Stroke: Vascular and Interventional Neurology

Background/ObjectiveData regarding treatment of infectious intracranial aneurysms most effectively remains sparse. With growing utilization of endovascular therapy for cerebrovascular disease, we examined trends in endovascular versus neurosurgical treatment of infectious aneurysms and investigated the impact of treatment modality on outcomes. MethodsUsing data from the National Inpatient Sample from 2000 to 2019, we conducted a trends analysis on rates of treatment modalities among hospitalizations with infective endocarditis with ruptured or unruptured cerebral aneurysms. Treatment modalities were categorized as endovascular versus open neurosurgical repair based on ICD-9 and ICD-10 codes. Logistic regressions were utilized to assess the association between treatment modality and the outcomes of in-hospital mortality and discharge disposition. ResultsWe identified 24,461 hospitalizations with an infectious intracranial aneurysm in the setting of infective endocarditis. Mean age was 56.0 years (SD, 17.8) and 61.8% were male. The overall rate of intervention was 5.8% (95% CI, 5.0-6.5%), and this did not change over time (p=0.669). There was a significant increase in the rate of endovascular repair (APC=3.6%; 95% CI, 1.2%-8.1%) and a significant decrease in the rate of open neurosurgical repair (APC= -5.4%; 95% CI, -8.1% to -3.5%). Treatment modality was not associated with in-hospital mortality (p=0.698) or non-home discharge disposition (p=0.897). ConclusionAlthough rates of infectious intracranial aneurysm intervention for infective endocarditis did not change, utilization of endovascular treatment increased while the use of open neurosurgical treatment decreased. Further directions include elucidating predictors of favorable outcomes for undergoing intervention and the most beneficial timing for the procedure during hospitalization. SummaryO_ST_ABSWhat is already known on this topicC_ST_ABS- Rates of infective endocarditis and infectious intracranial aneurysms continue to rise, however, there lacks a standard of care in management of this complication. Prior studies have only looked at national trends up until 2011, whereas ours not only analyzes trends up until 2019, but analyzes open neurosurgical and endovascular approaches separately. What this study adds- Our study indicates a significant increase in the use of endovascular treatment with a concomitant significant decrease in open neurosurgical clipping of infectious intracranial aneurysms. While patients undergoing any intervention had better mortality rates than patients treated with medical management alone, we found no statistical difference in mortality rates or disposition between the two treatment modalities. How this study might affect research, practice or policy- Our study highlights the need for further investigation of prognostic factors and timing of intervention in patients with infectious intracranial aneurysms, to standardize management to improve outcomes.

BackgroundEvidence from large, prospective studies in treating ruptured intracranial aneurysms (RIAs) using stent-assisted coiling (SAC) technique is lacking, biases and uncertainty regarding the safety of SAC persist. We aimed to evaluate the safety and efficacy of SAC compared to coiling alone (CA) for treatment RIAs. MethodsWe conducted an observational registry of patients with subarachnoid hemorrhages (SAH) caused by RIAs treated with endovascular treatment at 33 centers from 20 provinces at China between April 2021 and February 2024. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at one-year follow-up. Multivariable logistic regression and propensity-score matching were performed to evaluate favorable functional outcome, perioperative complications and angiographic results. ResultsAmong the 3353 enrolled patients, the median age of patients is 58 years old (IQR, 50 - 66), 66.7% were female. After adjustment for confounders, there was no significant difference between SAC and CA in the rate of favorable functional outcomes (87.9% vs. 88.1%; adjusted odds ratio [aOR], 1.020 [95% CI, 0.820- 1.270]). Compared with the CA group, the SAC group had a higher incidence of intraprocedural thrombosis (4.2% vs. 1.8%; aOR, 3.097 [95% CI, 1.950-4.920]) and postoperative cerebral infarction (9.7% vs. 8.2%; aOR, 1.293 [95% CI, 1.007- 1.660]). At angiographic follow-up, the SAC group demonstrated a higher rate of complete occlusion (80.3% vs. 63.8%; aOR, 2.848 [95% CI, 2.344-3.460]) and a lower recurrence rate (7.7% vs. 20.4%; aOR, 0.289 [95% CI, 0.224-0.373]). ConclusionsDespite a more than two-fold increase in intraoperative thrombosis risk, SAC for RIAs achieved comparable functional and superior immediate and long-term angiographic outcomes to CA, supporting its status as a safe and effective strategy. Registration: https://www.chictr.org.cn, ChiCTR2000032657

ImportanceThe multicenter, prospective, single-arm, non-randomized SCENT trial on flow diverter (FD) treatment for intracranial aneurysms (IA) was analyzed for patients age and IA characteristics impacting stroke and occlusion rates over 5 years. DesignThe impact on major ipsilateral stroke and IA occlusion was studied by stratifying age as [&le;] 65 years versus >65 years. Product-limit (Kaplan-Meier) estimates of time to both endpoints, stratified by age group, were created. Univariate predictors of time to stroke were identified by including candidate variables in univariable proportional hazards regression models. Those variables found to be significant (p<0.10) at the univariate level were entered into a multivariable survival model to identify independent predictors. The stepwise selection produced a final reduced model with a significance level to both enter and stay set at 0.05. FindingsOf 180 patients with 180 large or giant IA enrolled in the modified intention-to-treat cohort, 119 subjects were [&le;] 65, while 61 patients were > 65 years old. When parent artery stenosis and IA size were entered into a multiple-stepwise survival model, only stenosis remained as an independently significant predictor of time to stroke. At 3-year follow-up, there were a total of 23 strokes (12.8%), with 11 occurring in subjects [&le;] 65 years; there was a greater risk for seniors (HR1.96, 95% CI 0.83-4.78). Four patients (4/180; 2.2%) experienced aneurysm rupture within the first week post-treatment, with 3 being [&le;] 65 and the fourth aged 66 years. No new strokes were reported between 3 and 5 years. Complete IA occlusion rates for seniors were 60.0% (33/55), 67.6% (25/37), and 85.7% (18/21) at 12, 36, and 60 months, respectively, as compared to 79.1% (87/110), 82.5% (66/80), and 91.8% (56/61) for younger subjects. The time to complete IA occlusion was shorter in younger patients (HR1.53, 95% CI 1.07-2.19). Five subjects (2.8%) underwent retreatment, 2 in 60-year-old patients, and one each aged 64, 70, and 75. Conclusions and RelevanceAge > 65 and parent artery stenosis are related to an increased risk of major ipsilateral stroke in patients with intracranial aneurysms treated with a flow diverter. Age > 65 is also predictive of increased time to and incomplete healing. With demographic shifts, future treatments need to focus on expedited and improved healing. Trial Registrationhttps://www.clinicaltrials.gov NCT01716117 KEY POINTSO_ST_ABSQuestionC_ST_ABSWhat key variables, including patients age and intracranial aneurysm (IA) characteristics, determine procedural stroke risks in subjects treated for large or giant IA with flow-diverting stents? FindingsAneurysm size and parent artery stenosis impacted occlusion rates and stroke risk, respectively. Over a 5-year observation period, the senior population had a significantly lower occlusion rate and higher risk for stroke, while the younger population was at higher risk for early aneurysm bleed following treatment. MeaningWith demographic shifts and a higher senior population being treated for IA, the stroke risk and incomplete occlusion rates need to be discussed with the patient before treatment.

BackgroundDelayed cerebral ischemia (DCI) due to vasospasm following subarachnoid hemorrhage (SAH) is considered a significant determinant of morbidity and mortality; however, no established method exists to prevent and treat vasospasm or DCI. This study aimed to evaluate the effectiveness of ventriculo-cisternal irrigation (VCI) in preventing vasospasms and DCI. MethodsWe retrospectively identified 340 SAH patients with ruptured intracranial aneurysms treated with postoperative VCI at our institution between December 2010 and January 2020. Ventricular/cisternal drainage (VD/CD) was inducted during aneurysm surgery, and lactated Ringers solution was used for irrigation until day 4 of SAH, followed by ICP control at 5-10 cmH2O until day 14. We collected data on total vasospasm, DCI, and modified Rankin Scale scores at discharge and analyzed the risk factors using logistic regression models. ResultsThe median age was 65 years (interquartile range: 52-75), with 236 female patients (69%). The World Federation of Neurosurgical Societies grade distribution was as follows: Grade I or II, 175 cases (51%); Grade III or IV, 84 (25%); Grade V, 81 (24%). With VCI management in all cases, total vasospasm occurred in 162 patients (48%), but DCI incidence was low (23 patients [6.8%]). Major drainage-related complications were observed in five patients (1.5%). Early surgery, performed on SAH day 0 or 1, was identified as a preventivefactor against DCI occurrence (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.07-0.67; p = 0.008), while additional surgery (OR 4.76, 95% CI 1.62-13.98; p = 0.005) and dyslipidemia (OR 3.27, 95% CI 1.24-8.63; p = 0.017) were associated with DCI occurrence. ConclusionsManaging vasospasms with VCI after SAH achieved a low incidence of 6.8% for DCI and is considered a safe and effective method. Early surgery after SAH occurrence was associated with a decreased risk of DCI with VCI therapy.

IntroductionManaging atherosclerotic large vessel occlusion is procedurally challenging. Prior literature pertaining to technical considerations remain heterogenous and further research is necessary to highlight important differences. As such, first-line thrombectomy technique remains an active area of debate with respect to rate of recanalization, need for rescue stenting, and hemorrhagic complications. MethodsThis is a pre-planned analysis of the prospective RESCUE-ICAS registry which included atherosclerotic large vessel occlusions treated with mechanical thrombectomy from 25 sites. Patients were excluded if they had missing data on first-line technique or primary outcomes. Patients were dichotomized into two cohorts based on whether their first-line thrombectomy technique was with aspiration alone or a stentriever (SR). Primary procedural outcome was first-pass effect while primary safety outcome was mortality at 90 days. Propensity score matching and inverse probability weighted analysis were performed with respect to primary and secondary outcomes. Results419 were patients included in this analysis with 266 and 153 patients in the aspiration and stentriever cohorts, respectively. The cohorts mean age was 68 (SD {+/-}13) years, and the majority of patients were white (59%) and male (62%). There were no significant baseline demographic differences between cohorts; however, ICA occlusions were more common in the stentriever cohort (52% vs 31%), while MCA occlusions were more frequent in the aspiration cohort (35% vs 15%). In the un-adjusted model, first pass effect was higher in stentriever versus aspiration (35.3% vs 23.7%, p = 0.01) with equivalent mortality rates (31% vs 26%, p = 0.31). Distal embolization rates were higher in the aspiration cohort (9.8% vs 3.9%, p = 0.03), yet aspiration was associated with lower composited procedural complications (6% vs 11%, p = 0.01). Propensity score matching and weighted analysis demonstrated that differences in primary clinical efficacy and safety outcomes were insignificant between cohorts. ConclusionIn patients with atherosclerotic large vessel occlusions, first line stentriever utilization was associated with higher first-pass effect rates, lower rates of distal embolization and shorter procedural length compared to aspiration. However, no clinical outcome difference was appreciated between the two groups and aspiration was associated with lower complication rates.

BACKGROUNDThis study aimed to evaluate subtraction CT angiography (sCTA) and MR angiography (MRA) as potential non-invasive alternatives for digital subtraction angiography (DSA) for the follow-up of intracranial aneurysms treated with flow diverter stent (FDS). METHODSForty patients with intracranial aneurysms treated with FDS were enrolled between August 2019 and November 2024 to evaluate the diagnostic performance of sCTA and MRA in assessment of aneurysm occlusion after FDS treatment. All patients were scheduled to undergo sCTA, MRA and DSA within 24 hours. sCTA was performed on a 160-row detector ultra-high resolution CT scanner. TOF MRA pre- and post-contrast, DWI and T1 sequences were acquired using a 3T MRI scanner. All studies were assessed by two blinded observers. Sensitivity, specificity, negative and positive predictive values were calculated for aneurysm occlusion. Interrater variability was assessed using the Cohens kappa. RESULTSCompared to DSA, specificity for evaluation of complete aneurysm occlusion was high for sCTA (88%), TOF MRA (92%) and post-contrast TOF MRA (83%). Post-contrast TOF MRA had the highest sensitivity (93%) and negative predictive value (95%). Interrater variability was good to excellent for all three modalities. Complications associated with DSA were observed in five patients; in one case, a 24-hour hospital admission was necessary for observation. CONCLUSIONsCTA, pre- and post-contrast TOF MRA seem to be appropriate for evaluating aneurysmal occlusion after FDS treatment, considering the high specificity and negative predictive value and non-invasive nature.

BackgroundIt is unknown whether balloon angioplasty can be a first-choice treatment for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) with small clot burden. The microcatheter "first-pass effect" is a valid predictor of ICAS-ELVO with small clot. ObjectiveTo determine balloon angioplastys efficacy as first-choice treatment for ICAS-ELVO involving the microcatheter "first-pass effect" during endovascular treatment (EVT). MethodsThis continuous retrospective analysis assessed ICAS-ELVO patients presenting with the microcatheter "first-pass effect" during EVT. Patients were divided into two first-choice treatment-based groups: preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT). Efficacy and safety outcomes were compared between groups. ResultsSeventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in PMT group, patients in PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p=.010) and complete reperfusion (expanded thrombolysis in cerebral ischemia[&ge;]2c; 76.0% vs. 53.8%, p=.049), (ii) a shorter puncture-to-recanalization time (49.5 min vs. 56.0 min, p<.001), (iii) less operation costs (48,499.5{yen} vs. 99,086.0{yen}, p<.001),and (iv) more excellent functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p=.032) at 90 days. No significant differences in symptomatic intracranial hemorrhage (12.0% vs. 15.4%, p>.999) and mortality (10.0% vs. 7.7%, p>.999) were noted. Logistic regression analysis revealed that first-choice treatment was an independent predictor of 90-day excellent functional outcomes (adjusted odds ratio [aOR] =0.10, 95% CI: 0.02-0.66, p=.017). ConclusionBalloon angioplasty, as the first-choice treatment, potentially improves 90-day functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" during EVT. What is already known on this topicCompared with large vessel occlusion caused by embolization, mechanical thrombectomy has lower recanalization rate, longer procedure time, and poorer prognosis for patients with intracranial atherosclerosis-related emergent large vessel occlusion(ICAS-ELVO). What this study addsThis study revealed that balloon angioplasty, as the first-choice treatment, potentially improves 90-day outcomes, shortens procedure time, and reduces operation costs for patients with ICAS-ELVO involving the microcatheter "first-pass effect" during endovascular treatment. How this study might affect research, practice or policyWe believe that our study makes a significant contribution to the literature because its findings suggest that rapid and accurate methods of diagnosing the etiology and clot burden of ELVO as well as the development of an individualized EVT strategy based on etiology and clot burden need to be established.

BACKGROUNDThis study is focused to identify the risk factors of shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) and develop a model to predict its incidence. METHODSMedical records of 118 consecutive patients with aSAH treated in our institution from January 2013 to October 2021 were reviewed retrospectively, 109 of them were enrolled in this cohort, the following data were analyzed based on presence or absence of SDHC: age, gender, body mass index, Fisher grade, Hunt and Hess scale (HHS), aneurysm location, treatment modality, new neurological deficits after aneurysm treatment, estimated glomerular filtration rate (eGFR), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and platelet-neutrophil ratio (PNR). We conducted univariate and multivariate logistic regression analyses to illustrate a nomogram for predicting SDHC risk. RESULTSThe stepwise logistic regression analysis with backward selection revealed three independent predictive factors of SDHC: age [&ge;]65 (odds ratio, 3.94; 95% CI, 1.4-11.00; p = 0.009), treatment modality (odds ratio, 4.36; 95% CI, 1.81-10.53; p = 0.001), and HHS [&ge;]3 (odds ratio, 3.59; 95% CI, 1.50-8.61; p = 0.004). A nomogram for SDHC risk prediction was developed based on the weight of these 3 factors. CONCLUSIONSAge, treatment modality (clipping vs coiling), and HHS are predictive for SDHC after aSAH. Endovascular embolization of aneurysm plays an important role in reducing risk of SDHC after aSAH.

BackgroundDolichoectatic Vertebrobasilar fusiform aneurysm (DVBFAs) presents a clinical challenge due to its complex anatomical features and associated neurological complications. This meta-analysis evaluates the clinical outcomes of endovascular treatment (EVT), open surgery, and conservative management for VBDA. MethodsA systematic review of the PubMed, Scopus, and Web of Science databases was conducted to identify studies reporting on radiologically confirmed DVBFAs. Clinical outcomes were assessed using the modified Rankin Scale (mRS) and mortality rates. Meta-regression was performed to identify potential predictors of treatment outcomes. ResultsTen studies with 219 patients were analyzed. Of the cohort, 58.4% underwent EVT, 24.6% received open surgery, and 16.9% were managed conservatively. The overall proportion of patients achieving a good clinical outcome (mRS <3) was 46.8%, with EVT showing the highest proportion at 59.4%, compared to 32.3% for open surgery and 24.7% for conservative management (p = 0.0145). The overall mortality rate was 25.98%, with EVT having the lowest mortality rate at 10.06%, followed by open surgery at 44.44% and conservative management at 63.30% (p = 0.0004). Subgroup analyses revealed statistically significant differences between treatment approaches in clinical outcomes and mortality. ConclusionEVT appears to provide better clinical outcomes for DVBFAs, though mortality rates remain high across all treatment modalities. The absence of significant differences in subgroup analysis suggests the need for further randomized controlled trials (RCTs) of EVT vs. conservative management to establish definitive treatment guidelines.

During the COVID-19 pandemic, radiology practices are reporting a decrease in imaging volumes. We review total imaging volume, CTA head and neck volume, critical results rate, and stroke intervention rates before and during the COVID-19 pandemic. Total imaging volume as well as CTA head and neck imaging fell approximately 60% since the beginning of the pandemic. Critical results fell 60-70% for total imaging as well as for CTA head and neck. Compared to the same time frame a year prior, the number of stroke codes at the early impact of the pandemic had decreased approximately 50%. Proportional reductions in total imaging volume, stroke-related imaging, and associated critical result reports during the COVID-19 pandemic raise concern for missed stroke diagnoses in our population.

BackgroundCircumferential aneurysm wall enhancement (CAWE) on high-resolution vessel wall imaging (HR-VWI) as a vessel wall inflammation marker is associated with the instability of unruptured intracranial aneurysms (UIAs) and recanalization after endovascular treatment. This study evaluates the association of CAWE with recanalization of small UIAs (<10 mm) treated with stent-assisted coiling (SAC) or coiling alone and aims to develop a prediction model for recanalization based on CAWE. MethodsWe analyzed patients with saccular UIAs who underwent 3T HR-VWI and were treated with SAC or coiling alone between October 2018 and May 2024. A 4-grade scale assessed aneurysm wall enhancement (none, focal thick wall enhancement, thin CAWE, thick CAWE). The aneurysm-to-pituitary stalk contrast ratio (CRstalk) quantified enhancement. We investigated the relationship between CAWE and recanalization and developed a recanalization prediction model. ResultsSixty-five patients with 69 small saccular UIAs were included; 11 aneurysms (15.9%) exhibited CAWE, and 10 aneurysms (14.5%) had a CRstalk [&ge;] 0.5. Sixty aneurysms received SAC. Recanalization occurred in 14 of 69 aneurysms (20.3%), assessed by digital subtraction angiography follow-up at 12.6 months. Multivariate analysis revealed that smoking, aneurysm size, CAWE, and CRstalk [&ge;] 0.5 predicted recanalization. A scoring prediction model was created using aneurysm size, treatment, embolization occlusion, and CAWE, with scores ranging from 0 to 6, where scores [&ge;] 3 indicated high risk and a C-statistic of 0.892 demonstrated excellent discrimination. ConclusionsCAWE on HR-VWI is a significant imaging marker for predicting recanalization in small UIAs undergoing SAC. The proposed recanalization risk scale needs further validation in larger studies.

Background and PurposeThe outcomes of endovascular therapy (EVT) across sexes for large infarcts remains unclear. This study aimed to evaluate the impact of sex on the outcomes of EVT for patients with large infarct. MethodsIn this secondary analysis of the ANGEL-ASPECT trial, we compared baseline characteristics and clinical outcomes between men and women, and each cohort further divided into EVT and medical management (MM) groups. The primary outcome was the 90-day modified Rankin Scale (mRS) score distribution. Safety outcomes included symptomatic intracranial hemorrhage (sICH) within 48 h and mortality within 90 days. ResultsThere were 177 of 455 patients enrolled in the ANGEL-ASPECT trial who were women. 53.7% (95/177) of women and 48.6% (135/278) of men underwent EVT, respectively. The treatment effect of EVT didnt vary in both sexes with large infarcts (all P >0.05 for interaction). Compared to MM, EVT improved 90-day functional outcomes for both men (3[2-5] vs. 4[3-5], common odds ratio [cOR]: 1.92, 95% CI: 1.26-2.95, P=0.003) and women (4[3-6] vs. 5[4-6], cOR: 2.50, 95% CI: 1.41-4.44, P=0.002). The sICH rate wasnt different in both treatment groups across both sexes (Men: 5.2% vs. 2.8%, RR: 2.04, 95%CI: 0.56-7.47, P=0.28; Women:7.4% vs. 2.4%, RR:3.00, 95%CI:0.57-15.68, P=0.19). ConclusionIn patients with large ischemic infarct, the treatment effect of EVT didnt differ between women and men, with better outcomes with EVT versus MM, without an increased risk of sICH. These findings emphasize the need for equal attention and care for both sexes with large infarcts in clinical practice.

BackgroundIntracranial atherosclerotic disease (ICAD) is associated with up to 10% of ischemic strokes and a high risk of recurrence. Endovascular treatments including percutaneous transluminal angioplasty and stenting have failed to demonstrate improved outcomes compared to medical therapy alone. Drug coated balloon (DCB) angioplasty has emerged as a promising alternative, though its safety and durability remains uncertain. MethodsThis single-center retrospective study analyzed consecutive patients with refractory ICAD treated with AGENT DCB submaximal angioplasty. Patients were treated either for refractory large-vessel occlusion during thrombectomy (emergency rescue) or for recurrent ischemic symptoms from high-grade stenosis (elective primary). Technical success was defined as <50% residual stenosis without adjunctive stenting. Safety outcomes included hemorrhage, dissection, stroke, and death at three months. ResultsOf the 11 identified patients, nine underwent successful DCB angioplasty, five for emergent rescue therapy and four for elective primary therapy. There was a combined 78% technical success rate, with no major procedural complications. Mean stenosis reduction was 53.6% (paired Wilcoxon p=0.014; pre-procedure mean (SD) stenosis 90.8% ({+/-}8.6%) to post-procedure 37.3% ({+/-}33.4%)). Restenosis occurred in three of the four (75%) elective primary patients without recurrent ischemic events. Follow-up angiographic data for the emergent rescue cohort was unavailable, though no symptomatic ischemic events were reported. ConclusionPaclitaxel-coated AGENT drug-coated balloon (DCB) submaximal angioplasty was safe and yielded immediate improvements in luminal diameter. However, high rates of re-stenosis emphasize the need for innovative devices and larger prospective studies to define its therapeutic role for refractory ICAD.

BackgroundClinical and administrative studies suggest better functional outcomes after endovascular treatment (EVT) of intracranial aneurysms (IAs) compared to neurosurgical clipping (NSC). However, it remains unclear whether this applies to modern EVT techniques, such as balloon-assisted coiling (BAC), stent-assisted coiling (SAC), flow diversion (FD), or intrasaccular flow disruption (IFD). This study compares nationwide in-hospital outcomes of modern EVT methods and NSC with standard coiling (SC). MethodsAdministrative data from all German hospitals (2013-2022) were analyzed using billing codes for SC, BAC, SAC, FD, IFD, and NSC in ruptured and unruptured IAs. Primary outcomes included functional independence (discharge type), poor outcomes (US Nationwide Inpatient Sample-Subarachnoid Hemorrhage Outcome Measure [NIS-SOM]), and in-hospital mortality. Propensity score weighting was used for comparisons. ResultsA total of 77,684 procedures were analyzed (46.8% ruptured, 53.2% unruptured). In ruptured IAs, SAC, FD, and NSC were associated with lower functional independence (p=0.001, p=0.007, p<0.001) and higher mortality (p<0.001, p=0.001, p=0.032). Poor outcomes were more frequent after SAC (p=0.001) and NSC (p<0.001). In unruptured IAs, functional independence improved with BAC (p=0.036), SAC (p=0.045), and IFD (p<0.001), but decreased with NSC (p=0.017). Poor outcomes were less frequent with IFD (p<0.001), and mortality was lower with NSC (p=0.020) and IFD (p=0.003). ConclusionsNationwide data from Germany reveal significant differences between EVT techniques and NSC for IA treatment. In ruptured IAs, SAC, FD, and NSC were associated with worse outcomes compared to SC. In unruptured IAs, BAC, SAC, and IFD improved functional outcomes, while NSC was linked to decreased functional outcomes. Notably, IFD consistently demonstrated superior functional outcomes despite limited utilization. Given the limitations of billing data, these findings suggest a potential shift favoring IFD as a safer treatment option in unruptured IAs.

BackgroundThe treatment of a ruptured aneurysm, in a center with expertise in aneurysmal subarachnoid hemorrhage (aSAH), is recommended preferably within 24 to 72 hr. We assessed the impact of long-distance aeromedical evacuation in patients presenting aSAH in a remote island without neuro-interventional capacities. MethodsThis was a case-control study of patients with aSAH flown from a French Caribbean island (Guadeloupe) to Paris, France (6750 km), for neuro-interventional and neuro-ICU management and identical patients from the Paris region over a 10-year period (2010 to 2019). The two populations were matched on age, sex, World Federation of Neurological Surgeons score, and Fisher score. The primary outcome was the 1-year modified Rankin Scale (mRS) score divided into two categories: good outcome (mRS 0 to 3) and poor outcome (mRS 4 to 6). A cost study was added. ResultsAmong 128 consecutive aSAH transferred from Guadeloupe, 93 could be matched with 93 patients with aSAH from the Paris area. The median [Q1,Q3] time from diagnosis to securing the aneurysm was 48 hr [30,63] in the Guadeloupe group versus 23 [12,24] in the control group (p<0.001). The rate of good clinical outcome (1-year-mRS [&le;] 3) was 75% in the Guadeloupe group and 82% in the control group (p=0.1). The groups did not differ in 1-year mortality (18% vs 14%, p=0.5) and duration of mechanical ventilation. However, Guadeloupe patients more frequently required mechanical ventilation (59% vs 38%, p<0.001) and external ventricular drainage (55% versus 39%, p=0.005) than the control group, although the number of hydrocephalus events did not differ. The additional cost of treating a Guadeloupe patient in mainland France was estimated at 7580 euros, or 17% of the estimated cost in Guadeloupe. ConclusionsLong distance aeromedical evacuation of Guadeloupe patients with aSAH resulted in a 25-hr increase in median embolization time but had no effect on mortality or functional prognosis at 1 year.

BACKGROUNDWhether remedial angioplasty or stenting (RAS) improves clinical outcomes of patients with basilar artery occlusion (BAO) undergoing endovascular treatment (EVT) is controversial. This study aimed to investigate the impact of RAS on prognosis in acute BAO. METHODSThis post-hoc analysis derived from the ATTENTION study. Patients undergoing EVT were categorized in the RAS group if they received balloon angioplasty, stent implantation, or balloon plus stenting. The primary outcome was favorable outcome (modified Rankin Scale score of 0-3) at 90 days. Safety outcomes included death within 90 days and any intracranial hemorrhage within 24 h. Control of confounders using inverse probability processing weighting (IPTW). RESULTSA total of 221 patients with BAO experiencing EVT were included, of whom 104 (47.06%) received RAS. Multivariate analysis by IPTW adjustment showed that there was no significant difference in favorable outcome between the two groups (OR, 0.81, 95% CI, 0.55, 1.19; P=0.282). But RAS was associated with decreased risk of excellent outcome (OR, 0.67; 95% CI, 0.45-0.98; P=0.042) and functional independence (OR, 0.64; 95% CI, 0.42-0.98; P=0.043). Regarding safety outcomes, the RAS group had a significantly lower incidence of any intracranial hemorrhage within 24 h (OR, 0.52; 95% CI, 0.28-0.92; P=0.027). However, there was little difference in 90-day mortality between the two groups. In non-atherosclerotic populations, RAS is usually associated with a worse clinical prognosis; however, this phenomenon has not been found in atherosclerotic populations (all P<0.05 for the stroke etiologyxRAS interaction). In RAS patients, we find that there was no difference in functional or safety outcomes between only balloon angioplasty (52 patients) compared with other remedy group (52 patients). CONCLUSIONSDespite the fact that RAS is secure, it didnt further improve favorable outcomes of patients with BAO undergoing EVT; particularly in the non-atherosclerotic population. In patients with RAS, balloon angioplasty alone is an appropriate remedial technique, additional stent implantation may not be required.

IntroductionEndovascular rescue treatment, including intra-arterial spasmolysis and/or transluminal balloon angioplasty, is widely used for symptomatic vasospasm and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH), yet its impact on functional recovery remains uncertain. We systematically reviewed and synthesized the evidence on patient-centered outcomes, exploring effects by follow-up time, intervention type, and clinical severity. Materials and methodsFollowing a prospectively registered protocol (Research Registry: reviewregistry1466) and PRISMA guidance, we searched PubMed, EMBASE, and Web of Science (January 2000-December 2024; final update July 2025). Prospective and retrospective studies of adult aSAH patients receiving endovascular treatment for symptomatic angiographic vasospasm were included. Data extraction followed a standardized PICO framework, and study quality was assessed using the Newcastle-Ottawa Scale. Because reporting of angiographic resolution and DCI-related infarction was sparse or inconsistent, quantitative synthesis focused on dichotomized favorable functional outcome (e.g., mRS 0-2 or GOS good recovery). Single-arm meta-analyses of proportions were performed on the logit scale using random-effects generalized linear mixed models, with subgrouping by follow-up, intervention, and clinical severity. ResultsThirty-nine studies (1,627 patients; 27 retrospective cohorts, 5 prospective cohorts, 5 case series, 2 randomized trials) met inclusion criteria; 38 contributed to meta-analysis. The pooled proportion of favorable functional outcomes was 0.55 (95% CI, 0.50-0.61) with substantial heterogeneity (I{superscript 2} {approx} 71%). Prespecified subgroup analyses by follow-up duration, intervention type, and baseline severity did not reveal significant differences. The two randomized trials reported conflicting short-term results with limited follow-up. Safety reporting was variable but generally acceptable for pharmacologic spasmolysis, while higher complication rates were occasionally observed with mechanical interventions. ConclusionAmong patients with symptomatic vasospasm or DCI requiring endovascular rescue, approximately half achieve a favorable functional outcome. However, marked heterogeneity and reliance on predominantly observational data preclude firm conclusions regarding comparative effectiveness. Standardized multicenter randomized trials with harmonized definitions of eligibility, timing, outcomes, and adverse events are needed to clarify the therapeutic role and optimize patient selection for endovascular rescue after aSAH.

BACKGROUNDCarotid Artery stenting (CAS) have been reported to be safe and effective option for treating carotid atherosclerotic diseases. The published data support the use of embolic protection devices (EPDs) to reduce periprocedural stroke. However, reports and studies from resource limited countries are scarce. This study aimed to evaluate the outcome of CAS procedures without EPDs in Yemen as one of the lowest-income countries. METHODSThis is a retrospective cohort study regarding carotid artery stenting (CAS) for symptomatic carotid artery stenosis that was conducted at the stroke center of and American Modern Hospital (AMH) during the period from March 2023 to March 2025. All Patients with symptomatic carotid artery stenosis were included in the study. CAS procedures were performed by a single interventional neurologist. The primary outcome included a 30-day periprocedural mortality, stroke, and myocardial infarction or arrythmia. Any other complications are considered secondary outcomes. RESULTSA total of 62 (53 males) patients included in this study, mean age 60.2 {+/-} 9.68 years. All Patients had symptomatic carotid artery stenosis. Technical success rate was 100%. (%). One patient developed transient dysarthria but DW-MRI was negative. Significant bradycardia occurred in two patients and responded immediately to atropine. Three patients developed mild local hematoma and one patient had femoral pseudoaneurysm. Closed-Cell Carotid Wall Stent (Boston Scientific) was used as a single stent in all patients. CONCLUSIONCAS conducted by a trained interventional neurologist without EPDs, demonstrates a low complication rate and it is effective and safe option in countries with-limited resources.

BackgroundCerebral venous thrombosis (CVT) is a rare but devastating disease, with some patients experiencing disease deterioration despite treatment. Endovascular treatment is an anticipated option, but its clinical relevance is yet to be determined. This observational study aimed to assess the clinical effects and identify patient populations that may benefit from treatment. MethodsPatient data from April 2014 to March 2022 were extracted from a nationwide Japanese database. The primary outcome was in-hospital mortality, while secondary outcomes included modified Rankin Score ([&ge;] 3) and posthospitalization complications. Severity adjustments were performed using a generalized linear mixed model and propensity score matching. ResultsThe analysis included 2901 patients; 240 patients in the endovascular treatment group were matched with 240 patients in the standard treatment group. After adjusting for background factors, endovascular treatment did not improve in-hospital mortality (adjusted odds ratio 1.45 [95% CI: 0.74-2.16]) or the modified Rankin Score (adjusted odds ratio 0.89 [95% CI: 0.56-1.23]). No subpopulations that could benefit from endovascular treatment were identified. However, posthospitalization intracranial complications did not increase with endovascular treatment (0.8% vs. 1.2% in the standard treatment group). ConclusionsEndovascular treatment did not show any clinical benefit in patients with CVT. These findings are crucial for guiding clinical decisions and suggest that further evidence is warranted.

BackgroundStroke patients with large vessel occlusion (LVO) benefit from thrombolysis (tPA) and mechanical thrombectomy (MT). We aim to characterize triaging patterns in these patients, specifically those who go to perfusion-based imaging first or direct to angio in the drip-and-ship model. Furthermore, we propose that select patients may benefit from CTP prior to MT. MethodsA total of 270 patients with acute ischemic stroke secondary to LVO/MeVO were retrospectively evaluated from January 2018 to June 2022. These patients received intravenous tPA from the outside hospital and were transferred for the intention of MT. We compared baseline characteristics between those who received CTP upon arrival and those who went either directly to the angiography suite (DTA) along with logistic regression and functional outcomes. ResultsPredictors of CTP utilization over DTA was the presence of an M3 occlusion (11.3% vs. 1.7%, p=0.005) and PCA occlusion (12.9% vs. 3.4%, p=0.015). The DTA approach was higher in M1 MCA occlusions (43.2% vs. 27.4%, p=0.038) and basilar occlusions (7.6% vs. 0, p=0.026). DTA patients had a higher NIHSS at the spoke (median NIHSS 15 [9-21] vs. 9 [4.75-14], p<0.001) and the hub (14 [7-20] vs. 7 [3-15.75], p<0.001). There was no significant difference between the DTA and CTP groups in regards to mRS at 90 days (39% vs. 48.4%, p=0.101). ConclusionIn the drip-and-ship model, NIHSS and location of an occlusion on initial CTA guide CTP utilization in LVO/ MeVO patients. Long term functional outcomes are not significantly affected by arrival at CTP over DTA. Patients whose transfer is delayed, improve after thrombolysis, present with a MeVO, or are limited by resources at the CSC may benefit from transfer to CT over a DTA approach. We propose this DIMR score may help guide triaging of patients who have an intracranial occlusion and receive thrombolysis.