angiography were randomly assigned (1:1) to either endovascular treatment with best medical treatment (endovascular treatment group) or best medical treatment alone (control group). Web-based randomisation, stratified by centre, was performed with the use of permuted blocks (block size eight to 20). The researchers who collected clinical outcomes and analysed the results were masked to treatment allocation; treating physicians, local investigators, and patients were aware of the received treatment. The primary outcome of MR CLEAN-LATE was the modified Rankin Scale (mRS) score at 90 days after randomisation. For this 2-year prespecified analysis, the primary outcome was mRS score at 2 years (minus 3 months to plus 6 months). Primary and safety analyses were performed based on the modified intention-to-treat principle, and included patients who provided (deferred) consent or died before consent could be obtained. Missing data were handled with multiple imputation by chained equations. The trial is completed and is registered at ISRCTN, ISRCTN19922220., Findings: Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned in the MR CLEAN-LATE trial, of whom 502 (94%) gave deferred consent and comprised the modified intention-to-treat population (255 in the endovascular treatment group and 247 in the control group). 261 (52%) patients were female and 241 (48%) were male. Data for mRS score at 2 years were available for 226 (89%) patients in the endovascular treatment group and for 202 (82%) patients in the control group. The median mRS score at 2 years was 4 (IQR 2-6) in the endovascular treatment group and 6 (2-6) in the control group. The endovascular treatment group demonstrated a shift towards better functional outcomes on the mRS (adjusted common odds ratio 1·41 [95% CI 1·00-1·99]; p=0·049). All-cause mortality at 2 years was 34% (87 of 255) in the endovascular treatment group and 41% (101 of 247) in the control group (adjusted hazard ratio 0·81 [95% CI 0·60-1·08]; p=0·15). Major vascular events (ie, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, and cardiac events) were reported between 90 days and 2 years in 23 patients in the endovascular treatment group and 13 patients in the control group., Interpretation: Our results show that the effectiveness of late-window (after 6-24 h) endovascular treatment in improving clinical outcomes is sustained for up to 2 years in a population preselected based on the presence of collateral flow on CT angiography. This finding might be important for prompting further evaluations of cost-effectiveness, health-care policy development, and clinical decision making., Funding: The Dutch Organization for Health Research and Health Innovation (ZonMW), Collaboration for New Treatments of Acute Stroke Consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Health Holland Top Sector Life Sciences & Health, and the Netherlands Brain Foundation., Competing Interests: Declaration of interests RJvO and WHvZ report financial support for the current manuscript from the Collaboration for New Treatments of Acute Stroke (CONTRAST) consortium (which was financed for the current study by the Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, the Netherlands Brain Foundation, Stryker, Medtronic, and Cerenovus), all paid to their institution. WHvZ reports speakers fees from Stryker, Cerenovus, Nicolab, Philips, Medtronic, and Microvention, and consulting fees from Philips, all paid to their institution; participated in the advisory boards of WeTrust (Philips) and ANAIS (Anaconda), all paid to their institution; and participated in the advisory board of InExtremis (CHU Montpellier, Montpellier, France), for which no payments were received. YBWEMR reports being a minor shareholder of Nicolab. CBLMM reports grants from the Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, TWIN Foundation, European Commission, Healthcare Evaluation Netherlands, Stryker, and Boehringer Ingelheim (all paid to their institution); and is a (minority interest) shareholder of Nicolab. AvdL reports financial support for this study by grants from The Netherlands Organization for Health Research and Development, and the Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, Brain Foundation Netherlands, Medtronic, and Cerenovus, all paid to their institution; reports grants from Stryker, Thrombolytic Science, Health Holland Top Sector Life Sciences & Health, Penumbra, GE Healthcare, Philips Healthcare, Boehringer Ingelheim, and Siemens Healthineers, all paid to their institution; participates in the advisory board of ESCAPE-MEVO; reports a speakers fee from Siemens Healthineers (paid to their institution); is a research leader of the CONTRAST consortium; and is part of the Research Cie of the European Society of Radiology. DWJD reports funding from the Dutch Heart Foundation, Netherlands Brain Foundation, the Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health, Penumbra, Stryker, Medtronic, Thrombolytic Science, and Cerenovus (all unrestricted grants for research), paid to their institution; participated in the data safety monitoring board of the ACT Global, TESLA, and LATE-MT trial; and was the research leader for the CONTRAST Consortium until 2023. AAP reports a grant from Siemens Healthineers, paid to their institution. HDB reports an unrestricted grant from Stryker, paid to their institution. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Introduction: Despite literature suggesting benefits of a balloon guide catheter (BGC) in stroke thrombectomy, BGCs are not routinely used. This study aimed to get insights in the use of a BGC and the reasons (not) to inflate the balloon., Methods: Data were used of the Maastricht Stroke Quality Registry (MaSQ-Registry), a prospective registry for quality purposes of stroke patients treated between September 2020-February 2023. Additionally, a Dutch nationwide questionnaire was sent among all stroke treating physicians of the Dutch Society of Interventional Radiology (NVIR). Information on the use and reasons for selecting a (non-)BGC and using the BGC was collected., Results: Out of 511 patients registered in the MaSQ-Registry, 458 were included. In 69% (n=317) of the patients a BGC was used; in 68% (n=214) the balloon was not inflated. In 95% of the posterior circulation occlusions a non-BGC was used. In total 47 treating physicians from sixteen stroke centers responded to the questionnaire. 51% (n=24) preferred a non-BGC and 30% (n=14) never used a BGC. 52% and 18% of the BGC-users estimated they inflate the balloon in 80-100% and 0-20% of the times, respectively. The main reasons reported for not inflating the balloon were when the BGC was occlusive (47%) or not placeable (34%) in the carotid artery., Conclusion: This study shows variation in the use of (non-)BGC use with and without inflated balloon among treating physicians in the Netherlands, highlighting current limited consensus regarding the use of (non-)BGCs among stroke treating physicians., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Digital subtraction angiography (DSA) devices are commonly used in numerous interventional procedures across various parts of the body, necessitating multiple scans per procedure, which results in significant radiation exposure for both doctors and patients. Inspired by generative artificial intelligence techniques, this study proposes GenDSA, a large-scale pretrained multi-frame generative model-based real-time and low-dose DSA imaging system., Methods: GenDSA was developed to generate 1-, 2-, and 3-frame sequences following each real frame. A large-scale dataset comprising ∼3 million DSA images from 27,117 patients across 10 hospitals was constructed to pretrain, fine-tune, and validate GenDSA. Two other datasets from 25 hospitals were used for evaluation. Objective evaluations included SSIM and PSNR. Five interventional radiologists independently assessed the quality of the generated frames using the Likert scale and visual Turing test. Scoring consistency among the radiologists was measured using the Kendall coefficient of concordance (W). The Fleiss' kappa values were used for inter-rater agreement analysis for visual Turing tests., Findings: Using only one-third of the clinical radiation dose, videos generated by GenDSA were perfectly consistent with real videos. Objective evaluations demonstrated that GenDSA's performance (PSNR = 36.83, SSIM = 0.911, generation time = 0.07 s/frame) surpassed state-of-the-art algorithms. Subjective ratings and statistical results from five doctors indicated no significant difference between real and generated videos. Furthermore, the generated videos were comparable to real videos in overall quality (4.905 vs. 4.935) and lesion assessment (4.825 vs. 4.860)., Conclusions: With clear clinical and translational values, the developed GenDSA can significantly reduce radiation damage to both doctors and patients during DSA-guided procedures., Funding: This study was supported by the National Key R&D Program and the National Natural Science Foundation of China., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty)., Competing Interests: Competing interests: All authors have completed a declaration of competing interests and details are available in online supplemental table 1., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy., Methods: Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614)., Results: In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879-0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886-0.944] and 0.909 [95% CI, 0.887-0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations., Conclusions: The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2., Competing Interests: Dr Brown reports consulting for B. Braun Interventional Systems, Inc, Medtronic, MicroVention, Inc, and the University of Calgary and is employed by BRIGHT Research Partners. Dr Goyal reports grants from Medtronic, Stryker, MicroVention, and Mentice; consulting for Stryker, Microvention, and Mentice; and a patent for systems and methods for acute stroke diagnosis with GE Healthcare. Dr Menon reports stock holdings in Circle Neurovascular Imaging and compensation from Roche and Boehringer Ingelheim. Dr Campbell reports grants from Covidien, Medtronic, and the National Health and Medical Research Council of Australia and fellowships from the National Heart Foundation of Australia, the National Stroke Foundation of Australia, and the Royal Australasian College of Physicians. Dr Mitchell reports consulting for Stryker and MicroVention and grants from Medtronic and Stryker. Dr Jovin reports consulting for Contego Medical; grants/contracts from Medtronic and Stryker; data safety monitoring board participation with Johnson & Johnson CERENOVUS; and stock holdings in Anaconda, Basking, Freeox Biotech, Galaxy, Gravity, Kandu, Methinks, Route92, StataDX, and Vizai. Dr Saver reports consulting for Abbott Laboratories, Aeromics, Biogen, Boehringer Ingelheim, BrainQ, BrainsGate, CSL Behring, Johnson & Johnson Health Care Systems, Medtronic, MindRhythm, Roche, and Stream Medical; data safety monitoring board participation with MIVI Neuroscience; and stock holdings in Neuronics Medical and Rapid Medical. Dr Muir reports consulting for Boehringer Ingelheim, Bayer, and Daiichi Sankyo. Dr White reports consulting for MicroVention and grants from the UK National Institutes for Health Research, MicroVention, Stryker, Medtronic, and Penumbra. Dr Bracard reports grants from the French Ministry of Health; others from GE Medical Systems; and nonfinancial support from MicroVention Europe. Dr Roos reports stock holdings in Nicolab. Dr van Zwam reports grants/contracts from Bayer HealthCare Pharmaceuticals, Stryker, and Johnson & Johnson; employment by Maastricht Universitair Medisch Centrum; and data safety monitoring board participation with Philips. Dr Hill reports consulting for BrainsGate; grants/contracts from Biogen, Boehringer Ingelheim, the Canadian Institutes of Health Research, Medtronic MicroVention, and NoNO; end point review committee participation with Merck; employment by the University of Calgary; and a patent for Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients with Circle Neurovascular Imaging. Dr Demchuk reports consulting for Boehringer Ingelheim, HLS Therapeutics, Hoffmann-La Roche, Medtronic, Nova-Signal, and Servier; data safety monitoring board participation with Philips and Lumosa; others from Novo Nordisk AS, Pfizer, and Astra Zeneca; and stock and patent for Stroke imaging software with Circle Neurovascular Imaging. The other authors report no conflicts.

Background: This study aimed to compare direct aspiration, stent retriever, and the combined thrombectomy technique on clinical, safety, and technical outcomes in late-window stroke patients included in the MR CLEAN-LATE trial., Methods: This post hoc analysis of the MR CLEAN-LATE trial included patients treated with direct aspiration, stent retriever, or combined thrombectomy technique as first-line approach. Primary outcome was the modified Rankin Scale (mRS) score at 90 days follow-up, and compared between the three groups with ordinal logistic regression analysis. Secondary outcomes included mortality at 90 days, total technique switches, procedure time, recanalization rate measured with the expanded thrombolysis in cerebral infarction (eTICI) score, and symptomatic intracranial hemorrhage (sICH). Predefined variables were used for adjustments., Results: In the MR CLEAN-LATE trial, 258 patients underwent endovascular treatment and 232 were included in our analyses. The mRS at 90 days did not differ (stent retriever vs. direct aspiration: adjusted common odds ratio (acOR) = 1.35, 95% confidence interval (CI) = 0.73 to 2.50; stent retriever vs. combined: acOR = 1.13, 95% CI = 0.64 to 2.00; direct aspiration vs. combined: acOR = 1.19, 95% CI = 0.64 to 2.21). Direct aspiration thrombectomy was accompanied with more switches to another technique compared to the stent retriever (adjusted odds ratio (aOR) = 6.50, 95% CI = 2.52 to 16.8) or combined group (aOR = 4.67, 95% CI = 1.80 to 12.1) and with higher sICH rates compared to the combined technique (13% vs. 2.5%; aOR = 8.19, 95% CI = 1.49 to 45.1). Mortality, procedure time, and eTICI did not differ., Conclusion: Stent retriever, direct aspiration, or the combined thrombectomy technique as first-line approach showed no differences in clinical outcome in late-window stroke patients. Direct aspiration was accompanied with higher sICH rates and more switcher to another technique compared to the combined group., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: W.H.v.Z. reports speaker fees from Stryker, Cerenovus, and Nicolab and consulting fees from Philips (all paid to institution); participated in the advisory boards of WeTrust (Philips) and ANAIS (Anaconda) (all paid to institution); and participated in the advisory boards of InEcxtremis (CHU Montpellier, Montpellier, France) and DISTAL (University Hospital Basel, Basel, Switzerland), studies for which no payments were received. B.J.E. reports funding from the Netherlands Organisation for Health Research and Development and Health Holland Top Sector Life Sciences & Health and unrestricted grants from Nicolab (all paid to institution). All other authors declare no competing interests.

Background: The extended Thrombolysis in Cerebral Infarction (eTICI) score is used in digital subtraction angiography (DSA) to quantify reperfusion grade in patients with an ischemic stroke who undergo endovascular thrombectomy (EVT). A previously developed automatic TICI score (autoTICI), which quantifies the ratio of reperfused pixels after EVT, demonstrates good correlation with eTICI., Objective: To evaluate the autoTICI model in a large multicenter registry of patients with an ischemic stroke, investigate the association with visual eTICI, and compare prediction of functional outcome between autoTICI and eTICI., Methods: Patients in the MR CLEAN Registry with an internal carotid artery, M1, and M2 occlusion were selected if both anteroposterior and lateral views were present in pre- and post-EVT DSA scans. The autoTICI score was compared with eTICI in predicting favorable functional outcome (modified Rankin Scale score 0-2), using area under the receiver operating characteristics curve (AUC) with a multivariable logistic regression model including known prognostic characteristics., Results: In total 421 of 3637 patients were included. AutoTICI was significantly associated with eTICI non-linearly (below 70% cOR=2.3 (95% CI 2.1 to 2.5), above 70% cOR=1.6 (95% CI 1.6 to 1.7) per 10% increment). The AUC of the model predicting favorable functional outcome was similar for autoTICI and eTICI (0.86, 95% CI 0.82 to 0.92 vs 0.86, 95% CI 0.83 to 0.90, P=0.73) and was higher than for a model with prognostic patient characteristics alone (0.86 vs 0.84, P=0.01)., Conclusion: Automatic quantitative assessment of reperfusion after EVT is associated with eTICI, and prediction of functional outcome is similar to that with visual eTICI. Therefore, autoTICI could be used as an alternative or additional review for visual reperfusion assessment to facilitate reproducible and uniform reporting., Competing Interests: Competing interests: Erasmus MC received funds from Stryker® by DD, AvdL, and Bracco Imaging® by DD. Amsterdam UMC received funds from Stryker® for consultations by CM, YR and OB. MUMC received funds from Stryker® and Codman® for consultations by WZ., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

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

Cerebral X-ray digital subtraction angiography (DSA) is a widely used imaging technique in patients with neurovascular disease, allowing for vessel and flow visualization with high spatio-temporal resolution. Automatic artery-vein segmentation in DSA plays a fundamental role in vascular analysis with quantitative biomarker extraction, facilitating a wide range of clinical applications. The widely adopted U-Net applied on static DSA frames often struggles with disentangling vessels from subtraction artifacts. Further, it falls short in effectively separating arteries and veins as it disregards the temporal perspectives inherent in DSA. To address these limitations, we propose to simultaneously leverage spatial vasculature and temporal cerebral flow characteristics to segment arteries and veins in DSA. The proposed network, coined CAVE, encodes a 2D+time DSA series using spatial modules, aggregates all the features using temporal modules, and decodes it into 2D segmentation maps. On a large multi-center clinical dataset, CAVE achieves a vessel segmentation Dice of 0.84 (±0.04) and an artery-vein segmentation Dice of 0.79 (±0.06). CAVE surpasses traditional Frangi-based k-means clustering (P < 0.001) and U-Net (P < 0.001) by a significant margin, demonstrating the advantages of harvesting spatio-temporal features. This study represents the first investigation into automatic artery-vein segmentation in DSA using deep learning. The code is publicly available at https://github.com/RuishengSu/CAVE&#95;DSA., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: - Danny Ruijters is an employee of Philips Healthcare. - Wiro J. Niessen is founder, scientific lead, and shareholder of Quantb B. - Aad van der Lugt has received research support from GE HealthCare, Siemens Healthineers, Philips Healthcare, Stryker, Penumbra, Cerenovus, Medtronic, and Thrombolytic Sciences inc (all paid to institution)., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: Balloon guide catheters (BGCs) are used in endovascular treatment (EVT) for ischemic stroke. Previous literature did not distinguish between BGC use with and without inflated balloon. This study aims to compare outcomes between non-BCG and BGC use with and without inflated balloon during EVT., Methods: Patients who underwent EVT for anterior circulation ischemic stroke between September 2020 and February 2023 were analyzed. Patients were divided into three groups: non-BGC, BGC with inflated balloon, or BGC without inflated balloon. The primary outcome was the ordinal modified Rankin Scale (mRS) at 90-day follow-up. Secondary outcomes included expanded Thrombolysis In Cerebral Ischemia score (eTICI) and periprocedural complications. Regression analyses with BGC with inflated balloon as comparator were performed with adjustments. Subgroup analyses were conducted based on first-line thrombectomy technique., Results: Out of 511 patients, 428 patients were included. Compared to BCG with inflated balloon, the mRS at 90 days did not differ in the group without inflated balloon (adjusted common [ac]OR: 1.07, 95%CI 0.67-1.73) or non-BGC (acOR: 1.42, 95%CI 0.83-2.42). Compared to patients treated with a BGC with inflated balloon, those treated with BGC without inflated balloon had lower eTICI scores (acOR: 0.59, 95%CI 0.37-0.94), and patients treated with non-BGC had lower chances of periprocedural complications (aOR: 0.41, 95%CI 0.20-0.86)., Conclusions: This study shows no clinical differences in ischemic stroke patients treated with BGC with inflated balloon compared to non-BGC and BGC without inflated balloon, despite lower periprocedural complication rates in the non-BGC group and lower eTICI scores in the BGC without inflated balloon group., Level of Evidence: Level 3, non-controlled retrospective cohort study., (© 2024. The Author(s).)

Background: Blood brain barrier disruption (BBBD) can be visualized by contrast extravasation (CE) after endovascular treatment (EVT) in patients with acute ischemic stroke. Elevated blood pressure is a risk factor for BBBD. However, the association between procedural blood pressure and CE post-EVT is unknown., Methods: In this single-center retrospective study, we analyzed 501 eligible patients who received a dual energy CT (DECT) immediately post-EVT for acute ischemic stroke. Procedural blood pressure values (SBP mean , SBP max, SBP max-min, and MAP mean ) were collected. CE was quantified by measuring the maximum parenchymal iodine concentration on DECT iodine overlay map reconstructions. As a measure for the extent of BBBD, we created CE-ASPECTS by deducting one point per hyperdense ASPECTS region on iodine overlay maps. The association between blood pressure and CE was assessed using multivariable linear regression., Results: The procedural SBP mean , SBP max , and MAP mean were 150 ± 26 mmHg, 173 ± 29 mmHg, and 101 ± 17 mmHg, respectively. The median maximum iodine concentration on post-EVT DECT was 1.2 mg/ml (IQR 0.7-2.0), and median CE-ASPECTS was 8 (IQR 5-11). The maximum iodine concentration was not associated with blood pressure. SBP mean , SBP max, and MAP mean were significantly associated with CE-ASPECTS (per 10 mmHg, β = -0.2, 95 % CI -0.31 to -0.09, β = -0.15, 95 % CI -0.25 to -0.06, β = -0.33, 95 % CI -0.49 to -0.17, respectively)., Conclusion: In acute ischemic stroke patients undergoing EVT, particularly in patients achieving successful recanalization, SBP mean , SBP max , and MAP mean are associated with the extent of BBBD on immediate post-EVT DECT, but not with maximum iodine concentration., Competing Interests: Declaration of competing interest W.Z reports consulting fees from Philips, and speaker fees from Stryker, Cerenovus, and Nicolab (all paid to the institution). Moreover, he is participating in the Safety Monitoring Board or Advisory Board of WeTrust (Philips), InEcxtremis (CHU Montpellier), ANAIS (Anaconda), and DISTAL (University of Hospital Basal) studies. A.P received an institutional grant from Siemens Healthineers and Bayer Healthcare. Other co-authors have nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To describe the incidence, risk factors, and prognostic relevance of intracranial haemorrhage (ICH) immediately after endovascular treatment (EVT) for ischaemic stroke in the anterior circulation., Methods: EVT records from 2010 to 2019 were screened. Included patients underwent DECT within 3h post-EVT. Virtual native reconstructions were evaluated for ICH according to the Heidelberg criteria and grouped into Heidelberg classes (HCs): [HC1] haemorrhagic infarction (HI)1, HI2 and parenchymal haematoma (PH)1; [HC2] PH2; [HC3] i.a. intraventricular and subarachnoid haemorrhage. If ICH corresponding to multiple HCs was observed, we assumed that the (largest) parenchymal ICH would have the greatest prognostic impact. Hence, a single HC was attributed by the following order of severity: HC2, HC1, HC3. The primary outcome was the modified Rankin Scale (mRS) at 90 days. The effect of asymptomatic ICH (aICH) and symptomatic ICH (sICH) of (1) HC1 or HC2 and (2) HC3 on patient outcomes was evaluated with multivariable regression after multiple imputation., Results: Out of 651 records, 498 patients were included. Eighty-one (16%) patients showed ICH on post-EVT DECT, of which 19 were classified as HC1 (21% symptomatic), 6 as HC2 (100% symptomatic), and 56 as HC3 (14% symptomatic). ICH development was mainly associated with unfavourable procedural characteristics. Both aICH and sICH of HC1 or HC2 were associated with the mRS (aICH: adjusted [a]cOR 4.92, 95%CI [1.48-16.35]; sICH: acOR 12.97, 95%CI [2.39-70.26]) and mortality (aICH: aOR 10.08, 95%CI [2.48-40.88]; sICH: aOR 9.92, 95%CI [1.48-66.31]). Likewise, sICH of HC3 was associated with the mRS and mortality (acOR 19.91, 95%CI [4.03-98.35], and aOR 13.23, 95%CI [2.27-77.18], respectively). aICH of HC3 was not significantly associated with the mRS or mortality (acOR 0.87, 95%CI [0.48-1.57], and cOR 0.84, 95%CI [0.32-2.20], respectively)., Conclusions: Immediate post-EVT ICH is a frequent finding. Except for aICH of HC3, any ICH is associated with poor long-term clinical outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper. The authors declare the following financial or personal relationships that could be viewed as influencing the work reported in this paper: H.D. Boogaarts received consultation fees from Stryker Neurovascular (paid to the institution). W.H. van Zwam received consultation fees from Stryker, Nicolab and Cerenovus (paid to the institution), and is a DSMB member of the Philips’ We-Trust study, Anaconda's Solonda study, and In Extremis study (all funding paid to the institution). A.A. Postma received an institutional grant from Siemens Healthineers and Bayer Healthcare., (Copyright © 2023 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background: The MR CLEAN-LATE trial has shown that patient selection for endovascular treatment (EVT) in the late window (6-24 h after onset or last-seen-well) based on the presence of collateral flow on CT-angiography is safe and effective. We aimed to assess the cost-effectiveness of late-window collateral-based EVT-selection compared to best medical management (BMM) over a lifetime horizon (until 95 years of age)., Materials and Methods: A model-based economic evaluation was performed from a societal perspective in The Netherlands. A decision tree was combined with a state-transition (Markov) model. Health states were defined by the modified Rankin Scale (mRS). Initial probabilities at 3-months post-stroke were based on MR CLEAN-LATE data. Transition probabilities were derived from previous literature. Information on short- and long-term resource use and utilities was obtained from a study using MR CLEAN-LATE and cross-sectional data. All costs are expressed in 2022 euros. Costs and quality-adjusted life years (QALYs) were discounted at a rate of 4% and 1.5%, respectively. The effect of parameter uncertainty was assessed using probabilistic sensitivity analysis (PSA)., Results: On average, the EVT strategy cost €159,592 (95% CI: €140,830-€180,154) and generated 3.46 QALYs (95% CI: 3.04-3.90) per patient, whereas the costs and QALYs associated with BMM were €149,935 (95% CI: €130,841-€171,776) and 2.88 (95% CI: 2.48-3.29), respectively. The incremental cost-effectiveness ratio per QALY and the incremental net monetary benefit were €16,442 and €19,710, respectively. At a cost-effectiveness threshold of €50,000/QALY, EVT was cost-effective in 87% of replications., Discussion and Conclusion: Collateral-based selection for late-window EVT is likely cost-effective from a societal perspective in The Netherlands., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This study was supported by a grant from the Dutch organization for Health research and Health innovation (ZonMw). H.B. received consultation fees from Stryker Neurovascular (paid to the institution). A.P. received an institutional grant from Siemens Healthineers and Bayer Healthcare. W.Z. received consultation fees from Stryker, Nicolab and Cerenovus (paid to the institution), and is a DSMB member of the Philips’ We-Trust study, Anaconda’s Solonda study, and In Extremis study (all funding paid to the institution).

Background: Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion., Methods: Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes., Results: Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients., Competing Interests: Competing interests: BJE reports grants from LtC (ZonMW and TKI-PPP of Health Holland). WHvZ reports speaker fees from Cerenovus, NicoLab and Stryker, and consulting fees from Philips, all paid to Institution. DWJD report grants from the Dutch Heart Foundation, Brain Foundation Netherlands, ZON MW, Stryker, Medtronic, Cerenovus, Thrombolytic Science, received by the Erasmus University Medical Center outside this project. AJY reports Research grants from Medtronic, Cerenovus, Penumbra, Stryker, and Genentech. Consultant for Penumbra, Cerenovus, Nicolab, Philips, Vesalio, Zoll Circulation, and NIH/NINDS. CBM: grants from Healthcare Evaluation Netherlands, CVON/Dutch Heart Foundation, TWIN foundation and Stryker during the conduct of the study and from European Commission outside this project (all paid to institution) and is shareholder of Nicolab. All other contributors report no other conflicts of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis., Methods: A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R., Results: Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively)., Conclusions: IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window., Competing Interests: Declaration of competing interest S.F. & J.P.O.: received speaker´s honoraria and travel support from Boehringer Ingelheim. W.H.v.Z.: reports speaker fees from Stryker, Cerenovus, and Nicolab, and consulting fees from Philips (all paid to institution); chaired the data safety monitoring boards of WeTrust (Philips), ANAIS (Anaconda) (paid to institution), InExtremis (CHU Montpellier, Montpellier, France), and DISTAL (Basel, Suisse) (no payments)., (Copyright © 2024. Published by Elsevier Inc.)

Background: To better understand the influence of treatment strategies on outcomes for patients with tandem lesions undergoing acute internal carotid artery (ICA) stenting during endovascular treatment (EVT), this study compared clinical, technical, and safety outcomes in patients with acute ischemic stroke due to a large vessel occlusion (LVO) who underwent ICA stenting before versus after intracranial thrombectomy., Methods: This single-center retrospective cohort study included patients who underwent EVT due to a LVO and periprocedural ICA stenting for significant ICA stenosis or occlusion between September 2020 and January 2023. Data were extracted from the Maastricht Stroke Quality Registry (MaSQ-Registry). Primary outcome was the modified Rankin Scale (mRS) at 3 months. Secondary outcomes included procedure times, number of total thrombectomy attempts, first-attempt excellent recanalization rates (extended Thrombolysis In Cerebral Infarction (eTICI) ≥ 2C after one thrombectomy attempt), and safety outcomes., Results: This study included 50 patients. Thirty-one patients (62%) underwent ICA stenting before intracranial thrombectomy. No significant differences between both groups were found regarding mRS, total procedure time, number of total thrombectomy attempts, first-attempt excellent recanalization, or complications. Time between groin puncture and recanalization (reperfusion time) was significantly longer in patients who had ICA stenting before intracranial thrombectomy versus after intracranial thrombectomy (45 min versus 28 min, P = 0.004)., Conclusion: ICA stenting after intracranial thrombectomy in patients with tandem lesions undergoing EVT did not lead to better patient outcomes compared to stenting before intracranial thrombectomy, despite shorter reperfusion times., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke., Methods: Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients., Results: 1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point., Conclusions: The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations., Competing Interests: Author Disclosures Links to the disclosure forms provided by the authors are available here., (Copyright © 2024. Published by Elsevier Inc.)

Acute ischemic stroke (AIS) is the most common type of stroke and requires immediate reperfusion. Current acute reperfusion therapies comprise the administration of intravenous thrombolysis and/or endovascular thrombectomy. Although these acute reperfusion therapies are increasingly successful, optimized secondary antithrombotic treatment remains warranted, specifically to reduce the risk of major bleeding complications. In the development of AIS, coagulation and platelet activation play crucial roles by driving occlusive clot formation. Recent studies implicated that the intrinsic route of coagulation plays a more prominent role in this development, however, this is not fully understood yet. Next to the acute treatments, antithrombotic therapy, consisting of anticoagulants and/or antiplatelet therapy, is successfully used for primary and secondary prevention of AIS but at the cost of increased bleeding complications. Therefore, better understanding the interplay between the different pathways involved in the pathophysiology of AIS might provide new insights that could lead to novel treatment strategies. This narrative review focuses on the processes of platelet activation and coagulation in AIS, and the most common antithrombotic agents in primary and secondary prevention of AIS. Furthermore, we provide an overview of promising novel antithrombotic agents that could be used to improve in both acute treatment and stroke prevention., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: H.t.C. has received consultancy fees from Aleveron, AstraZeneca, Galapagos and Novostia and research funding from Bayer; all revenues are deposited at the CARIM Institute and labelled for research. H.t.C. and H.M.H.S. are shareholders of Coagulation Profile, a spinoff diagnostic company of Maastricht University. The other authors declared no conflict of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT)., Methods: We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAP mean ), mean SBP (SBP mean ), and SBP max-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression., Results: We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBP max , SBP mean , and MAP mean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02-1.39), 1.22 (95%CI, 1.03-1.46), and 1.40 (95%CI, 1.09-1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH., Conclusion: Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

Background: Occlusion of the anterior cerebral artery (ACA) is uncommon but may lead to significant disability. The benefit of endovascular treatment (EVT) for ACA occlusions remains uncertain., Methods: We included patients treated with EVT and compared patients with ACA occlusions with patients who had internal carotid artery (ICA) or proximal (M1/M2) middle cerebral artery (MCA) occlusions from the MR CLEAN Registry. Primary outcome was the modified Rankin Scale score (mRS). Secondary outcomes were functional independence (mRS 0-2), National Institutes of Health Stroke Scale (NIHSS) score, delta-NIHSS (baseline minus NIHSS score at 24-48 h), and successful recanalization (expanded thrombolysis in cerebral infarction (eTICI) score 2b-3). Safety outcomes were symptomatic intracranial hemorrhage (sICH), periprocedural complications, and mortality., Results: Of 5193 patients, 11 (0.2%) had primary ACA occlusions. Median NIHSS at baseline was lower in patients with ACA versus ICA/MCA occlusions (11, IQR 9-14; versus 15, IQR 11-19). Functional outcome did not differ from patients with ICA/MCA occlusions. Functional independence was 4/11 (36%) in patients with ACA versus 1949/4815 (41%) in ICA/MCA occlusions; median delta-NIHSS was - 1 (IQR - 7 to 2) and - 4 (IQR - 9 to 0), respectively. Successful recanalization was 4/9 (44%), versus 3083/4787 (64%) in ICA/MCA occlusions. Mortality was 3/11 (27%) versus 1263/4815 (26%). One patient with ACA occlusion had sICH; no other complications occurred., Conclusion: In this cohort ACA occlusions were uncommon. Functional outcome did not differ between patients with ACA occlusions and ICA/MCA occlusions. Prospective research is needed to determine feasibility, safety, and outcomes of EVT for ACA occlusions., (© 2023. The Author(s).)

Purpose: After endovascular therapy (EVT) for ischemic stroke, post-EVT CT imaging often shows areas of contrast extravasation (CE) caused by blood brain barrier disruption (BBBD). Before EVT, CT-perfusion (CTP) can be used to estimate salvageable tissue (penumbra) and irrevocably damaged infarction (core). In this study, we aimed to correlate CTP deficits to CE, as a surrogate marker for BBBD, after EVT for ischemic stroke., Methods: In this single center study, EVT patients between 2010 and 2020 in whom both CTP at baseline and DECT post-EVT was performed were included. The presence of core and penumbra on CTP was assessed per ASPECTS region, resulting in a CTP-ASPECTS core and a CTP-ASPECTS core+penumbra . Likewise, CE on DECT was scored per ASPECTS region, resulting in a CE-ASPECTS. Correlation was assessed using Kendall's tau correlation and positive predictive values (PPV) were calculated per ASPECTS region. Bland-Altman plots were created to visualize the agreement between the two scores., Results: 194 patients met our inclusion criteria. The median core and penumbra were 8 cc (IQR 1-25) and 103 cc (IQR 68-141), respectively. The median CTP-ASPECTS core , CTP-ASPECTS core+penumbra , and CE-ASPECTS were 7 (IQR 4-9), 3 (IQR 1-4), and 6 (IQR 4-9), respectively. The correlation between CTP-ASPECTS core and CE-ASPECTS was τ = 0.21, P <.001, and τ = 0.13, P =.02 between CTP-ASPECTS core+penumbra and CE-ASPECTS. Bland-Altman plots showed a mean difference (CTP-ASPECTS minus CE-ASPECTS) of 0.27 (95 %CI -6.7-7.2) for CTP-ASPECTS core and -3.2 (95 %CI -9.7-3.2) for CTP-ASPECTS core+penumbra . The PPVs of the CTP-ASPECTS core and CTP-ASPECTS core+penumbra were highest for the basal ganglia., Conclusion: There is a weak although significant correlation between pre-EVT CTP-ASPECTS and post-EVT CE-ASPECTS. The weak correlation may be attributed to various imaging limitations as well as patient related factors., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: W.Z reports consulting fees from Philips, and speaker fees from Stryker, Cerenovus, and Nicolab (all paid to the institution). Moreover, he is participating in the Safety Monitoring Board or Advisory Board of WeTrust (Philips), InEcxtremis (CHU Montpellier), ANAIS (Anaconda), and DISTAL (University of Hospital Basal) studies. A.P received an institutional grant from Siemens Healthineers and Bayer Healthcare. Other co-authors have nothing to disclose., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: CT perfusion (CTP) has been suggested to increase the rate of large vessel occlusion (LVO) detection in patients suspected of acute ischemic stroke (AIS) if used in addition to a standard diagnostic imaging regime of CT angiography (CTA) and non-contrast CT (NCCT). The aim of this study was to estimate the costs and health effects of additional CTP for endovascular treatment (EVT)-eligible occlusion detection using model-based analyses., Methods: In this Dutch, nationwide retrospective cohort study with model-based health economic evaluation, data from 701 EVT-treated patients with available CTP results were included (January 2018-March 2022; trialregister.nl:NL7974). We compared a cohort undergoing NCCT, CTA, and CTP (NCCT + CTA + CTP) with a generated counterfactual where NCCT and CTA (NCCT + CTA) was used for LVO detection. The NCCT + CTA strategy was simulated using diagnostic accuracy values and EVT effects from the literature. A Markov model was used to simulate 10-year follow-up. We adopted a healthcare payer perspective for costs in euros and health gains in quality-adjusted life years (QALYs). The primary outcome was the net monetary benefit (NMB) at a willingness to pay of €80,000; secondary outcomes were the difference between LVO detection strategies in QALYs (ΔQALY) and costs (ΔCosts) per LVO patient., Results: We included 701 patients (median age: 72, IQR: [62-81]) years). Per LVO patient, CTP-based occlusion detection resulted in cost savings (ΔCosts median: € - 2671, IQR: [€ - 4721; € - 731]), a health gain (ΔQALY median: 0.073, IQR: [0.044; 0.104]), and a positive NMB (median: €8436, IQR: [5565; 11,876]) per LVO patient., Conclusion: CTP-based screening of suspected stroke patients for an endovascular treatment eligible large vessel occlusion was cost-effective., Clinical Relevance Statement: Although CTP-based patient selection for endovascular treatment has been recently suggested to result in worse patient outcomes after ischemic stroke, an alternative CTP-based screening for endovascular treatable occlusions is cost-effective., Key Points: • Using CT perfusion to detect an endovascular treatment-eligible occlusions resulted in a health gain and cost savings during 10 years of follow-up. • Depending on the screening costs related to the number of patients needed to image with CT perfusion, cost savings could be considerable (median: € - 3857, IQR: [€ - 5907; € - 1916] per patient). • As the gain in quality adjusted life years was most affected by the sensitivity of CT perfusion-based occlusion detection, additional studies for the diagnostic accuracy of CT perfusion for occlusion detection are required., (© 2023. The Author(s).)

The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow., Competing Interests: N. Arrarte Terreros is co-founder of inSteps, a start-up that focuses on in-silico stroke models. D.W.J. Dippel reports unrestricted grants from Stryker, Penumbra, Medtronic, Cerenovus, Thrombolytic Science, LLC, Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and Thrombolytic Science, LLC for research, paid to institution. H.A. Marquering is co-founder of inSteps and Nico.lab, a company that focuses on the use of artificial intelligence for medical image analysis. C.B.L.M. Majoie reports grants from the European Commission during the conducting of the study; grants from CVON/Dutch Heart Foundation, TWIN Foundation, Healthcare Evaluation Netherlands and Stryker, outside the submitted work; and is a shareholder of Nico.lab. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: Computed tomography perfusion (CTP)-estimated core volume is associated with functional outcomes in acute ischemic stroke. This relationship might differ among patients, depending on brain volume., Materials and Methods: We retrospectively included patients from the MR CLEAN Registry. Cerebrospinal fluid (CSF) and intracranial volume (ICV) were automatically segmented on NCCT. We defined the proportion of the ICV and total brain volume (TBV) affected by the ischemic core as ICV core and TBV core . Associations between the core volume, ICV core , TBV core , and functional outcome are reported per interquartile range (IQR). We calculated the area under the curve (AUC) to assess diagnostic accuracy., Results: In 200 patients, the median core volume was 13 (5-41) mL. Median ICV and TBV were 1377 (1283-1456) mL and 1108 (1020-1197) mL. Median ICV core and TBV core were 0.9 (0.4-2.8)% and 1.7 (0.5-3.6)%. Core volume (acOR per IQR 0.48 [95%CI 0.33-0.69]), ICV core (acOR per IQR 0.50 [95%CI 0.35-0.69]), and TBV core (acOR per IQR 0.41 95%CI 0.33-0.67]) showed a lower likelihood of achieving improved functional outcomes after 90 days. The AUC was 0.80 for the prediction of functional independence at 90 days for the CTP-estimated core volume, the ICV core , and the TBV core ., Conclusion: Correcting the CTP-estimated core volume for the intracranial or total brain volume did not improve the association with functional outcomes in patients who underwent EVT.

Background: The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry., Methods: Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0-3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied., Results: A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61-1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33-8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT., Conclusions: We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation., Competing Interests: Disclosures Dr Majoie reports grants from the Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, European Commission, Healthcare Evaluation Netherlands, Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie Foundation, and Stryker (all paid to institution); and is a (minority interest) shareholder of Nicolab. Dr Emmer reports grants from leading the Change Healthcare Evaluation program, ZorgOnderzoek Nederland Medische Wetenschappen (ZonMw), Nico-Lab, and Top Consortia for Knowledge and Innovation- Public Private Partnership (TKI-PPP) Grant Topsector Lifesciences (all paid to institution); and participates as a representative of the European Union of Medical Specialists (UEMS) Neuroradiology Dutch, and as Board member of the Dutch Society of Radiology. Dr Vos reports compensation from Stryker Corporation for other services. Dr van Doormaal reports consulting fees from Stryker, Siemens, and Stryker (all paid to institution); participates in the advisory board of DX Medical solutions; and is shareholder of DX Medical Solutions. Dr Yoo reports grants from Medtronic, Cerenovus, Penumbra, Stryker, Genentech, and Johnson & Johnson Medical Devices & Diagnostics Group, Latin America LLC; holds stock options in Nico-Lab, Insera; and is a consultant for Vesalio, Cerenovus, Rapid Medical Ltd, Penumbra, Inc, Nico-Lab, ZOLL Circulation, Inc, and Philips, all outside the submitted work; compensation from American Heart Association for other services; compensation from National Institutes of Health for data and safety monitoring services. Dr van Zwam reports speaker fees from Stryker, Cerenovus, and Nicolab, and consulting fees from Philips (all paid to institution); participated in the advisory boards of WeTrust (Philips) and ANAIS ([Advanced Neurovascular Access in Combination With a Stent Retriever in Patients With Acute Ischemic Stroke]; Anaconda; all paid to institution); and participated in the advisory boards of InEcxtremis (CHU Montpellier, Montpellier, France) and DISTAL ([Endovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for Medium Vessel Occlusion Stroke - a Pragmatic, International, Multicentre, Randomized Trial]; University Hospital Basel, Basel, Switzerland), studies for which no payments were received. The other authors report no conflicts.

Introduction: Imaging biomarkers, such as the collateral score as determined from Computed Tomography Angiography (CTA) images, play a role in treatment decision making for acute stroke patients. In this manuscript, we present an end-to-end learning approach for automatic determination of a collateral score from a CTA image. Our aim was to investigate whether such end-to-end learning approaches can be used for this classification task, and whether the resulting classification can be used in existing outcome prediction models., Methods: The method consists of a preprocessing step, where the CTA image is aligned to an atlas and divided in the two hemispheres: the affected side and the healthy side. Subsequently, a VoxResNet based convolutional neural network is used to extract features at various resolutions from the input images. This is done by using a Siamese model, such that the classification is driven by the comparison between the affected and healthy using a unique set of features for both hemispheres. After masking the resulting features for both sides with the vascular region and global average pooling (per hemisphere) and concatenation of the resulting features, a fully connected layer is used to determine the categorized collateral score., Experiments: Several experiments have been performed to optimize the model hyperparameters and training procedure, and to validate the final model performance. The hyperparameter optimization and subsequent model training was done using CTA images from the MR CLEAN Registry, a Dutch multi-center multi-vendor registry of acute stroke patients that underwent endovascular treatment. A separate set of images, from the MR CLEAN Trial, served as an external validation set, where collateral scoring was assessed and compared with both human observers and a recent more traditional model. In addition, the automated collateral scores have been used in an existing functional outcome prediction model that uses both imaging and non-imaging clinical parameters., Conclusion: The results show that end-to-end learning of collateral scoring in CTA images is feasible, and does perform similar to more traditional methods, and the performance also is within the inter-observer variation. Furthermore, the results demonstrate that the end-to-end classification results also can be used in an existing functional outcome prediction model., Competing Interests: VF was employed by Quantib BV. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) WZ and RB declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Fortunati, Su, Wolff, van Doormaal, Hofmeijer, Martens, Bokkers, van Zwam, van der Lugt and van Walsum.)

Background and Purpose: Endovascular treatment (EVT) is the preferred treatment option in eligible acute ischemic stroke (AIS) patients with a large vessel occlusion of the anterior circulation. Several comorbidities have been identified that can affect clinical outcomes. Various studies have investigated the association between anemia and clinical outcome and found conflicting., Results: . The aim is to investigate the association between pre-EVT anemia and clinical outcomes at different time points post-EVT, primarily focusing on the National Institutes of Health Stroke Scale (NIHSS) at 24-48 hours., Methods: We prospectively included 560 AIS patients who received EVT in the Maastricht University Medical Center+. Hemoglobin levels (Hb; g/dL) were determined on admission. Hb levels were also categorized into two groups: anemia (male: Hb ≤12.9 g/dL; female: Hb ≤11.9 g/dL) and no anemia. Multiple imputation was used to handle missing data. Multivariable regression was used to investigate the association between anemia or Hb levels and clinical outcomes., Results: Anemia was present in 26% of the patients. Multivariable regression did not show a significant association between anemia or Hb levels and NIHSS at 24-48 hours (adjusted β [aβ]anemia: 1.44, 95% confidence interval [CI]: -0.47 to 3.36; aβHb: -0.37, 95% CI: -0.88 to 0.13). However, multivariable regression showed significant associations with modified Rankin Scale (adjusted common odds ratio [acOR]anemia: 1.66, 95% CI: 1.12 to 2.48; acORHb: 0.83, 95% CI: 0.75 to 0.93) and poor functional outcome at 90 days (adjusted OR [aOR]anemia: 2.09, 95% CI: 1.21 to 3.63; aORHb: 0.80, 95% CI: 0.69 to 0.92)., Conclusion: Anemia was not independently associated with early neurological deficit (NIHSS) post-AIS, suggesting it is more suitable as a general frailty marker.

Direct oral anticoagulants (DOACs) changed stroke prevention and decreased the risk of ischemic and hemorrhagic complications in patients on oral anticoagulation (OAC) therapy. The numbers of patients prescribed DOACs has increased rapidly. Availability of specific reversal agents opened new avenues in the prevention and management of DOAC complications. An ideal specific reversal agent for a DOAC in acute stroke is an agent which lacks safety concerns and immediately reverses DOAC anticoagulation activity, thereby enabling effective treatment. Reversal of anticoagulant activity is mandatory in patients with acute ischemic stroke (AIS) before performing therapeutic procedures such as intravenous thrombolysis (IVT) and neurosurgery in intracranial hemorrhage (ICH) in order to improve clinical outcomes. In this manuscript we pursue an interdisciplinary approach in discussing advantages and concerns of specific reversal agents in acute stroke DOAC-treated patients in everyday clinical practice., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: S.F., P.K., J.P.O and M.Š. received speakeŕs honoraria from AstraZeneca in Boehringer Ingelheim. Other than that, they have no competing financial interests or personal relationships that could have influenced the work reported in this paper.