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Background Cerebral 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. Methods This 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. Results Thirty 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. Conclusions The 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. [ABSTRACT FROM AUTHOR]

Background The 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. Methods Up 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). Results The 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). Conclusion POSITIVE 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. [ABSTRACT FROM AUTHOR]

Background Thrombectomy 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. Objective To 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. Methods Data were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 highvolume 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. results Adequate 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. Conclusion This 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. [ABSTRACT FROM AUTHOR]

Background Thrombectomy 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. Objective To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting. Methods Data 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. Results Adequate 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. Conclusions Our 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. [ABSTRACT FROM AUTHOR]

The concept of scale in human geography has been profoundly transformed over the past 20 years. And yet, despite the insights that both empirical and theoretical research on scale have generated, there is today no consensus on what is meant by the term or how it should be operationalized. In this paper we critique the dominant – hierarchical – conception of scale, arguing it presents a number of problems that cannot be overcome simply by adding on to or integrating with network theorizing. We thereby propose to eliminate scale as a concept in human geography. In its place we offer a different ontology, one that so flattens scale as to render the concept unnecessary. We conclude by addressing some of the political implications of a human geography without scale. [ABSTRACT FROM AUTHOR]