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.

Background: Even for experienced operators, endovascular treatment of unruptured intracranial aneurysms involves intraoperative uncertainty that may lead to adjustments in strategy, prolong the procedure, and potentially cause inefficiency and device waste. This study aimed to evaluate whether pre-procedural testing (PPT) of endovascular treatment using patient-specific models was associated with increased operator confidence and perceived clinical utility, including improvements in procedural efficiency and reduced resource waste. Methods: We enrolled a cohort of patients who underwent PPT before endovascular treatment for complex unruptured intracranial aneurysms and compared their outcomes with a control group treated without PPT. The primary outcome was the Training Fidelity Score, a composite of three operator-reported Likert items defined a priori. Secondary outcomes included perceived clinical utility, intraoperative strategy changes, procedural time, radiation exposure, device waste and safety. Results: A total of 85 patients met the inclusion criteria (PPT=40; control=45). The Training Fidelity Score was high across the PPT group (median, 4.33/5). Perceived clinical utility was high and further increased significantly after the procedure. A significant reduction was observed in intraoperative strategy changes, with no changes recorded in the PPT group, compared to 6/45 in the control group (RR 0.09; p=0.027). Reductions in treatment time, radiation exposure and device waste were also noted. Conclusion: PPT using patient-specific models was associated with increased operator confidence, fewer intraoperative strategy changes, improved procedural efficiency, and reduced device waste without compromising safety. These findings support its use in pre-interventional preparation, but require prospective multicenter validation.

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

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.

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.

IntroductionBalloon guide catheters (BGC) are used to prevent distal emboli during endovascular treatment (EVT) for acute ischemic stroke. Although literature reports benefit of BGC, these are not universally used and randomized head-to-head comparisons are lacking. This study compared functional, safety, and technical outcomes between patients treated with different sizes non-BGC and with BGC during EVT in a nationwide prospective multicenter registry. MethodsPatients from the MR CLEAN Registry (2014-2018), who underwent EVT with a 5-7French (Fr) non-BGC, a 8-9Fr non-BGC, or a 8-9Fr BGC were included. Primary outcome was the modified Rankin Scale (mRS) score at 90 days, secondary outcomes included procedure time and first-attempt successful reperfusion (eTICI [&ge;] 2C). Treatment-effect modification and subgroups were analyzed according to first-line thrombectomy technique: stent retriever (SR) or direct aspiration (ASP). ResultsIn total 2808 patients were included, and 1671 (60%) were treated with 8-9Fr BGC. Overall, no significant differences in clinical outcome were seen between non-BGC and BGC groups. The 8-9Fr non-BGC was associated with lower first-attempt successful revascularization rates compared to BGC (aOR:0.76, 95%CI:0.59-0.998), the 5-7 Fr non-BCG was not. Regression analysis showed a significant interaction between BGC use and device type. In the subgroup with SR as first-line technique, 90 day mRS scores were significantly higher in the 8-9Fr non-BGC group compared with BCG (acOR:0.77; 95%CI:0.59-0.996), but not in the 5-7Fr non-BCG. Direct aspiration combined with 5-7Fr non-BGC resulted in higher first-attempt rates compared to BGC (aOR:1.75; 95%CI:1.16-2.63). ConclusionThis large prospective multicenter registry showed no differences in clinical outcome between patients treated with 5-7Fr non-BGC, 8-9Fr non-BGC, and 8-9Fr BGC. Subgroup analyses, however, suggest that BCG outperforms the non-BGC when SR is used as first-line technique.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

2.BackgroundThe AXS Vecta 46 intermediate catheter (Stryker) provides a large enough inner diameter to achieve effective aspiration with a small enough outer diameter and soft distal-tip flexibility to track safely through more tortuous and smaller arterial segments to non-traumatically target medium vessel occlusions. The efficacy of the Vecta 46 in the spectrum of large and medium vessel occlusions has not been well elucidated in the literature. MethodsThis retrospective cohort study included patients who underwent MT for acute ischemic stroke at the University of Florida between July 2022 and June 2024. The outcomes of patients treated with the Vecta 46 was compared to that of all other catheters used at the institution. ResultsThe distribution of aspiration and stent retriever attempts in Vecta 46 procedures versus non-Vecta 46 procedures was significantly different (p = 0.00325). Aspiration was attempted 1.66 {+/-} 0.936 times in the Vecta 46 group and 1.12 {+/-} 0.650 times in the non-Vecta 46 group (p = 0.00135). More mechanical thrombectomies with the Vecta 46 included aspiration of a secondary thrombus (p = 0.0314), despite no difference in distribution of primary or secondary occlusion location. There were no statistically significant differences in recanalization success (p = 0.800), recanalization time (p = 0.245), procedure duration (p = 0.580), discharge modified Rankin Score (p = 0.875), or intracranial hemorrhage rate (p = 0.720) between non-Vecta 46 and Vecta 46 procedures. ConclusionsVecta 46 has similar safety and functional outcomes compared to other endovascular treatment options despite procedural differences.

BackgroundDifferentiating between intra-cerebral atherosclerotic disease (ICAD) and non-ICAD large vessel occlusion (LVO) is crucial for selecting the appropriate mechanical thrombectomy (MT) technique and device. We developed an algorithm to predict LVO etiology using clinical and radiographic features in the emergent setting. MethodsWe conducted a retrospective chart review of middle cerebral artery (MCA) occlusions treated with MT and confirmed as ICAD or non-ICAD. We recorded common risk factors and radiographic features from CT angiography to identify significant differences between groups. These factors were used in a multivariable logistic regression to create the algorithm. The ROME score was then tested against the ABC2D algorithm for predicting ICAD LVO in a prospective cohort. ResultsThe analysis included 33 ICAD and 327 non-ICAD LVO strokes. ICAD LVO patients were less likely to have atrial fibrillation (9.1% vs 53.8%; [points: 4]) or systolic heart failure with EF[&le;]35% (9.1% vs 27.8%; [points: 1) and more likely to present with progressive or fluctuating symptoms (21.2% vs 4.6%; [points: 1). ICAD patients had a higher incidence of multi-vessel atherosclerotic disease (84.8% vs 37%; [points: 1]), tapered appearance of occlusion (60.6% vs 0.9%; [points: 6]), and extra-cranial ICA atherosclerotic plaque with high-risk features (plaques with lengths [&ge;]1cm or thickness >3mm perpendicular to the long axis of the artery with associated ulceration or with soft plaque component (87.9% vs 37.6%; [points: 4]). AUC for the ROME score was 0.9666 with the highest sensitivity (97%) and specificity (88%) at a cut-off of 9. In the prospective cohort of 201 patients, the ROME score showed 81.3% sensitivity and 98.8% specificity, while the ABC2D score showed 90.6% sensitivity and 50.3% specificity. ConclusionOur scoring system effectively differentiates between ICAD and non-ICAD LVO, with greater specificity than the ABC2D score. Future steps will include validation in external databases and clinical trials.

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.