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Intrasaccular flow disruption is a viable alternative to other endovascular treatments for saccular or wide-necked bifurcation intracranial aneurysms; however, wide neck aneurysms with irregular shapes or shallow depth may not be amenable to treatment currently available intrasaccular devices. Here, we present the first ever case report of the novel Saccular Endovascular Aneurysm Lattice Embolization System (SEAL™). The versatile utility of the SEAL™ device is demonstrated in a patient with acute subarachnoid hemorrhage (SAH) from a ruptured, complex, left middle cerebral artery (MCA) trilobed shallow wide-necked bifurcation aneurysm. Deployment and implantation of the SEAL device were technically feasible, safe, and conformed well to the irregular shape of the complex, ruptured aneurysm. Immediate total aneurysm occlusion was observed after implantation. Importantly, 1-year angiographic follow-up demonstrated durable, complete occlusion with no safety concerns. The SEAL device is a promising new novel technology which has the potential to treat very shallow aneurysms with limited height and irregular, multilobulated aneurysms.

Everything is affective; everythingis infrastructural. Or: (1) affectivity is the relational force of materiality and (2) a thing is the convergence of a range of relations and is itself a compositional element of others. Or again: if affect and infrastructure associate, it is on the order of what, in 2010, I called ‘abrupt conditions’ and tend, sometimes, toward the organization of a ‘site’. This dynamic system is ontologically ‘flat’ in the sense that it does not prioritize in advanceany entities or relations. However, all such emergence negotiates an already complex, actual system of social unevenness because it unfolds amidst sociality (everything is affective; everythingis infrastructural). Thus, while I agree with almost all of Bosworth's (2023) treatment of affective infrastructures, our understandings diverge on the political consequences of flatness. PaceBosworth, a ‘first’ philosophy of emergence (flatness) is necessary for conceiving the possibility of actual change and, by extension, for realizing efforts to abolish unevenness. What follows animates this notion through several gestures to the banal sociality of academic working life and intellectual exchange, its confused affinities and familiar misunderstandings, its good vibes and bad energies.

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BackgroundCerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study.MethodsThis was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device.ResultsThirty patients with a mean age of 52±11 years and mean Hunt–Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae.ConclusionsThe NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.

BackgroundThere is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsThis was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration.ResultsIn the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0–2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0).ConclusionsPrior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

BackgroundThe PerfusiOn imaging Selection of Ischemic sTroke patIents for endoVascular thErapy (POSITIVE) trial was designed to evaluate functional outcome in patients with emergent large vessel occlusion (ELVO) presenting within 0–12 hours with pre-specified bifurcated arms of early and late window presentation, who were selected for endovascular thrombectomy with non-vendor specific commercially available perfusion imaging software. Recent trials demonstrating the benefit of thrombectomy up to 16–24 hours following ELVO removed equipoise to randomize late window ELVO patients and therefore the trial was halted.MethodsUp to 200 patients were to be enrolled in this FDA-cleared, prospective, randomized, multicenter international trial to compare thrombectomy and best medical management in patients with ELVO ineligible for or refractory to treatment with IV tissue plasminogen activator (IV-tPA) selected with perfusion imaging and presenting within 0–12 hours of last seen normal. The primary outcome was 90-day clinical outcome as measured by the raw modified Rankin Scale (mRS) with scores 5 and 6 collapsed (mRS shift analysis).ResultsThe POSITIVE trial suspended enrollment with the release of results from the DAWN trial and was stopped after the release of the DEFUSE 3 trial results. Thirty-three patients were enrolled (21 for medical management and 12 for thrombectomy). Twelve of the 33 patients were enrolled in the 6–12 hour cohort. Despite the early cessation, the primary outcome demonstrated statistically significant superior clinical outcomes for patients treated with thrombectomy (P=0.0060). The overall proportion of patients achieving an mRS score of 0–2 was 75% in the thrombectomy cohort and 43% in the medical management cohort (OR 4.00, 95% CI 0.84 to 19.2).ConclusionPOSITIVE supports the already established practice of delayed thrombectomy for appropriately selected patients presenting within 0–12 hours selected by perfusion imaging from any vendor. The results of the POSITIVE trial are consistent with other thrombectomy trials. The statistically significant effect on functional improvement, despite the small number of patients, reinforces the robust benefits of thrombectomy.Clinical trial registrationNCT01852201

Background We describe the first-in-human experience using the Balloon Occlusion Stroke Sheath (BOSSTM) balloon-guide catheter to perform stroke thrombectomy in 50 consecutive patients enrolled in the Flow Arrest Safety and Technical success with balloon-guide catheters trial. This aspiration system includes a novel 9.4F balloon-guide catheter conduit for the insertion and guidance of catheters with a balloon providing temporary flow arrest.Methods The Flow Arrest Safety and Technical success with balloon-guide catheter trial is a single-arm, prospective, multi-center, non-randomized, observational registry evaluating the use of the market-released BOSSTMballoon-guide catheter in adult patients diagnosed with an acute ischemic stroke attributable to large vessel occlusion. The purpose of the current trial was to assess the safety and technical success associated with the use of the BOSSTMballoon-guide catheter.Results Fifty patients met inclusion criteria with a mean baseline National Institutes of Health Stroke Scale (NIHSS) of 16. Treatment devices, including aspiration and stent retriever devices, were used in a total of 88 passes. The BOSSTMballoon-guide catheter was compatible with all stroke thrombectomy treatment devices used in 98% (49/50) of procedures. Balloon inflation and flow arrest were achieved in 100% (50/50) and 98% (49/50) of cases, respectively. Balloon deflation and retraction were observed in 100% (50/50) of cases. Successful reperfusion (modified thrombolysis in cerebral infarction score > 2b) was achieved in 100% of cases with single-pass reperfusion achieved in 62% (31/50) of cases.Conclusions The BOSSTMballoon-guide catheter is a safe and technically effective adjunctive device for mechanical thrombectomy of acute ischemic stroke due to large vessel occlusion.

BackgroundClot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion.MethodsClot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis.ResultsAmong all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034).ConclusionsClot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.

BackgroundThrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS.ObjectiveTo provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting.MethodsData were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged <80 years with an average 1.7±0.1 passes taken with the primary technique and in 88.0% of patients aged ≥80 years with an average 1.7±0.2 passes. Despite similar baseline characteristics, mRS scores were significantly higher in older patients postoperatively and at 90 days after intervention. Age was a significant predictor of 90-day mRS across the study population.ConclusionThis analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes.

This forum brings together perspectives from geography, philosophy, and political science to reflect on Elizabeth Povinelli’s, 2016book, Geontologies: A Requiem for Late Liberalism.Contributions come from both junior and senior scholars across a range of interests and backgrounds. Elizabeth Povinelli’s Geontologiesis the fourth in her series on Dwelling in Late Liberalism that began in 1994 with Labor’s Lot: The Power, History and Culture of Aboriginal Action. In this latest text, she offers a retheorization of power and governance that challenges Foucauldian biopolitics. In its place, Povinelli maps a mode of power that she calls geontopower: a power that operates over the distinction between Life and Nonlife. Together with accounts of ethnographic encounters in Indigenous Australia, Povinelli’s text weaves together political theory, anthropology, philosophy, and cultural studies. With consequences for human geographers as well as thinkers concerned with the Anthropocene, climate change, and new materialism, Povinelli’s work connects the experience of late liberalism and settler colonialism across space, place, and matter.

BackgroundThrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to ’real-world' practice.ObjectiveTo compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting.MethodsData from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever.ConclusionsOur data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.

Despite the proven benefit of stent retrievers, challenges to rapid revascularization of large vessel occlusions (LVO) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed with openings in the basket cell structure (“drop zones”) intended to capture organized thrombi within the central scaffold during retrieval. Prospective, multicenter, open label, single arm, FDA-regulated IDE study to evaluate the performance of the NeVa device for recanalizing occluded intracranial vessels including ICA, M1/M2 MCA, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of eTICI 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a margin of -10%. Additional efficacy endpoints included first pass effect to eTICI 2b-3 (FPE) and 90-day mRS 0-2. Primary safety endpoint was 90-day mortality. (ClinicalTrials.gov NCT04514562) (Site-adjudicated revascularization results are reported here. Final core lab results will be presented at the conference.) From April 1, 2021 to April 28, 2022, 139 subjects were enrolled at 25 centers in the US and Europe. Mean age was 67 ± 13 years; 47% were female. Median NIHSS score was 16 (IQR: 12-20). Occlusions were 14 (10%) ICA, 85 (61%) M1, 38 (27%) M2, 1 (1%) Basilar and 1 (1%) PCA. Mean time to first pass was 19 ± 12 minutes. eTICI 2b-3 within 3 NeVa passes occurred in 87.8% (122/139; CI 81.1%,92.7%; non-inferiority p<0.0001; post hoc superiority p=0.002, tested against performance goal of 72%). FPE (to eTICI 2b-3) was observed in 67.6% (94/139), with first pass to eTICI 2b67-3 in 61.2% (85/139) and to eTICI 2c-3 in 43.9% (61/139). Median number of passes was 1 (IQR 1-2). Final eTICI 2b-3 rate was 94.2% (131/139); final eTICI 2c-3 rate was 65.5% (91/139). Good outcome (90-day mRS 0-2) was seen in 62.6% (87/139) and was 74.4% in patients with FPE (70/94 vs. 17/45 (37.8%) without FPE; p<0.0001). Mortality was 9.4% (13/139) with sICH in 8 (5.8%) subjects. The NeVa device is effective and safe for revascularization of LVO strokes and demonstrates high first pass success in this international multicenter study. First pass reperfusion (eTICI 2b-3) was strongly associated with functional independence.

Introduction:EXCELLENT (NCT03685578) is a global prospective, multicenter, real-world registry of mechanical thrombectomy for stroke with the EmboTrap device as first line treatment which includes clot collection and analysis.Aim of the study:To report the rates of clinical outcomes and clot characteristics associated with first pass reperfusion in EXCELLENT.Methods:Per pass angiographic outcomes assessed by an independent core lab were available in 984 subjects Analysis of clot from 538 cases was performed by independent central labs blinded to clinical data. 90-day mRS assessment was blinded to subject data.Results:First pass reperfusion of mTICI 2b-3 (63.2%) and 2c-3 (38.3%) was significantly predictive of mRS 0-2 or ≤pre-stroke (p=0.011 and p=0.016) but not all-cause mortality at 90 days (p=0.080 and p=0.123, respectively). Further, mTICI 2c-3 in one pass was associated with a higher rate of mRS 0-2 or ≤pre-stroke vs. mTICI 2c-3 reperfusion in >1 pass, (55.5% and 45.1%, respectively, p=0.013) and a rate of all-cause mortality at 90 days of 14.6% vs. 19.8% (p=0.097). Full patient characteristics and clinical outcomes are shown in Table 1. Notable clot composition findings included: RBC (%, mean±SD): mTICI 2c-3, 1 pass 47.69±22.25, mTICI 2c-3, >1 pass 43.86±19.05, (p=0.088); fibrin: mTICI 2c-3, 1 pass 23.20±13.80, mTICI 2c-3 >1 pass 25.40 ± 13.52 (p=0.131); von Willebrand factor (VWF): mTICI2c-3, 1 pass 16.09±14.62, mTICI 2c-3, >1 pass 19.42±17.15 (p=0.038).Conclusions:First pass reperfusion in the EXCELLENT registry was associated with better clinical outcomes at 90 days. Clots retrieved with first pass reperfusion had higher RBC and lower fibrin and VWF content compared to those who achieved reperfusion at greater than one pass.

Here I discuss how Guattari’s ‘impracticality,’ as Gerlach and Jellis put it, harbours rich models for political and theoretical practice. I describe these in terms of Guattari’s participation in militant activism and anti-psychiatric organizations, as well as his cross-disciplinary theoretical engagements, all of which exemplify nuanced navigations of ‘problematic fields’. After surveying what these are and how they work in Guattarian philosophy, I briefly engage Gerlach and Jellis’s dismissal of certain tendencies within geographic theory.

Introduction:Despite advanced imaging and rapid recanalization, the majority of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) do not achieve functional independence at 90 days. Here, we explore the hypothesis that prolonged ischemia worsens clinical outcome beyond changes reflected in final infarct size, particularly in elderly patients.Methods:From the prospective, multicenter COMPLETE (Penumbra, Inc) registry, patients were included if they underwent endovascular therapy (EVT) for anterior circulation LVO, achieved TICI 2b/3 reperfusion, and EVT began within 90 minutes of imaging. Final infarct volumes (FIV) were measured on 24-48h post-EVT scans using ASPECTS. Multivariable logistic regression was used to determine the effect of stroke onset to hospital arrival time (OTA) on likelihood of functional independence (mRS 0-2) at 90 days, adjusting for age, NIHSS, occlusion location, pre-morbid mRS and final infarct. The effect of OTA on outcome was evaluated in older vs. younger patients using propensity score matching. Data are presented as median [IQR] or OR [95% CI].Results:Among 302 patients, median age was 71 [61-79], NIHSS was 15 [10-20], 56% were female, median OTA was 154 [75-320]. Median FIV ASPECTS was 7 [6-8]. In multivariable analysis adjusting for FIV, longer OTA was associated with decreased likelihood of functional independence (OR 0.74 [0.57-0.96]). FIV-independent worsening with prolonged OTA was more pronounced with advanced age (Figure). Using propensity score matching, elderly patients (age > 70) matched by age, NIHSS, occlusion location and FIV were less likely to have functional independence with prolonged OTA (Coef -0.2, p<0.01), but not younger patients (age ≤ 70, Coef -0.1, p=0.3).Conclusions:In patients with LVO AIS who achieve successful reperfusion, delays in EVT reduce the likelihood of good clinical outcomes independent of FIV. This effect is more pronounced with advanced age.

Introduction:Red blood cell (RBC) rich vs fibrin rich clots have different mechanical properties and greater knowledge about clot composition in the context of clinical, imaging, and procedural factors in mechanical thrombectomy (MT) may help with procedural optimization. The EXCELLENT Registry (NCT03685578) is a prospective, global, multi-center, observational registry of EmboTrap as the first line MT device for large vessel occlusion (LVO). We present an interim analysis of clot collected per pass in the registry.Methods:Five hundred thirty-three clot specimens from 376 subjects were collected by 20 sites and sent for analysis by independent Central Labs under standardized protocol. Analysis was interrupted by COVID-19, but the labs were fully operational as of June 2020 and on track to deliver results for 300 subjects in Q4. At the time of abstract submission, composition data for 234 clots from 163 subjects was available. All available data will be presented at the time of the conference.Results:Cardioembolic etiology (n=100) was associated with lower RBC (40.2 vs 47.2%) and higher fibrin content (31.7 vs 26.7%) compared to large artery disease (n=12). Hyperdense/vessel susceptibility sign (78+, 24-, per independent imaging core lab) corresponded to higher mean RBC content (44.4 vs 34.9%). Treatment with IV tPA (60+, 91-) had no clear impact on clot composition (42.3 vs 40.6% RBC; 30.4 vs 30.0% fibrin). Notably, clots retrieved with the first 2 passes of were more RBC rich (42.1 vs 28.0%) and clots retrieved in higher passes had a higher average fibrin content (35.5 vs 29.6%) suggesting that higher fibrin content leads to greater refractoriness.Conclusions:Clot density/susceptibility on baseline imaging, stroke etiology and number of thrombectomy passes were associated with differential clot composition. These findings may have potential implications for the development of better MT strategies.

Background:EXCELLENT (NCT03685578) is a large, prospective, single-arm, multicenter, international registry of mechanical thrombectomy (MT) with EmboTrap as the first attempted device in routine clinical practice. The study collects per pass data on procedural and technical details that are based on interventionalists’ preference, providing an opportunity to assess current practices in MT across multiple international high-volume stroke centers.Methods:Subjects treated according to standard of care were eligible for inclusion in the study if EmboTrap was used in the first MT pass. Interim analysis focusing on procedural details and per pass clot retrieval technique was performed based on 689 subjects enrolled by 79 physicians across 26 international sites (US, Belgium, Germany, France) between Sept 2018 and Jul 2020.Results:Mean #passes was 2.1 (median=1, max=10), 50.3% subjects had only 1 pass and 84.8% had 3 or fewer. Per pass use of stent retriever, aspiration, balloon guide, intermediate catheter and long sheath catheter, along with technique details (e.g. incubation time, device positioning, co-aspiration) are summarized in Table 1. Rates and reasons for device changes are also given.Conclusion:Interim analysis of the ongoing EXCELLENT registry informs on current practice patterns in MT. This is the first report of detailed per pass clot retrieval strategies in a large international multicenter cohort.

This article reports that Warrington Social Services opt for electronic versions of paper client files to save space, ensure security and to provide a first step to an integrated Electronic Social Care Record. Warrington Social Services evaluated the options and solution providers available and selected SQUARE3 based upon cost-effectiveness, project management and timescales/delivery. SQUARE3 has been commissioned to scan the 20,000 files and provide ancillary services to aid the process. These services include SQUARE3's same-day secure courier service, file preparation and indexing, secure document storage and confidential destruction. Scanned images are indexed upon the client's ID number, name, address and date of birth and the images uploaded to Warrington's On-Demand.NET CareStore system. Industry standard formats are utilized to ensure flexibility and enable Warrington to populate other systems with the images if required. Through the first stage of the project, Warrington's CareStore will act as a stand-alone document repository.