Stroke: Vascular and Interventional Neurology

BackgroundEndovascular treatment (EVT) is widely accepted for intracranial aneurysms due to its safety and efficacy. However, EVT of ruptured very small intracranial aneurysms (RVSIA) ([≤]3 mm) is still challenging and the risk-benefit ratio of EVT remains unclear. The aim of this study was to evaluate the safety and efficacy of EVT of RVSIA. MethodsWe performed a systematic review and meta-analysis of the studies on EVT of RVSIA. Pooled prevalence rates were calculated for initial and follow-up complete occlusion rates (Raymond Roy Grade 1), recanalization, retreatment, long-term favorable outcome (modified Rankins scale score 0 to 2 or Glasgow Outcome Scale 4 or 5), procedure-related complications (coil herniation, thromboembolism, and intraprocedural re-rupture), and procedure-related mortality. Pooled odds ratios were calculated to compare these outcomes between simple coiling and stent-assisted coiling (SAC). ResultsOf the 600 studies screened, 24 studies with a total of 1355 RVSIAs treated with EVT were included. The initial and follow-up complete aneurysm occlusion rates were 64% (95% confidence interval [CI]: 52-74%) and 85% (95% CI: 74-92%). The rates of recanalization and retreatment were 6% (95% CI: 3-10%) and 3% (95% CI: 2-4%). The favorable long-term follow-up outcome was observed in 91% (95% CI: 89- 93%) of patients. The rates of coil herniation, thromboembolism, and intraprocedural rupture were 2% (95% CI: 1-8%), 4% (95% CI: 3-6%), and 4% (95% CI: 2-7%), respectively. Mortality was 3% (95% CI: 2-4%). Comparison of outcomes between simple coiling and SAC revealed no significant difference, except for a higher likelihood of recanalization in the coiling group (Odds ratio, 3.51 [95% CI, 1.31-9.45]). ConclusionsOur meta-analysis demonstrates that EVT for RVSIA is a feasible, effective, and safe approach that is associated with favorable clinical outcomes in both the short and long term.

BackgroundEarly assessment and management of cerebral edema and hematoma following aneurysmal subarachnoid hemorrhage (a-SAH) can significantly impact clinical cognitive outcomes. However, current clinical practices lack predictive models to identify early structural brain abnormalities affecting cognition. To address this gap, we propose the development of a predictive model termed the a-SAH Early Brain Edema/Hematoma Compression Neural (Structural Brain) Networks Score System (SEBE-HCNNSS). MethodsIn this study, 202 consecutive patients with spontaneous a-SAH underwent initial computed tomography (CT) or magnetic resonance imaging (MRI) scans within 24 hours of ictus with follow-up 2 months after discharge. Using logistic regression analysis (univariate and multivariate), we evaluated clinically relevant factors and various traditional scale ratings for cognitive impairment (CI). Risk factors with the highest area under the curve (AUC) values were included in the multivariate analysis and least absolute shrinkage and selection operator (LASSO) analysis or Cox regression analysis. ResultsA total of 177 patients were enrolled in the study, and 43 patients were classified with a high SEBE-HCNNSS grade (3 to 5). After a mean follow-up of 2 months, 121 individuals (68.36%) with a-SAH and 3 control subjects developed incident CI. The CT inter-observer reliability of the SEBE-HCNNSS scale was high, with a Kappa value of 1. Furthermore, ROC analysis identified the SEBE-HCNNSS scale (OR 3.322, 95% CI 2.312-7.237, p = 0.00025) as an independent predictor of edema, CI, and unfavorable prognosis. These results were also replicated in a validation cohort. ConclusionOverall, the SEBE-HCNNSS scale represents a simple assessment tool with promising predictive value for CI and clinical outcomes post-a-SAH. Our findings indicate its practical utility as a prognostic instrument for risk evaluation after a-SAH, potentially facilitating early intervention and treatment.

BackgroundMechanical thrombectomy (MT) has significantly improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusions (LVOs) up to 24 hours post-onset. The effectiveness of MT for medium vessel occlusions (MeVOs) in the M2 or M3 segments of the middle cerebral artery beyond 6 hours is less investigated. MethodsThis retrospective study analyzed 80 patients who underwent MT for primary, isolated M2 or M3 segment occlusions between January 2020 and August 2023. Patients were categorized by time from stroke onset to groin puncture into two groups: [&le;]6 hours (n=61) and >6 hours (n=19). Outcomes assessed included clinical severity (NIH Stroke Scale [NIHSS]), functional outcomes (modified Rankin Scale [mRS]), symptomatic intracranial hemorrhages (sICH), and reperfusion success (modified Thrombolysis in Cerebral Infarction [mTICI] scale). ResultsMean onset-to-puncture time was 192{+/-}57 minutes for the [&le;]6 hours group and 611{+/-}327 minutes for the >6 hours group. Baseline NIHSS scores were 9.5 (IQR 9) and 7 (IQR 8), respectively (p=0.418). While the NIHSS improvement was greater in the [&le;]6 hours group (median: -5 vs. -2; p=0.028), both groups showed significant improvement from baseline NIHSS scores (p<0.001 and p=0.014). Rates of sICH were low in both groups (1.5% vs. 0.5%; p=0.421). Recanalization rates were lower in the >6 hours group (84.2% vs. 96.7%; p=0.084), with more attempts (2.37 vs. 1.66; p=0.024). ConclusionMT for M2 and M3 segment occlusions in the MCA shows benefits beyond 6 hours from stroke onset, with earlier treatment yielding greater improvement. Extending MTs treatment window could be valuable for MeVOs in the MCA.

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.

ObjectiveWith the recent expansion of the Centers for Medicare and Medicaid Services (CMS) coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. This study evaluates the tfCAS learning curve using VQI data. MethodsWe analyzed tfCAS patient data from 2005-2023. Each physicians procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. Primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA. The relationship between outcomes and procedure counts was analyzed using Cochran Armitage test and a generalized linear model with restricted cubic splines, validated using generalized estimating equations. ResultsWe analyzed 43,147 procedures by 2,476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2% to 1.7%), in-hospital stroke/death/MI (5.8% to 1.7%), 30-day mortality (4.6% to 2.8%), in-hospital stroke/TIA (5.0% to 1.1%) (all p-values<0.05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1% to 1.6%), in-hospital stroke/death/MI (2.6% to 1.6%), 30-day mortality (1.7% to 0.4%), and in-hospital stroke/TIA (2.8% to 1.6%) with increasing physician experience (all p-values<0.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. ConclusionsIn-hospital stroke/death and 30-day mortality rates post-tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians early cases may not be included in the VQI, the learning curve was likely underestimated. With the recent CMS coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications. ARTICLE HIGHLIGHTSO_ST_ABSType of ResearchC_ST_ABSRetrospective analysis of prospectively collected Vascular Quality Initiative registry data. Key FindingsIn patients undergoing tfCAS in VQI, in-hospital stroke/death, in-hospital stroke/death/MI, 30-day mortality and in-hospital stroke/TIA decreased with increasing physician experience in both symptomatic and asymptomatic patients. In symptomatic patients, in-hospital stroke/death rate did not drop below 4% until after 235 procedures, and it remained above 2% until 13 procedures in asymptomatic patients. Take home MessageThis study showed a decrease in post-operative in-hospital stroke/death with a substantially high risk in an operators first 25 procedures in VQI. The recent expansion of the Center for Medicare and Medicare Services coverage of tfCAS warrants caution since a rise in early-phase physicians could lead to increased post-operative complication rates in transfemoral carotid artery stent patients. Table of Contents SummaryIn this retrospective analysis of the tfCAS learning curve, in-hospital stroke/death, in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA rates decreased significantly with increased physician experience. With the recent CMS coverage expansion for tfCAS, more physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications.

BackgroundEndovascular thrombectomy (EVT) revolutionized large vessel occlusion (LVO) stroke. However, treatment decisions and prognostication are challenging without advanced imaging. We sought to determine the relationship of simple CTA collateral patterns and outcomes after EVT. MethodsWe identified patients with anterior LVO who underwent guideline based EVT from a single center from 2019-2020. Inclusion criteria were available CTA and 90-day modified Rankin Scale (mRS). Arterial-phase CTA collaterals were categorized as malignant, other, or symmetric. ResultsAmong 74 patients, the median age was 75 and 49% were female. Collaterals were symmetric (36%), malignant (24%), or other (39%). Comparing collateral patterns there were no differences in demographics, presentations, time from last well, good reperfusion, or intracerebral hemorrhage. Median NIHSS was 18 for malignant, 19 for other, and 11 for symmetric (p=0.02). Intracranial ICA occlusions were present in 28% of malignant, 3% of other, and 11% of symmetric (p=0.04). Ninety-day mRS [&le;]2 was achieved in 17% of malignant, 38% of other, and 67% of symmetric. Collateral pattern was a significant determinant of 90-day mRS [&le;]2 (aOR=6.62, 95%CI=2.24,19.53; p=0.001) in a multivariable model including age, NIHSS, baseline mRS, thrombolysis, LVO location, and good reperfusion. ConclusionsSimple CTA collateral pattern is a robust determinant of 90-day outcomes after EVT. Further prospective studies are needed to understand how collateral pattern can guide EVT treatment decisions and long-term prognosis.

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

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.

Background: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) remains associated with high mortality and severe disability, yet contemporary outcomes may differ substantially from historical estimates. We performed a systematic review and meta-analysis to evaluate long-term outcomes after poor-grade aSAH and assess temporal, geographic, and treatment-related factors associated with prognosis. Methods: PubMed/MEDLINE, Embase, Cochrane Central, Scopus, and Google Scholar were searched from inception through March 2026. Studies enrolling consecutive adults with poor-grade aSAH (World Federation of Neurosurgical Societies grades IV-V, Hunt-Hess grades IV-V, or equivalent) reporting mortality and/or functional outcomes at 3 months were included. To minimize survivorship bias, studies excluding untreated patients or patients dying before aneurysm treatment were excluded. Random-effects meta-analyses of proportions were performed using generalized linear mixed models. Prespecified subgroup analyses and exploratory meta-regression analyses evaluated temporal, geographic, and treatment-related factors associated with outcomes. Results: Forty-two studies including 7,726 patients from 16 countries across 4 continents were included. The pooled favorable functional outcome rate was 27.2% (95% CI, 23.9%-30.8%), whereas pooled overall mortality was 53.3% (95% CI, 49.0%-57.5%). Pre- and post-treatment mortality were 25.9% and 33.9%, respectively. Aneurysm treatment rate was 72.0% (95% CI, 65.6%-77.7%). Favorable outcomes improved over time from 13.5% (95% CI, 7.0%-24.3%) in the 1980s to 33.7% in the 1990s but plateaued thereafter. In exploratory meta-regression analyses, higher aneurysm treatment rates were independently associated with improved favorable functional outcome (0.134 log-odds increase per 10% increase in treatment rate; p = 0.01) and lower mortality (-0.224 log-odds per 10% increase in treatment rate; p < .001). Publication year was associated with lower mortality (p = 0.03) but not favorable outcome. Geographic region, country income group, and the proportion of grade V patients were not independently associated with outcomes. Conclusions: Mortality after poor-grade aSAH remains high, but approximately one-third of patients achieved favorable outcome. Higher aneurysm treatment rates were independently associated with improved functional outcomes and lower mortality.

BackgroundIn patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO), improved functional outcomes have been reported in patients who achieve Modified Thrombolysis In Cerebral Infarction (mTICI) 2c/3 (excellent recanalization) over mTICI 2b. We aimed to determine pretreatment and interventional variables that could predict achieving mTICI 2c/3 over 2b reperfusion in patients who underwent technically successful mechanical thrombectomy (MT). MethodsIn this retrospective study, consecutive AIS patients with anterior circulation LVO who underwent MT and achieved recanalization with mTICI 2b/2c/3 were included. We evaluated the association between pretreatment clinical and imaging variables and interventional parameters in patients who achieved mTICI 2c/3 vs. 2b using logistic regression and ROC analyses. ResultsFrom 5/11/2019 to 10/09/2022, 149 consecutive patients met our inclusion criteria (median 70 years old [IQR 65 - 78.5], 57.7% female). Adjusted multivariate regression analyses showed that patients with excellent recanalization had lower admission NIHSS (aOR 0.93, p = 0.036), were less likely to have a history of diabetes mellitus (DM) (aOR 0.42, p = 0.050) and prior stroke (aOR 0.27, p = 0.007), had a cerebral blood volume (CBV) index >= 0.7 (aOR 3.75, p = 0.007), and were more likely to achieve excellent recanalization with aspiration alone (aOR 2.89, p = 0.012). A multivariate logistic regression model comprising these independent factors predicted mTICI 2c/3 with an AUC 0.79 (95% CI: 0.68-0.86; p < 0.001), sensitivity of 94%; specificity of 41%. ConclusionRobust collateral status (CS) defined by CBV index >= 0.7, absence of DM and prior stroke, lower initial stroke severity, and direct aspiration are all predictive of excellent recanalization in successfully recanalized AIS-LVO patients. Our findings highlight the prognostic implications of robust CS, DM and stroke prevention, as well as use of aspiration alone in maximizing the likelihood of excellent recanalization.

IntroductionPopliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysm and carry substantial risks of limb loss. Both open and endovascular repair are widely used, yet optimal patient selection remains uncertain. We evaluated institutional operative practices and examined associations between aneurysm morphology, procedural approach, and major adverse limb events (MALE). MethodsWe conducted a retrospective cohort study at a tertiary care center to identify patients with PAAs from 2008-2022. Chart review confirmed aneurysm presence and captured demographics, comorbidities, medications, aneurysm characteristics, and operative details. Cox proportional hazards models were used to evaluate time to MALE defined as reintervention or amputation. ResultsAmong 330 PAAs, median follow-up was 7.4 months (IQR 3.4-12.7). Open repair comprised 79% (250/330), most often a medial approach (75%, 187/250) with autologous vein conduit (65%, 162/250). Open-repair patients were younger than endovascular (69 vs 74 years; p=0.006) with similar cardiovascular profiles. Indications differed by approach, with aneurysm size >20 mm most common for open repair (35.2%, 87/250) and mural thrombus most common for endovascular repair (33.3%, 24/80). MALE occurred in 30.3% (100/330). In univariate analyses, clopidogrel use was associated with increased MALE risk (HR 1.74, 95% CI 1.17-2.59; p=0.006), while descending aortic aneurysm was associated with decreased risk (HR 0.47, 95% CI 0.23-0.92; p=0.029). Operative approach, aneurysm diameter, and thrombus burden were not associated with MALE, and findings were unchanged after multivariable adjustment. ConclusionsMALE risk was comparable across operative strategies and aneurysm morphologies, suggesting that aneurysm size and thrombus burden alone should not preclude consideration of either open or endovascular repair.

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative strategy for the management of chronic subdural hematoma (cSDH). Although accumulating studies suggest potential benefit, uncertainty remains regarding its safety profile, recurrence-prevention effect, and the reliability of adverse event reporting. This systematic review and meta-analysis re-evaluate contemporary evidence, incorporating new randomized trials and large observational cohorts. MethodsThis systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. PubMed, Scopus, Web of Science Core Collection, Embase, and CENTRAL were searched from inception to 12 September 2025 without language restrictions. Randomized controlled trials, prospective or retrospective cohort studies, and non-randomized clinical studies evaluating middle meningeal artery embolization (MMAE) for chronic subdural hematoma were eligible. Data extraction and risk-of-bias assessment were performed independently using Joanna Briggs Institute appraisal tools. Where outcomes were sufficiently comparable, quantitative synthesis was undertaken using random-effects single-arm proportion meta-analysis with logit transformation. Recurrence after MMAE was pooled across observational studies and MMAE arms of randomized trials with available event-level data, with prespecified subgroup analyses by study design. Mortality was synthesized from randomized trials reporting event-level data within a [&le;]90-day follow-up window. Complication rates and technical success were analyzed descriptively due to heterogeneity in definitions and follow-up durations. ResultsNineteen studies met eligibility criteria, including seven randomized controlled trials, sixteen retrospective cohorts, and one prospective cohort, comprising an elderly and medically complex population (mean ages 61-89 years). Common comorbidities included hypertension, diabetes, cardiovascular and cerebrovascular disease, renal dysfunction, and antithrombotic use. Technical success of middle meningeal artery embolization (MMAE) was consistently high, with a pooled success rate of 100% (95% CI 0.99-1.00; I2 = 0%). Recurrence after MMAE was consistently low across randomized and observational studies, including high-risk populations, and was uniformly lower than in comparator groups. Radiographic outcomes showed substantial hematoma volume reduction and high rates of complete or near-complete resolution, with favorable functional recovery. Complications were uncommon but heterogeneous; the pooled overall complication rate was 14% (95% CI 0.08-0.21). Pooled 90-day all-cause mortality from randomized trials was 8% (95% CI 0.07-0.10; I2 = 0%). ConclusionMMAE is a safe and effective adjunctive or alternative treatment for chronic subdural hematoma, demonstrating a reproducible and clinically meaningful reduction in recurrence across randomized and observational datasets with homogeneous outcome definitions. However, variability in adverse event reporting, insufficient documentation of rare complications, and inconsistent definitions of radiographic versus clinical recurrence highlight the need for standardized outcome frameworks and harmonized follow-up protocols. Future well-designed trials with robust adverse event adjudication are essential to define the long-term safety profile of MMAE and to guide its optimal integration into cSDH management pathways.

BackgroundNeurointerventional therapy is a cornerstone in managing head and neck vascular disorders, with cerebral angiography serving as its fundamental diagnostic and therapeutic backbone. However, manual cerebral angiography is associated with several inherent limitations. While existing robotic-assisted systems have shown promise in mitigating some of these issues, they face challenges such as limited compatibility, lengthy setup times, and a lack of high-quality real-world evidence. MethodsThe ERASE trial is a multicenter, prospective, randomized controlled trial (RCT). A total of 450 eligible patients will be enrolled from six comprehensive stroke centers in China and randomized 1:1 to either the robotic-assisted group or the control group. Both groups use the Seldinger technique for femoral/radial artery access. Operators undergo standardized training on the robotic system, and all patients are followed up at baseline, end of surgery, 24 hours postoperatively, and 7 days post-discharge. ResultsThe primary efficacy outcome is the clinical success rate. The primary safety outcome is the incidence of perioperative/postoperative complications (e.g., vascular perforation, dissection, pseudoaneurysm), serious adverse events, and device malfunctions. Secondary outcomes include technical failure rate, overall procedural time, pre-puncture setup time, target vessel super-selective catheterization time, digital subtraction angiography fluoroscopy time, participant radiation doses and contrast agent volume. A key safety endpoint is the rate of new asymptomatic cerebral infarctions detected via postoperative brain MRI-diffusion-weighted imaging. ConclusionsAs the RCT focusing on the YDHB-NS01 Ver 2.0 system, the ERASE trial addresses critical unmet needs in neurointerventional practice and will generate high-quality evidence for robotic-assisted cerebral angiography. Trial registration number: ClinicalTrials.gov NCT07182188. Clinical Perspective1) What Is New? This multicenter RCT evaluates the YDHB-NS01 Ver 2.0 robotic-assisted system and provides rigorous evidence on its safety and efficacy compared with manual cerebral angiography, while validating targeted design enhancements addressing prior systems shortcomings 2) What Are the Clinical Implications? The study s findings could standardize the clinical application of robotic-assisted cerebral angiography and inspire further research on refining robotic interventional workflows to improve patient outcomes and provider safety.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a severe form of stroke associated with higher morbidity and mortality. Posterior circulation aneurysms are considered to have worse prognosis than anterior circulation aneurysms due to anatomical location, hemorrhage severity, and treatment complexity. We aimed to determine whether aneurysm location independently influences clinical outcomes following aSAH Methods: PubMed, Scopus, Embase, and Web of Science were searched from January 2000 to December 2025 for studies reporting outcomes in anterior or posterior circulation aSAH. The outcome analysis included mortality, functional recovery (modified Rankin Scale [mRS] 0-2 and 3-6 at 6 months and 1 year), hydrocephalus, delayed cerebral ischemia (DCI), and symptomatic cerebral vasospasm. Pooled proportions and subgroup comparisons were performed using random-effects meta-analysis (DerSimonian-Laird method). Publication bias was evaluated using contour-enhanced funnel plots and Egger's test. Results: Nineteen analytic entries from 18 studies (anterior: n = 1,625; posterior: n = 986; total N = 2,611) were included. Pooled mortality was 13% (95% CI: 10%-17%; I2 = 84.6%), with no significant difference between the anterior (14%; 95% CI: 10%-20%) and posterior (11%; 95% CI: 7%-18%) circulation subgroups (p = 0.437). Good functional outcome was 60% at 6 months (95% CI: 51%-67%) and 55% at 1 year (95% CI: 46%-64%), with no location-based differences. Hydrocephalus (35% vs 35%; p = 0.979) and DCI (17% vs 17%; p = 0.939) were comparable between subgroups. Symptomatic cerebral vasospasm was the only outcome differing significantly by location, occurring more frequently in anterior circulation aSAH (24% vs 11%; {chi}2 = 5.59; p = 0.018). Conclusion: Aneurysm location does not independently determine mortality, functional recovery, hydrocephalus, or DCI following aSAH. Symptomatic cerebral vasospasm was the only location-specific outcome. Admission neurological grade (World Federation of Neurosurgical Societies [WFNS]), rather than vascular territory, appears to be the primary determinant of mortality. Aneurysm location alone should not guide prognostic decisions or limit aggressive treatment.

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.

BackgroundBlood-brain barrier disruption is a prominent pathological characteristic of aneurysmal subarachnoid hemorrhage (aSAH), which can be measured as Ktrans using CT perfusion. PurposeTo monitor Ktrans within 24 hours of aSAH and during the time window associated with a delayed cerebral ischemia (DCI) event (DCITW), and to explore its association with the trajectory of DCI, including outcome at three months. MethodsWe retrospectively assessed consecutive aSAH patients from a prospective database between July 2020 and September 2022. Patients were grouped according to the DCI occurrence and three months modified Rankin scale. Ktrans at admission (admission Ktrans) and during DCITW (DCITW Ktrans) were compared between DCI and non-DCI groups, and between good outcome and poor outcome groups. The changes in Ktrans were also analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of DCI and poor outcome. ResultsOne hundred and twenty-eight patients (mean age, 61{+/-}12 [SD]; 75 women) were included. Both admission Ktrans (0.58{+/-}0.18 vs 0.47{+/-}0.12, P=0.002) and DCITW Ktrans (0.54{+/-}0.19 vs 0.41{+/-}0.14, P<0.001) were significantly higher in the DCI group compared with the non-DCI group. Both of those were also higher in the poor outcome group compared with the good outcome group, but the difference was not statistically significant at admission (0.53{+/-}0.18 vs0.49{+/-}0.14, P=0.198). Ktrans in the non-DCI group (0.47{+/-}0.12 vs 0.41{+/-}0.14, P=0.004) and good outcome group (0.49{+/-}0.14 vs 0.41{+/-}0.14, P<0.001) decreased significantly from admission to DCITW. Multivariate analysis identified DCITW Ktrans and admission Ktrans as independent predictors of poor outcome (OR=1.73, 95%CI: 1.24-2.43, P=0.001) and DCI (OR=1.75, 95%CI: 1.25-2.44, P=0.001), respectively. ConclusionElevated Ktrans at admission is associated with the occurrence of DCI, but not with outcome at three months. Continuous monitoring of Ktrans from admission to DCITW can accurately identify reversible and irreversible changes in Ktrans, and can predict outcome.

BackgroundEndovascular stroke treatment (EST) has become the treatment of choice for middle cerebral artery (MCA) M1-segment occlusions. Little is known about the implications for revascularization success of occlusions with persisting antegrade perfusion before initiation of treatment (modified Treatment In Cerebral Ischemia (mTICI 1)) compared to a complete occlusion (mTICI 0). Here, we compared the impact of these two states of target vessel occlusion on recanalization success and clinical outcome. MethodsRetrospective, single-center analysis of patients treated for M1-segment MCA occlusion with EST from 01/2015 until 05/2020 in a tertiary stroke center. Primary study endpoint was successful recanalization (mTICI 2c-3) after one thrombectomy attempt (first pass effect). Secondary endpoints were the clinical outcome (as modified Rankin Scale 90 days after stroke onset) and the complication rate. The two study groups were compared in univariate analysis including patient characteristics and procedural details. ResultsIn this study, 422/581 patients (72.6 %) presented with complete M1-occlusion compared to 159/581 (27.4 %) with incomplete M1-occlusion. Neither did the rate of FPE differ between the study groups nor the rate of procedural complications (mTICI 0: 10 (2.4%), mTICI 1: 1 (0.6%), p = 0.304). Patients with incomplete initial occlusion showed a lower mRS at discharge (median (IQR) mTICI0: 4 (3-5) vs. mTICI1: 3 (2 - 6), p = 0.014), but a comparable mRS 90 days after stroke onset (mTICI0: 3 (2-6) vs. mTICI:1 4 (2-6), p = 0.479). ConclusionComplete M1-occlusions (mTICI 0) and incomplete occlusions (mTICI 1) show the same recanalization success and complication rate as well as a comparable clinical outcome. Thus, incomplete M1-occlusions should be treated with the same urgency as initial complete occlusions.

BackgroundCavernous sinus dural arteriovenous fistulas (CS-DAVFs) present significant treatment challenges when the inferior petrosal sinus (IPS) is not opacified during cerebral angiography. However, the widely accepted transvenous IPS recanalization approach is associated with a high failure rate. The consistently visible superior ophthalmic vein (SOV) offers a promising alternative, though it has yet to be fully evaluated in large-scale studies. MethodsThis retrospective, case-control study was conducted between May 2017 and October 2024. Data collection for this multicenter, population-based study took place across eight tertiary referral centers. Eligible patients were diagnosed with CS- DAVF with occluded IPS. Endovascular treatment via the transvenous SOV approach versus the IPS recanalization approach in patients with occluded IPS. ResultsOf 178 eligible cases, 70 cases (39.3%) were treated using the transvenous SOV approach, while 108 cases (60.7%) underwent the transvenous IPS approach. The initial treatment success rate was significantly higher in the SOV group compared to the IPS group (91.4% vs. 75.9%; odds ratio [OR], 3.38; 95% CI, 1.30-8.35; P = 0.0092). The overall complication rate was 1.4% in the SOV group and 2.8% in the IPS group (OR, 0.51; 95% CI, 0.04-3.47; P > 0.9999). After classifying the SOV approach into simple and complex types, the SOV-simple type further demonstrated significant advantages, including shorter average operation times (126.20 {+/-} 46.99 minutes, P = 0.0197) and a higher initial treatment success rate (95.7%, P = 0.0027) compared to the IPS group. ConclusionThe SOV approach should be considered a first-line treatment for CS- DAVF patients with invisible IPS. These findings establish a new treatment standard, underscoring the importance of precise preoperative classification and individualized surgical planning.

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.

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.