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Background and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). Methods This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). Results Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P

Introduction The 2015 American Heart Association Guidelines recommended mechanical thrombectomy with stent‐retriever devices. A prior published analysis of national trends after one year in mechanical thrombectomy use and outcomes for stroke before and after publication of the 2015 US guideline update showed improved functional outcomes and lower peri‐procedural mortality. We analyze the national trends in mechanical thrombectomy use and outcomes for stroke five years after publication of the US guideline update. Methods We analyzed the National Inpatient Sample from 2012‐2019. ICD‐9 and ICD‐10 codes identified Ischemic stroke and mechanical thrombectomy patients. Similar to the previous study, discharge to home was the primary efficacy outcome measure in this study since it strongly correlates with mild degree of disability at discharge and 3 months post‐stroke. Safety outcomes include in‐hospital medical complications and mortality. We utilized multivariate logistic regression to assess outcomes. Results From 2012‐2019, 4,003,405 individuals with a diagnosis of ischemic stroke were recorded, 103,605 (2.6%) of which were treated with mechanical thrombectomy, proportionally increased from 4,910/452,905 (1.1%) in 2012 to 26,365/552,780 (4.8%) in 2019. The proportion of endovascular thrombectomy performing hospitals nearly doubled during the study period from 2012 (295/4,378; 6.7%) to 2019 (582/4,568; 12.7%). Odds of a mild disability outcome increased from 16% to 20%, OR 0.65 (0.57, 0.74), while mortality decreased from 15% to 12%, OR 0.69 (0.61, 0.78). Compared with 2012‐2014, the 2015‐2019 cohort showed increased odds of ICH and shock while the odds of DVT, pulmonary embolism, pneumonia, and UTI were significantly lower. The presence of septicemia, shock, and cardiac arrest were unchanged. Conclusion The number of large vessel occlusion stroke patients receiving mechanical thrombectomy treatment in the United States is increasing rapidly each year after the 2015 US guideline update. As the use of mechanical thrombectomy expands, included patients have more medical complications at baseline, but experience fewer complications, peri‐procedural mortality and overall improved outcomes.

Introduction There is growing evidence supporting endovascular treatment with middle meningeal artery embolization (MMAE) for the treatment of chronic subdural hematoma (cSDH). We aimed to compare Onyx vs. N‐Butyl cyanoacrylate (n‐BCA) as liquid embolic materials for MMAE. Methods We included all eligible patients undergoing MMAE for cSDH at University of Pittsburgh Medical Center from April 2019 to December 2022. The main outcomes included radiographic resolution of cSDH with at least 50% reduction of hematoma thickness as a surrogate for treatment success in addition to the need for rescue surgical intervention. Additional outcomes including complication rates and hematoma thickness at the last available follow up. Results A total of 195 patients underwent embolization of 234 hemispheres including 39 bilateral procedures and had available data for final analysis (168 (71.8%) in Onyx group vs. 66 (28.2%) in n‐BCA group). There were no significant differences in age, sex, co‐morbidities, prior SDH/evacuation, pre‐operative cSDH thickness, or use of antithrombotic therapy(P>0.05) while concurrent surgical intervention and midline shift showed a statistically significant difference (P

Introduction Dural Sinus Malformation (DSM) is a rare and high risk mortality vascular pathology identified early postnatal due to common clinical symptoms like macrocephaly, downward wandering eyes, bulging and pulsatile fontanels and heart failure. Most DSMs resolves prenatally. It is characterized by giant venous lake at the torcular region expanding towards the infratentorial and supratentorial spaces with usually existence of Dural arteriovenous fistulas (dAVF). Pathophysiology of DSMs are ballooning and malformation of the distal jugular bulb or persistence abnormal of the transverse sinus. Methods We performed the staged trans arterial Onyx‐18 embolization 5 times of a 3 mo infant boy with dural sinus malformation with multiple arteriovenous fistula using the 4 French GlideSim 2 Catheter, Headway Duo 167 micro catheter, and numerous microwires including Aristotle 014, Chikai Black Soft 014 and 010 and Synchro 014, 010 and 080 through alternated sides of transfemoral accesses. Embolizations were performed through the bilateral branches of the left and right middle meningeal arteries, posterior meningeal arteries and left occipital artery. Limitations during procedure are body weight to use contrast, fluoroscopy time and access sides. Results Post embolization injections demonstrated significant flow reduction into the malformation through ECA branches. No neurological complications occurred due to the procedures. MRI Brains in following weeks did not show large thrombus formation, hydrocephalus, or parenchymal injury. Patient showed clinical improvements with stable macrocephaly and decreased frontal pulsation and bulging. Conclusions Staged trans arterial embolization seems a safe approach on high mortality DSM. Thrombus is not formed all at once and mass effect from thrombosed sinus is avoided. Sinus has time to shrink.

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon variant of strokes, accounting for 0.5‐1% of all cases. Current guidelines recommend systemic anticoagulation as the first line therapy with endovascular approach reserved for those who fail to recanalize. We describe a 24‐year old female who presented with 3 days of headache and right sided weakness and was found to have extensive deep CVST with intracerebral hemorrhage and obstructive hydrocephalus. She underwent successful emergent intravenous thrombectomy with complete recanalization after clinical and radiological deterioration despite optimal systemic anticoagulation and bilateral external ventricular drains (EVDs). Methods The patient underwent thrombectomy under general anesthesia. Angiogram through the right radial artery was performed showing extensive thrombosis involving straight sinus, inferior sagittal sinus, vein of Galen and the internal cerebral vein. A right common femoral vein access was obtained and 80 cm Cook shuttle was placed and advanced to left internal jugular vein. Two passes mechanical thrombectomy using Y stent technique with the solitaire 6×40mm and Embotrap 6.5×45 mm stent retrievers and Zoom 008 with 071 aspiration catheters was performed with minimal recanalization of straight and inferior sinus. Attempted active aspiration and Power Pulse lytic thrombectomy through AngioJet Ultra Solent Omni Set 120cm but it was not long enough which was switched with 135cm length with successful access. This was followed by repeated attempts of aspirations with zoom 088 and 071 aspiration catheters resulting in near complete recanalization of straight, inferior sagittal sinuses, internal cerebral vein and vein of Galen. Results Two pass Simultaneous Mechanical Y‐Stent Retriever Thrombectomy andContact Aspiration Thrombectomy was performed with minimalrecanalization and reperfusion of straight sinus and inferiorsagittal sinus. This was followed by three pass Contact Aspiration Thrombectomy with large aspiration catheters and AngioJet Sets with near complete recanalization and drainage of straight sinus, inferior sagittal sinus, internal cerebral vein and vein of Galen. After 7 days of close ICU monitoring for malignant intracranial hypertension, patient was ultimately weaned off sedation and bilateral EVDs, extubated and transitioned to oral anticoagulation with significant clinical improvement and minimal residual neurological deficits. Conclusions Limited data is available on mechanical thrombectomies in deep CVST with hemorrhagic transformation. Our study describes a favorable outcome with combined stent retriever and aspiration thrombectomy approach. AngioJet 135cm Aspiration Catheter with Power Pulse lytic are also possible option to treat tough venous intracranial clots. Additional randomized controlled trials are needed to establish superiority between various approaches of mechanical venous thrombectomy in patients who have deep venous sinus thrombosis that fail medical management.