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While traditional vascular risk factors (eg, hypertension, dyslipidemia, tobacco use) account for 20% of the explained variance in carotid atherosclerosis, they remain a prominent focus for primary and secondary ischemic stroke prevention strategies. Among other potential contributors to atheroma formation and cerebrovascular disease, the gut microbiome has become increasingly implicated as a mediator of vascular risk. The foods we eat, coupled with our physiology and exposures (eg, antibiotics, supplements), directly contribute to atherosclerotic disease in complex ways that are mediated by gastrointestinal flora and metabolic by‐products. Proliferation of “pathogenic” gut microbes such as Enterobacteriaceae and Streptococcus spp, decrement of “commensal” species such as Akkermansia spp and the biodiversity of gut flora are directly related to an individual's dietary intake and exposure history. Each of these components of the gut microbiome correlate with the development or progression of many conditions including atherosclerosis. Moreover, the metabolism of certain substrates found in animal products (notably l‐carnitine and choline) and of refined sugars by these microorganisms leads to buildup of circulating metabolites with known links to atherogenesis, platelet activation, atrial fibrillation, and other adverse vascular outcomes. Several of these toxic metabolites, including trimethylamine and trimethylamine N‐oxide, have been extensively studied in cardiovascular and cerebrovascular disease. Trimethylamine and trimethylamine N‐oxide represent not only biomarkers of gut dysbiosis and cardiovascular risk, but they are increasingly recognized as therapeutic targets for novel interventions in atherosclerotic vascular disease. The individualized targeting of one's microbiome, and perhaps more generalized targeting of toxic microbial metabolites, has the potential to revolutionize the treatment of vascular disease. In this review, we summarize the latest evidence illustrating the impact of the microbiome on cerebrovascular disease and highlight the potential applications of this information on individualized and global scales.

Background In 2019 and 2020, 2 randomized trials of basilar artery occlusion (BAO) thrombectomy reported no improvement in functional outcomes with thrombectomy, despite observational evidence. The objective of this study was to assess whether neutral clinical trials may have influenced BAO thrombectomy practice. Methods The National Inpatient Sample (2018–2020) was queried for US patients with BAO, and comparisons were made between patients admitted in 2020 versus 2018 to 2019 for the primary outcome of thrombectomy. Unadjusted and adjusted multivariable regression was used, accounting for demographic and clinical covariates, with propensity‐score matching to balance clinical and hospital‐level characteristics between years. Results Of the 14 945 patients with BAO, 3,605 (24.1%) underwent thrombectomy,with an increase in the unadjusted rate of thrombectomy between 2020 and 2018–2019 (26.9% vs 22.9%, P = 0.04). Following multivariable adjustment, BAO thrombectomy was not independently associated with a year of treatment (adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 0.95–1.54, P = 0.12). Thrombectomy was independently associated with having a NIHSS of 10–19 (OR: 3.67, 95% CI: 2.79–4.83, P < 0.01) or >19 (OR: 5.80, 95% CI: 4.41–7.64) versus a NIHSS of 10, while uinsured patiends hadal owe likelihood of receiving a thombectomy (OR: 0.49, 95% C: 0.26–0.92). These relationships were preserved in the PSM cohort, and admission year lacked association with thrombectomy for BAO (aOR: 1.10, 95% CI: 0.83–1.45, P = 0.52). Conclusion Following publication of neutral BAO randomized clinical trials in late 2019 and 2020, there was no significant change in thrombectomy rate among US patients with BAO. The latest trials support thrombectomy for select patients with moderate‐to‐severe BAO symptoms, and this appears consistent with the practice of US clinicians before these trials.

BackgroundThe optimal antiplatelet therapy regimen for certain neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor in patients undergoing acute neuroendovascular interventions.MethodsWe conducted a retrospective chart review of all consecutive patients on intravenous cangrelor for neuroendovascular procedures between September 1, 2020, and March 13, 2022. We also conducted an updated systematic review and meta-analysis using PubMed, Scopus, Web of Science, Embase and the Cochrane Library up to February 22, 2023.ResultsIn our cohort, a total of 76 patients were included [mean age (years): 57.2 ± 18.2, males: 39 (51.3), Black: 49 (64.5)]. Cangrelor was most used for embolization and intracranial stent placement (n = 24, 32%). Approximately 44% of our patients had a favorable outcome with a modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n = 25/57); within 1 year, 8% of patients had recurrent or new strokes (n = 5/59), 6% had symptomatic intracranial hemorrhage [sICH] (4/64), 3% had major extracranial bleeding events (2/64), and 3% had a gastrointestinal bleed (2/64). In our meta-analysis, 11 studies with 298 patients were included. The pooled proportion of sICH and intraprocedural thromboembolic complication events were 0.07 [95% CI 0.04 to 1.13] and 0.08 [95% CI 0.05 to 0.15], respectively.ConclusionOur study found that intravenous cangrelor appears to be safe and effective in neuroendovascular procedures, with low rates of bleeding and ischemic events. However, further research is needed to compare different dosing and titration protocols of cangrelor and other intravenous agents.

Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only. Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only. Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

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

Introduction Ticagrelor use has become more prominent in acute ischemic stroke management in the presence of clopidogrel resistance(1‐2). This study compares the effectiveness of aspirin plus ticagrelor at different doses versus clopidogrel in reducing the risk of recurrent stroke and other thrombotic events without increasing the risk of bleeding. Methods We performed a retrospective chart review of patients diagnosed with acute ischemic stroke at a large academic comprehensive stroke center from September 1, 2020, to July 1, 2022. A total of 3 separate groups, low‐dose ticagrelor (45 mg or 60 mg twice a day), full‐dose ticagrelor (90 mg twice a day) and clopidogrel (75 mg daily) were created. We compared baseline characteristics and completed a one‐way ANOVA to analyze for outcome measures such as in‐hospital mortality, 90‐day mortality, favorable functional outcome defined as modified Rankin Score (mRS) of 0‐2, at 90 days, symptomatic intracranial hemorrhage (sICH) and asymptomatic hemorrhage (aICH) between groups. All data was analyzed via IBM SPSS v28.0. Results A total of 445 patients were included in our study. The mean age was 66.1 ± 12.8 years and the majority of patients were female (52.9%). The most common ethnicity was African American (82.9%). Sixty patients were discharged on low‐dose ticagrelor, 39 on full dose ticagrelor and 351 on clopidogrel. A total of 162/433 (36.0%) had a presumed stroke etiology of intracranial atherosclerotic disease (ICAD). Only 24 patients received intravenous thrombolytics (5.3%) and 47 had stent placement (10.4%). Out of 445 patients, 288 were on aspirin 81 mg at time of discharge. Of that group, 228 were on both aspirin and clopidogrel, 60 were on aspirin and low‐dose ticagrelor and 39 were on aspirin and full‐dose ticagrelor. There was no statistical significance for new or recurrent ischemic stroke between groups (low‐dose vs full‐dose vs clopidogrel) determined by one‐way ANOVA (10.0% vs. 17.9% vs. 7.8%, F(2,103) = 0.01, p=0.99). Symptomatic ICH was also similar between the groups (3.3% vs. 2.6% vs. 1.1%, F(2,101) = 0.68, p=0.51). There was no significance for favorable functional outcomes and mortality as well (26.7% vs. 23.1% vs. 24.2%, F(2,173) = 0.62, p=0.54; 80.0% vs. 79.5% vs. 81.5%, F(2,150) = 1.5, p=0.22). Conclusion These findings suggest that a lower dose of ticagrelor may be a safe and effective alternative to full dose ticagrelor or clopidogrel for the prevention of recurrent ischemic stroke without increasing hemorrhagic complications. Larger randomized trials are necessary to further evaluate these findings.

Introduction Cocaine‐induced vasospasm of small vessels has long been proposed as a mechanism for ischemic stroke (1). However, there are limited studies to date that have classified cocaine‐related ischemic strokes under a subtype of the Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria. This study aims to describe cocaine‐related ischemic strokes by TOAST criteria, treatment, and clinical outcome. Methods A retrospective review was performed to identify patients with acute ischemic stroke and a positive cocaine urine toxicology screen at our stroke center from June 2020 – May 2022. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, TOAST criteria, location of stroke, home medications, comorbidities, medical management, and in‐patient outcomes were collected. Data analysis was conducted on IBM SPSS Version 28. Results A total of 74 patients were identified to have a positive cocaine status on admission with a diagnosis of new strokes. The mean age was found to be age 60.8 years old with a majority male population at 73.0% (54/74). Seventy‐eight percent (58/74) were found to be cocaine positive on admission with the remaining endorsing a history of cocaine use. The most common category under the TOAST criteria was large artery atherosclerosis 39.2% (29/74). Among the cocaine‐positive cohort, 10.8% (8/74) of patients received thrombolytics. Most patients had intracranial atherosclerotic disease (46/74, 62.2%) on imaging and in the area of the stroke (41/74, 55.4%). Overall mortality was low (72/74, 97.3%) and modified Rankin score (mRS) at discharge was less than 3 for 59.5% (44/74) of patients. Conclusion Our data suggests that although cocaine may contribute to small vessel disease, cocaine‐related ischemic strokes may have a higher association with large artery atherosclerosis. This study highlights the importance of future larger studies to investigate atherosclerosis as a contributor to cocaine‐induced ischemic strokes.

Introduction The safety of thrombolytic therapy in patients with cocaine‐related acute ischemic strokes (AIS) has been investigated, but the safety of endovascular thrombectomy in cocaine‐related AIS remains unknown (1‐2). Here, we report preliminary descriptive data on endovascular thrombectomy with or without thrombolytics performed in cocaine‐related ischemic strokes at our institution. Methods A retrospective chart review was performed at our comprehensive stroke center from June 2020 to May 2022 to identify AIS patients with cocaine‐positive urine toxicology screens on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria, location of stroke, home medications, comorbidities, medical management, and outcomes including modified Rankin Score (mRS) were reported. Results A total of 74 AIS patients were identified to be cocaine‐positive. Of these patients, 14 underwent endovascular thrombectomy (EVT). Only 3 of these 14 patients received intravenous thrombolytics. Including the EVT group, 8 out of 74 AIS patients received thrombolytics. The mean age was found to be 61 years with 86% being male. The most common locations of large vessel occlusion were the M2 branch of the right middle cerebral artery (MCA) (40%), the M2 branch of the left MCA (33%), the M1 branch of the right MCA (13%), left internal carotid artery (7%), and A1 branch of the anterior cerebral artery (7%). Based on TOAST criteria, 64% of strokes were large artery atherosclerosis, 29% cardioembolic, and 7% cryptogenic stroke. The mean initial NIHSS was 14. Average mRS on admission was found to be < 1 and follow‐up mRS at 3 months was found to be 3. Conclusion Our data suggest that cocaine patients who underwent EVT on average had unfavorable functional outcomes defined as mRS > 2, on follow‐up mRS at 3 months. This study highlights the importance of future larger studies to investigate endovascular thrombectomy +/‐ thrombolytics in cocaine‐related AIS.

Background Mechanical thrombectomy (MT) failure occurs in ≈10% to 20% of MTs. Among the common causes of failed MT is residual underlying intracranial stenosis (ICAS), typically attributable to atherosclerotic disease. ICAS large‐vessel occlusion (ICAS‐LVO) remains poorly understood, and management of ICAS‐LVO is unclear. The RESCUE‐ICAS (Registry of Emergent Large Vessel Occlusion Due to Intracranial Stenosis) aims at providing better understanding of the prevalence of ICAS‐LVO, and the overall safety and efficacy of various rescue therapies. Methods RESCUE‐ICAS is a multicenter, international, prospective registry that is currently enrolling patients with ICAS‐LVO who underwent MT. All sites are required to report monthly MT cases that meet inclusion criteria. The decision of whether to use rescue therapy is up to the interventionist. Results We will collect patients’ demographic, clinical, and radiographic data at baseline. Also, we will capture variables related to the MT procedure and rescue therapy (if performed), and postprocedural clinical and imaging variables. Outcomes include the rate of successful recanalization, defined by modified Thrombolysis in Cerebral Infarction score of ≥2b, the rate of symptomatic intracranial hemorrhage, the 90‐day modified Rankin scale score, and mortality. Conclusions No strong evidence is currently available to support an optimal treatment strategy for patients with ICAS‐LVO undergoing MT. RESCUE‐ICAS is a prospective cohort study that will provide important data to help design randomized controlled trials.

Introduction Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies.Methods and analysis We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data.Ethics and dissemination This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences.PROSPERO registration number CRD42022315608.

Introduction Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in‐hospital mortality, 90‐day mortality, and 90‐day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥ 2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.054). In‐hospital and 90‐day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0–2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in‐hospital mortality (OR = 4.1, 95% CI 1.7‐9.7), 90‐day mortality (OR = 3.7, 95% CI 1.6‐8.6), and poor functional outcome at 90 days (OR = 5.5, 95% CI 1.6‐19.4). Conclusions Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high‐risk population.

Introduction There is clinical equipoise behind bridging intravenous thrombolysis (BT) with endovascular thrombectomy (EVT). We performed a cost‐effectiveness analysis comparing EVT and BT versus EVT alone. Methods We conducted a model‐based cost‐utility analysis comparing the cost‐effectiveness of EVT alone vs. EVT and BT for patients with acute ischemic stroke. We used a decision tree to examine the short‐term costs and outcomes at 90 days after the index stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1‐year, 5‐year, and 20‐year time horizons. Treatment costs were based on administrative data. Clinical outcome inputs were derived from literature included in our systematic review. We considered the impact of disability and recurrent stroke on mortality risk, health‐related quality of life, and costs. We estimated total and incremental cost, quality‐adjusted life years (QALYs), and incremental cost‐effectiveness ratio (ICER), expressed as an incremental cost per QALY gained of EVT and BT compared with EVT alone.Probabilistic analysis was used to calculate the reference case estimates. Results The average costs per patient were estimated to be $55,503, $57,814, $68,183, and $84,946 for EVT only strategy, and $47,311, $49,556, $59,625, and $75,898 for EVT and BT over 90‐day, 1‐year, 5‐year, and 20‐year, respectively. The cost saving of EVT only strategy was driven by the avoided medication costs of IVT (ranging from $8,193 to $9,048). The additional thrombolytics led to slight decrease in QALY estimate during the 90‐day time horizon (loss of 0.0016 QALY), but a small gain over 1‐year, 5‐year, and 20‐year time horizons (0.0108, 0.0638, and 0.1481 QALY). With similar outcomes and less cost, the EVT only strategy was cost‐effective compared with EVT and BT. Analyses with longer time horizon show lower probabilities of EVT only strategy being cost‐effective. At a fixed willingness to pay threshold of $50,000, the probabilities of EVT only to be cost‐effective were 100%, 100%, 99.0%, and 65.9% over 90‐day, 1‐year, 5‐year, and 20‐year time horizons. At the willingness to pay thresholds of $100,000 per QALY, the probabilities of EVT only strategy being cost‐effective was 22.8% over the 20‐year time horizon. Conclusions Our cost‐effectiveness model suggested that bridging with thrombolytics may not be cost‐effective for patients with acute ischemic stroke secondary to large vessel occlusion.

Introduction There has been an increase in use of ticagrelor in patients with ischemic stroke, particularly in the setting of clopidogrel resistance. Our study aims to retrospectively determine if aspirin plus ticagrelor at a reduced dose is effective in reducing the risk of recurrent stroke and/or other thrombotic events, without increasing the risk of bleeding. Methods In a prospectively maintained database, we performed a retrospective analysis of consecutive patients with acute ischemic stroke in a large academic comprehensive stroke center between September 1, 2020 to July 1, 2022. We compared in‐hospital mortality, 90‐day mortality, favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0 to 2, at 90 days, symptomatic intracranial hemorrhage (sICH), and asymptomatic intracranial hemorrhage (ICH), between patients on reduced‐dose ticagrelor versus those on full‐dose ticagrelor, in unadjusted and adjusted logistic regression models. Results We included 567 patients in our study. The mean age of these patients was 67.0 ± 15.0 years. Females represented 59.5% of the patients, and the majority of the patients were Black (80.0%). Intracranial atherosclerotic disease was the presumed stroke etiology in 96 patients (17.0%). Out of 567 patients, 432 were on a combination of both ticagrelor and aspirin. A total of 62 patients were on a reduced dose of ticagrelor (45 mg or 60 mg twice daily). The remaining 505 patients were on 90 mg twice daily dosing. New or recurrent ischemic stroke was similar across both groups (10.2% vs. 12.0%, p = 0.08). Symptomatic ICH was also found to be similar across both groups (8.2% vs. 9.3%, p = 0.06). Mortality or favorable functional outcome at 90 days also did not differ between the two groups (25.3% vs. 24.7%, p = 0.007; 28.2% vs. 27.3%, p = 0.006). Conclusions A lower dose of ticagrelor (45 or 60 mg twice daily) appears to be a safe and effective regimen in reducing risk of ischemic strokes without increasing hemorrhagic complications when compared to full‐dose ticagrelor at 90 mg twice daily. Further randomized trials are necessary to inform this recommendation.

Introduction Chronic subdural hematomas (SDH) have a higher prevalence among the elderly population and can cause significant morbidity and mortality when they recur after surgical intervention. Use of n‐butyl‐2‐cyanoacrylate (n‐BCA) has proven to be an effective and safe therapeutic agent for embolization of the middle meningeal artery (MMA). In our study, we present a retrospective analysis of 31 patients who underwent MMA embolization for chronic SDH. Methods In a prospectively maintained database in a single center, we retrospectively analyzed 31 patients admitted to our institution who were diagnosed with chronic SDH, acute on chronic SDH, and acute SDH, and underwent MMA embolization with n‐BCA between May 20th, 2021, and June 28th, 2022. Our primary endpoint was >50% SDH reduction on follow‐up imaging. Our secondary endpoint was all‐cause mortality. Patients were separated into outcome groups and their baseline demographic, clinical, and procedural variables were compared using t‐test, Wilcoxon rank‐sum test, chi‐squared test, and Fisher’s exact test. Through univariate logistic regression, we attempted to determine if these variables directly influenced SDH reduction and mortality. Results In our study, a total of 42 MMA embolizations for 31 patients were included. We found that a greater number of patients with hypertension (n = 23; p = 0.04), use of antiplatelet (AP) medication (n = 8; p = 0.02), and those who underwent MMA embolization via the radial approach (n = 18; p = 0.004) were among those with < 50% SDH reduction. We also found that MMA embolization via the femoral approach (n = 13; p = 0.004) were more likely seen in those with >50% SDH reduction. The mean fluoroscopy time was longer in patients with >50% SDH reduction compared to those with < 50% reduction (43.2 minutes vs. 28.2 minutes, respectively; p = 0.03). On linear regression analysis, history of hypertension showed a non‐significant trend towards < 50% resolution of SDH (OR 5.67; 95% CI 0.99, 32.43; p = 0.05). Femoral approach for MMA embolization was associated with >50% of hematoma reduction (OR 12.00; 95% CI 1.89, 76.38; p = 0.004). Longer fluoroscopy time showed the same association (OR 1.05, 95% CI 1.00, 1.11; p = 0.03). All‐cause mortality was seen in 6 of the 31 patients, none of them associated with the SDH or the n‐BCA embolization procedure with no significant difference between groups. Conclusions MMA embolization with n‐BCA appears to be an effective and safe method for management of SDH as has been shown in prior retrospective studies. Our small sample size may underestimate the effect some variables have on radiographic and clinical outcomes. Hypertension and use of AP seem to play a role in hematoma resolution; however, a bigger cohort is needed to confirm these hypotheses. Femoral approach and longer fluoroscopy time were associated with hematoma resolution, but other variables should be considered to rule out any procedure‐related confounders. Future randomized controlled trials may help establish MMA embolization as the primary method for SDH management given its safety and morbidity compared to traditional methods of SDH evacuation.

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke that can be difficult to treat. Endovascular thrombectomy techniques have evolved over time, but evidence behind the efficacy and safety of these techniques for CVST is still lacking. The Penumbra Indigo® Aspiration System (Penumbra, Inc., Alameda, California, USA) is designed to remove emboli from the peripheral arteries and veins and can potentially restore blood flow in cases of limb ischemia and venous thrombosis. We report our initial experience in the treatment of CVST using the Penumbra Indigo® Aspiration System. Methods A 35‐year‐old African American male with no major past medical history presented to the hospital with altered mental status. Computed tomography (CT) showed multiple areas of venous infarction. CT vessel imaging revealed extensive dural venous sinus thrombosis involving the superior sagittal sinus (SSS), torcula, left transverse sinus, right paramedian transverse sinus with partial filling defects in the left sigmoid sinus and distal right transverse sinus with a matched defect in the left paramedian anterior frontal lobe corresponding to the area of evolving infarct. Continuous low‐dose heparin infusion was started. Cerebral angiogram revealed evidence of extremely slow perfusion to the brain with no significant drainage through the dural sinuses with complete occlusion of the distal portion of the SSS and bilateral transverse sinuses. Furthermore, angiogram of the right internal jugular (IJ) vein displayed complete occlusion of the bilateral transverse sinuses. Results An Aristotle® 24, 200‐cm Guidewire (Scientia Vascular, Salt Lake City, Utah, USA) was inserted into a 160‐cm‐long Zoom 35™ catheter (Medtronic, Minneapolis, Minnesota, USA), and this system was then advanced within the CAT12 aspiration catheter within a right IJ 12 French Sheath under fluoroscopic guidance across the occlusion to the superior sagittal sinus, Multiple aspiration attempts were then performed. The CAT 12 Aspiration was performed in the SSS and bilateral transverse sinuses. Afterwards, CAT8 and then CAT7 were then advanced into the thrombus more proximally in the SSS and multiple aspiration attempts were performed in the SSS with the aid of the separator device. There was evidence of partial recanalization of the SSS with significant improved flow of bilateral sigmoid sinuses and bilateral transverse sinuses. A decision was made to stop the intervention. There were no complications related to these procedures. Conclusions The Penumbra Indigo® Aspiration System has been used in various arterial and venous systems but this is the first report to demonstrate its technical feasibility in thrombectomy for CVST. Further feasibility studies are necessary to inform its applicability in CVST.

Introduction The optimal antiplatelet therapy regimen for certain neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose‐adjusted cangrelor in patients undergoing neuroendovascular procedures. Methods We conducted a retrospective chart review of all consecutive patients who underwent neuroendovascular procedures and were placed on intravenous cangrelor between September 1, 2020 and March 13, 2022. Cangrelor was administered as a 15 mcg/kg bolus followed by 2 mcg/kg/min infusion titrated to goal P2Y12reaction unit (PRU) level of 50 to 150, and then transitioned to oral antiplatelet therapy. Demographic characteristics, interventional variables, and clinical outcomes were collected. Results A total of 50 patients were included. The mean age (years) was 56.0±18.6, and 26 (52.0%) were males. Most patients were African American (n = 39/48, 81.3%). The most common comorbidities were hypertension (n = 25/49, 51.0%), active smoking status (n = 14/40, 35.0%), and prior ischemic stroke (n = 13/49, 26.5%). Intravenous thrombolysis was used in 4 patients (8.0%). Cangrelor infusion was used for the following procedures: embolization (n = 10/50, 20.0%), embolization and stent placement (n = 9/50, 18.0%), thrombectomy alone (n = 5/50, 10.0%), thrombectomy and stent placement (n = 10/50, 20.0%), and stent placement only (n = 14/50, 28.0%). Stent placement occurred intracranially beyond petrous segment of the internal carotid artery in 18 patients, remainder of internal or common carotid artery in 12 patients, and both intracranial and carotid arteries in 3 patients. PRU levels were measured in 48 patients (96.0%), with 26 patients (54.2%) achieving a PRU level of 50–150 greater than or equal to 50% of the time. Approximately 51.5% of the patients had a favorable functional outcome with modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n = 17/33).During 1‐year follow up, approximately 4 patients had recurrent or new strokes (9.5%), 1 patient had in‐stent thrombosis (2.9%) and 1 patient with symptomatic intracranial hemorrhage [sICH] (2.4%), both while not on antiplatelet therapy, 2 patients with asymptomatic intracranial hemorrhage [ICH] (4.8%), and no gastrointestinal bleeding events were recorded. When stratified by PRU level, there were no significant differences in sICH (p = 0.841) or asymptomatic ICH (p = 0.853). Conclusions To our knowledge, this is the first report to demonstrate the safety and effectiveness of intravenous cangrelor use titrated based on platelet function testing in the largest cohort of patients who underwent neuroendovascular procedures to date. Further studies, including comparative studies to standard dose maintenance cangrelor, are necessary.

Introduction There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries. Methods In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization. Results A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization. Conclusions To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population.

Introduction Current published guidelines and meta‐analyses comparing direct mechanical thrombectomy (MT) alone versus MT with bridging intravenous thrombolysis (IVT) suggested that MT alone is non‐inferior to MT with bridging thrombolysis in achieving favorable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta‐analyze data from randomized trials comparing MT alone versus MT with bridging thrombolysis. Methods We searched MEDLINE (through Ovid), EMBASE, and the Cochrane Library from inception to December 14, 2021 without any language restrictions to identify randomized controlled trials (RCTs) and post‐hoc analyses of RCTs comparing direct MT with or without bridging IVT in patients presenting with acute ischemic stroke secondary to a large vessel occlusion. We conducted meta‐analyses using random‐effects models to compare the rates for favorable functional outcome (defined as modified Rankin scale [mRS] score of 0 to 2) and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH), between MT and MT with IVT. We also assessed the risk of bias using the Cochrane risk‐of‐bias tool (RoB) and the certainty of evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Of 11,111 citations, we identified 53 eligible studies, and included 8 studies with a total of 3,008 participants. We found low‐certainty evidence suggesting that there is probably a small increase in the proportion of patients with favorable functional outcome with an mRS of 0 to 2 at 90 days for those who underwent MT with IVT compared to those with MT alone (risk ratio [RR] 1.08, 95% CI 0.99 to 1.19); moderate‐certainty evidence that there is probably a small decrease in mortality at 90 days for patients with MT plus IVT compared to MT alone (RR 0.86, 95% CI 0.71 to 1.03); and very low‐certainty evidence that there is possibly an increase in sICH for patients with MT plus IVT compared to MT alone (RR 1.17, 95% CI 0.85 to 1.61). When we restricted the analyses to RCTs only, we found no significant differences in favorable functional outcome (RR 2.05, 95% CI 0.97 to 1.13), mortality (RR 0.94, 95% CI 0.78 to 1.14), or sICH (RR 1.20, 95% CI 0.85 to 1.70). Conclusions Low‐certainty evidence shows that there is probably a small increase in the proportion of patients with favorable functional outcome, moderate‐certainty evidence shows that there is probably a small decrease in mortality, and very low‐certainty evidence that there is possibly an increase in sICH for patients with MT plus IVT compared to MT alone.

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.

Introduction: The importance of early mechanical thrombectomy (MT) has shown to improve functional outcomes for patients with acute large vessel occlusion (LVO). As well, prior studies have shown that earlier MT resulted in reduced hospital stay, more home‐time, and more desirable living situation in the 90 days after stroke. We hypothesized that delay in MT in patients with LVO would result in worse clinical outcome and increased mortality. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. We compared outcomes including in‐hospital mortality and 90‐day modified Rankin Scale (mRS) based on time from door‐to‐puncture and door‐to‐reperfusion, adjusting for relevant covariates using logistic regression. Results: Patients that had shorter door‐to‐puncture time were found to have higher probability of a lower modified Rankin Scale (mRS 0–2) at discharge (p = 0.03). Patients with door‐to‐puncture less than 60 minutes had a probability of 50% of achieving a good outcome. Longer door‐to‐puncture times were associated with lower probability of achieving mRS 0–2 at discharge. A similar finding was seen in patients that had shorter times to reperfusion (p = 0.05). Adjusting for age, baseline NIHSS score, and final TICI score, delayed door‐to‐reperfusion time in minutes was an independent predictor of increased mortality at 90 days of 9% for every 10 minutes delay (OR 1.009, 95% CI 1.003‐1.016, p = 0.006). Every 10 minutes delay in door‐to‐reperfusion time had 7% higher chance of poor functional outcome at 90 days (OR 1.007, 95% CI 1.004‐1.019, p = 0.015). Conclusions: Shorter times to MT and reperfusion impact functional outcome and mortality in LVO stroke patients. This indicates that an adequate hospital protocol and continuous education may lead to faster and more efficient stroke activations leading to a shorter time to MT and eventual reperfusion. Goals of door‐to‐puncture must be established in order to achieve better outcomes.

Introduction: There are no studies investigating the safety and efficacy of covered stent grafts, particularly the newly developed stents such as the PK Papyrus stent, for endovascular treatment of direct carotid cavernous fistulas (CCFs). Methods: We present a case of a 75‐year‐old female who presented to the hospital with a three‐week history of worsening left eye vision, chemosis, proptosis, and partial third nerve palsy. Patient was found to have left direct Type A CCF secondary to ruptured cavernous segment carotid aneurysm. Results: The CCF was treated with coil embolization and pipeline Shield stent embolization devices with immediate stagnation and improvement of symptoms. Patient had history of an aortic mechanical valve and thus was started on warfarin and ASA. After achieving INR level of 2.5‐3.5, patient started to have recurrent swelling of the left eye associated and decreased visual acuity. Repeated diagnostic cerebral angiogram revealed residual CCF. Onyx liquid embolization and a Surpass Evolve Flow Diverter were attempted to slow the fistulization with no success. Multiple attempts for direct percutaneous superior ophthalmic vein cannulation were also unsuccessful. At this point, two coronary graft‐covered PK Papyrus stents were implanted across the fistula pouch, which resulted in immediate resolution of the CCF with evidence of persistent normal flow within left ophthalmic artery. Patient’s visual acuity and left eye movement improved. Conclusions: This case report highlights the effectiveness and safety of covered stent grafts, particularly more flexible stents such as the PK Papyrus stent, in navigating the carotid vasculature and closing direct CCFs and may be used as a first‐line technique. More large‐scale studies are warranted to investigate the safety and efficacy of using such stent grafts to treat direct CCFs in the setting of antithrombotic agents and anticoagulation.

Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies.