Search

Background and Objectives: Mechanical thrombectomy (MT) is crucial for improving functional outcomes for acute ischemic stroke. Length of stay (LOS) is a reimbursement metric implemented to incentivize value-based care. Our study aims to identify predictors of LOS in patients undergoing MT at a high-volume center in the United States., Methods: This was a retrospective study of patients who underwent MT at a single institution from 2017 to 2023. Patients who experienced mortality during their course of hospital stay were excluded from this study. Extended LOS (eLOS) was defined as the upper quartile (≥75th) of the median duration of hospital stay. Univariate and multivariate analyses were performed, with P values < .05 denoting statistical significance., Results: Seven hundred three patients met criteria for inclusion. The median age of the cohort was 72 years (IQR: 61-82), and 57.2% was female. The median LOS was 6, IQR: 4-10. A total of 28.9% of the cohort (n = 203) patients experienced eLOS. The multivariate regression model identified age (odds ratio [OR]: 0.98, 95% CI: 0.97-0.99), diabetes mellitus (OR: 1.68, 95% CI: 1.15-2.44), and hemorrhagic transformation of stroke (OR: 2.89, 95% CI: 0.39-0.90) as predictors of eLOS, whereas antiplatelet use before admission (OR: 0.55, 95% CI: 0.34-0.89) and higher baseline modified Rankin Scale before stroke were associated with lower odds (OR: 0.59 [0.39-0.90]; P < .05) of eLOS., Conclusion: By identifying predictors of eLOS, we provide a foundation for targeted interventions aimed at optimizing post-thrombectomy care pathways and improving patient outcomes. The implications of our study extend beyond clinical practice, offering insights into healthcare resource utilization, reimbursement strategies, and value-based care initiatives., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

The Woven EndoBridge (WEB) device is FDA-approved for the treatment of bifurcation aneurysms. Despite its wide popularity, it has been under scrutiny for its association with potential aneurysm recanalization and retreatment due to device shape modification. This study aims to analyze the shape modification rate of WEB devices and identify factors associated with this phenomenon, as well as its correlation with aneurysm retreatment. We conducted a retrospective review of the WorldWide WEB Consortium database, including adult patients treated for intracranial aneurysms with the WEB device. We assessed aneurysm occlusion using the WEB Occlusion Scale and defined WEB shape modification as a percentage reduction in the distance between two WEB markers. Logistic regression and Cox proportional hazards models were utilized to evaluate predictors of shape modification and retreatment. Kaplan-Meier curves were used to estimate the time-dependent probability of no or minor shape modification. A total of 405 patients were analyzed, with minor and major shape modification occurring in 31.4% and 10.1% of cases, respectively. Major shape modification was associated with lower rates of adequate occlusion (70.7%) compared to no or minor shape modification (86.6%) and a higher rate of retreatment (26.8% vs. 8.1%). Predictors of major shape modification included the presence of daughter sac, bifurcation aneurysms, absence of immediate flow stagnation, and a WEB width minus aneurysm width ratio ≤ 0.5. The probability of no or minor shape modification declined within the first 25 months and stabilized thereafter. WEB device shape modification is a significant predictor of aneurysm occlusion efficacy and retreatment. Recognizing the factors influencing shape modification can guide treatment decisions and follow-up protocols to improve patient outcomes., Competing Interests: Declarations. Informed consent and ethical approval: The study protocol was approved by the institutional review boards of each participating center. Patient informed consent was waived by our review boards for this retrospective study. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background and Objectives: Although previous trials have established the efficacy and safety of endovascular thrombectomy (EVT) in large ischemic core strokes, most of them excluded patients with extracranial internal carotid artery (e-ICA) occlusion. We aimed to compare outcomes in patients with e-ICA occlusion and large ischemic core infarcts treated with EVT vs medical management (MM)., Methods: This was a secondary analysis of the SELECT2 trial, a randomized controlled trial conducted at 31 international sites. Adult patients with proximal intracranial anterior circulation large ischemic strokes, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3-5 on noncontrast CT or ischemic core ≥50 mL on CT-perfusion/magnetic resonance-diffusion imaging, and concomitant e-ICA occlusion were selected. The primary outcomes were the distribution of modified Rankin Scale (mRS) score at 90-day follow-up and symptomatic intracranial hemorrhage (sICH)., Results: Among 352 enrolled patients, 62 (17.6%) with e-ICA occlusions were included. Of those 62 patients, 37 received EVT (median [interquartile range (IQR)] age, 65 [58-71] years; 15 women [38.5%]) and 25 received MM (median [IQR] age, 66 [61-71] years; 7 women [28%]). ASPECTS (EVT: 5 [3-5] vs MM: 5 [4-5]) and ischemic core volume (EVT: 100 [69-134] mL vs MM: 103 [78-135] mL) were similar between groups. The successful reperfusion rate with EVT was 64.9%. Patients receiving EVT demonstrated significantly better functional outcomes (adjusted generalized odds ratio 2.51; 95% CI 1.43-4.39; p = 0.001) and a higher proportion of patients achieving 90-day independent ambulation (EVT: 37.8% vs MM: 8%; adjusted relative ratio [aRR] 4.58; 95% CI 1.18-17.79; p = 0.037) and functional independence (EVT: 21.6% vs MM: 8%; aRR 2.16; 95% CI 0.53-8.83; p = 0.285). Furthermore, no heterogeneity of EVT benefit was observed by the presence or absence of e-ICA occlusion ( p -interaction = 0.248). There were no sICH or parenchymal hemorrhage type 2 events in either group, and mortality was similar in the 2 groups (aRR 0.75; 95% CI 0.39-1.45; p = 0.388)., Discussion: Among patients with e-ICA occlusions and large ischemic core stroke, EVT was associated with better functional outcomes without significant safety concerns when compared with MM. Our findings suggest that EVT in these patients is beneficial, while the optimal treatment of the extracranial carotid occlusion remains unclear., Trial Registration Information: Name of the trial: SELECT2 trial. Registration number: ClinicalTrials.gov Identifier: NCT03876457. Date of registration submission: August 3, 2019. Date of first patient enrollment: November 10, 2019., Classification of Evidence: This study provides Class II evidence that for patients with large core acute ischemic stroke and concomitant e-ICA occlusion, EVT is associated with better functional outcome at 90 days compared with MM alone.

Background: Reperfusion therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are crucial for improving outcomes in patients with acute ischemic stroke (AIS). However, access to these treatments can vary significantly due to ethnicity, socioeconomic status (SES), and geographical location, impacting patient outcomes., Objectives: The Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS) study aims to systematically assess disparities in access to IVT and EVT on the basis of ethnicity, SES, and geographical location., Methods: A comprehensive meta-analysis was conducted, incorporating data from 38 studies involving 5,256,531 patients with AIS. The analysis evaluated IVT and EVT utilization rates across ethnic groups, SES levels, and geographical locations., Results: The findings reveal substantial disparities in access to reperfusion therapies. IVT and EVT utilization rates varied significantly by ethnicity (9% ethnic, 11% non-ethnic for IVT; 7% ethnic, 6% non-ethnic for EVT), SES (13% low SES, 16% high SES for IVT; 7% low SES, 10% high SES for EVT), and geography (9% rural, 12% urban for IVT; 1% rural, 4% urban for EVT). Black patients had significantly lower odds of receiving IVT (OR 0.69, p = 0.001) and EVT (OR 0.87, p = 0.005) compared with white patients. Similarly, patients with low SES and those from rural areas faced reduced odds of receiving IVT (OR 0.74, p < 0.001; OR 0.72, p = 0.002) and EVT (OR 0.74, p < 0.001; OR 0.39, p < 0.001). Rural patients also had significantly lower odds of timely hospital arrival (p < 0.001), posing a barrier to accessing reperfusion therapies., Conclusions: The DARTS study (and this meta-analysis) reveals significant access disparities in AIS treatment related to ethnicity, geography, and SES, particularly affecting Black communities, low SES individuals, and rural populations. Despite advances in reperfusion therapies, suboptimal implementation rates persist. To address these issues, we recommend the EQUITY framework: Educate, Ensure Quality, provide Universal Access, Implement Inclusive Policy Reforms, Enhance Timely Data Collection, and Yield Culturally Sensitive Care Practices. Adopting these recommendations will improve access, reduce disparities, and enhance stroke management and outcomes globally. Equitable access is essential for all eligible patients to fully benefit from reperfusion treatments., Competing Interests: Declarations. Funding: No external funding was used in the preparation of this manuscript. Conflicts of Interest: S.M.M.B. reports leadership or fiduciary roles in various organizations, including the National Cerebral and Cardiovascular Center (Osaka, Japan) as Visiting Director (2023–2025); Rotary District 9675 (Sydney, Australia) as District Chair for Diversity, Equity, and Inclusion; the Global Health and Migration Hub Community, Global Health Hub Germany (Berlin, Germany) as chair, founding member, and manager; and editorial board memberships at PLOS One, BMC Neurology, Frontiers in Neurology, Frontiers in Stroke, Frontiers in Public Health, Journal of Aging Research, and BMC Medical Research Methodology. Additionally, S.M.M.B. serves as a member of the College of Reviewers for the Canadian Institutes of Health Research (CIHR), Government of Canada; Director of Research for the World Headache Society (Bengaluru, India); a member of the Scientific Review Committee at Cardiff University Biobank (Cardiff, UK); and as an expert adviser/reviewer for the Cariplo Foundation (Milan, Italy). These roles are unrelated to the submitted work. T.N.N. reports being associate editor of Stroke and on advisory board Brainomix, Aruna Bio. All other authors declare that they have no potential conflicts of interest that might be relevant to the contents of this manuscript. The funding body had no influence on the study design, data collection, analysis, interpretation of findings, or manuscript preparation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the affiliated or funding organizations. Author Contributions: S.M.M.B. conceived the study; contributed to the planning, drafting, and revision of the manuscript; and supervised Global Health Neurology Lab team members. S.M.M.B. encouraged R.B. to investigate and supervised the findings of this work. R.B. and S.M.M.B. wrote the first draft of this paper. All authors (R.B., T.W., K.Z., B.B.H., M.I., M.C.K., R.G.B., M.G., A.S., D.K., P.J., T.N.N., and S.M.M.B.) contributed to the overall discussion on the design and findings of the study and the revision of the manuscript. All authors approved the final draft. Data Availability: The original contributions presented in the study are included in the article and online Supplementary Information, and further inquiries can be directed to the corresponding author. Ethics Approval: Not applicable. Code Availability: Not applicable. Consent to Participate: Not applicable. Consent for Publication: Not applicable., (© 2025. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: In recent years, there has been a shift toward the endovascular treatment of intracranial aneurysms, particularly among elderly patients, that is, those aged 70 years and older. However, microsurgical clipping remains the preferred modality for aneurysms of a certain morphology and location. The authors of this study aimed to compare the outcomes of clipping on the basis of age., Methods: This was a retrospective single-center study of patients who had undergone microsurgical clipping of an intracranial aneurysm between February 2016 and November 2022. Propensity scores were estimated using the 1:2 nearest neighbor method. Outcomes of interest were intraoperative and postoperative complications, length of stay (LOS), nonhome discharge (NHD), functional dependence on discharge, and mortality., Results: After propensity score matching, 50 patients older than 70 years were matched with 100 patients younger than 70 years of age. Aneurysm location, morphology, and rupture status were comparable between the matched cohorts. There was no significant difference in complications (14.0% for age ≥ 70 vs 13.0% for age < 70, p > 0.99), extended LOS (30% vs 19%, respectively, p = 0.129), NHD (38.0% vs 26.0%, respectively, p = 0.131), functional dependence on discharge (22% vs 17%, respectively, p = 0.509), or mortality (8.0% vs 2.0%, respectively, p = 0.077)., Conclusions: The study results demonstrated rates of complications, LOS, NHD, functional dependence, and mortality in elderly patients comparable to those in younger patients. The authors acknowledge the importance of patient selection and encourage further studies to assess the safety of clipping in the elderly.

Background and Objectives: Endovascular treatment (EVT) has been demonstrated to have improved post-operative outcomes and fewer complications compared to open microsurgical clipping of unruptured intracranial aneurysms (UIAs). Our study analyzes patient selection and outcomes for open versus EVT stratified by frailty measured using the Risk Analysis Index (RAI)., Methods: This was a retrospective study of patients who underwent open or EVT for an UIA at our institution between March 2017 and June 2022. Propensity-score matching (PSM) was performed using the 1:1 nearest neighbour method to create two groups (open and EVT) matched by demographics and treatment modality. RAI-measured frailty was used to categorize patients into 4 tiers: robust (0-10), pre-frail (11-20), frail (21-30) and severely frail (≥31). Outcomes of interest were length of stay (LOS), functional dependence at discharge and 30-day readmission., Results: After PSM, 209 patients were stratified into two groups, open and EVT, respectively. Patients who received EVT were older compared to open surgery (mean ± SD: 62.6 ± 11.4 vs. 60.8 ± 10.6, P < 0.05), however, RAI-measured frailty did not differ significantly between the two groups (median (IQR) open: 3 (2-7), vs. EVT: 3 (2-9)), P = 0.090. Among robust and pre-frail patients, EVT was associated with significantly shorter LOS compared to open surgery, median (IQR): 1 (1-2) vs. 3 (2-4) and 1 (1-2), vs. 3 (2-6); P < 0.001, respectively). Neither functional dependence at discharge nor 30-day readmission rates were different after stratification by frailty., Conclusion: Patients in the robust and pre-frail tiers experienced significantly shorter LOS after EVT compared to open surgery. We would like to encourage the use of frailty assessment as a pre-operative risk stratification tool patients undergoing treatment of UIAs., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Jabbour is a consultant for Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for MicroVention. Dr. Gooch is a consultant for Stryker. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background and Objectives: As the radial approach is gaining popularity in neurointervention, new radial-specific catheters are being manufactured while taking into consideration the smaller size of the radial artery, different trajectories of angles into the great vessels from the arm, and subsequent force vectors. We compared outcomes of transradial procedures performed using the Armadillo catheter (Q'Apel Medical Inc.) and the RIST radial guide catheter (Medtronic)., Methods: This is a retrospective multicenter study comparing outcomes of transradial neuroendovascular procedures using the Armadillo and RIST catheters at 2 institutions between 2021 and 2024., Results: The study comprised 206 patients, 96 of whom underwent procedures using the Armadillo and 110 using the RIST. Age and sex were comparable across cohorts. In most procedures, 1 target vessel was catheterized (Armadillo: 94.8% vs 89.1%, P = .29) with no significant difference between cohorts. The use of an intermediate catheter was minimal in both cohorts (Armadillo 5.2% vs RIST: 2.7%, P = .36), and the median number of major vessel catheterization did not significantly differ between cohorts (Armadillo: 1 [1-4] vs RIST: 1 [0-6], P = .21). Failure to catheterize the target vessel was encountered in 1 case in each cohort (Armadillo: 1.0% vs RIST: 0.9%, P = .18), and the rate did not significantly differ between cohorts. Similarly, the rate of conversion to femoral access was comparable between cohorts (Armadillo: 2.1% vs RIST: 1.8%, P = .55). There was no significant difference in access site complications (Armadillo: 1% vs RIST: 2.8%, P = .55) or neurological complications (Armadillo: 3.1% vs RIST: 5.5%, P = .42) between cohorts., Conclusion: No significant difference in successful catheterization of target vessels, procedure duration, triaxial system use, complication rates, or the need for transfemoral cross-over was observed between both catheters. Both devices offer high and comparable rates of technical success and low morbidity rates., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: The WovenEndoBridge Device (WEB) is an intrasaccular flow disruptor that has demonstrated satisfactory results with treating intracranial aneurysms of varying size and morphology. Our systematic review of literature compares WEB embolization to microsurgical clipping., Methods: PubMed and Scopus were searched from inception until October 9, 2024. Articles that reported comparative outcomes for WEB embolization versus microsurgical clipping of intracranial aneurysms were included. A qualitative assessment was performed using the ROBINS-I tool., Results: 3074 abstracts and 8 full-text articles were reviewed. 3 articles describing outcomes in 243 patients who underwent microsurgical clipping and 269 patients who underwent WEB embolization met criteria for inclusion. Microsurgical clipping was associated with higher rates of aneurysm occlusion and lower rates of re-treatment compared to WEB embolization. Rates of peri-procedural complications were higher with microsurgical clipping. Functional outcome was comparable across cohorts., Conclusion: Our review identified higher rates of angiographic occlusion, greater technical success, and lower rates of re-treatment with microsurgical clipping compared to WEB embolization. However, this was at the cost of increased peri-procedural complications. Further research is needed to help identify the optimal treatment modality for specific patient populations., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Objective: Tobacco smoking is among the factors known to significantly augment the risk of untreated intracranial aneurysm (IA) growth and rupture. Smoking appears to have a variable effect on different endovascular treatment modalities. The impact of smoking on the safety, efficacy, and outcomes of Woven EndoBridge (WEB) device use for wide-neck IAs has not been evaluated. This study aimed to investigate the outcomes of WEB devices by smoking status., Methods: A retrospective multicenter analysis was conducted on the data of patients from 36 sites worldwide treated with the WEB device for intracranial saccular aneurysms. Patients were stratified based on smoking status (current, former, and never smokers). The Student t-test and chi-square test were performed for continuous and categorical variables, respectively. Multivariable logistic regression was used to adjust for confounders., Results: Of 1376 patients with available smoking status, 504 were current smokers, 358 were former smokers, and 514 were never smokers. Upon adjusting for significant confounders, no association was found between smoking and recurrence outcomes (OR 1.39, 95% CI 0.69-2.80; p = 0.36), thromboembolic and hemorrhagic complications, and mortality among IAs treated with the WEB device. There was no statistically significant difference in outcomes between former and never smokers (OR 1.23, 95% CI 0.70-2.18; p = 0.46). The location of aneurysms differed between smoking groups, with former smokers having more anterior circulation aneurysms compared with current and never smokers (99.0% vs 96.9% vs 95.3%; p = 0.01). In terms of clinical symptoms, headache and dizziness were more common in the never smokers compared with current and former smokers (13.9% vs 8.9% vs 7.7%, p = 0.01)., Conclusions: This large-scale study suggests no significant correlation between smoking and the recurrence of IAs treated with the WEB device. Biological studies are warranted to better understand the biological impact of smoking on the growth and rupture of treated IAs.

Large language models (LLMs) have been utilized to automate tasks like writing discharge summaries and operative reports in neurosurgery. The present study evaluates their ability to identify current procedural terminology (CPT) codes from operative reports. Three LLMs (ChatGPT 4.0, AtlasGPT and Gemini) were evaluated in their ability to provide CPT codes for diagnostic or interventional procedures in endovascular neurosurgery at a single institution. Responses were classified as correct, partially correct or incorrect, and the percentage of correctly identified CPT codes were calculated. The Chi-Square test and Kruskal Wallis test were used to compare responses across LLMs. A total of 30 operative notes were used in the present study. AtlasGPT identified CPT codes for 98.3% procedures with partially correct responses, while ChatGPT and Gemini provided partially correct responses for 86.7% and 30% procedures, respectively (P < 0.001). AtlasGPT identified CPT codes correctly in an average of 35.3% of procedures, followed by ChatGPT (35.1%) and Gemini (8.9%) (P < 0.001). A pairwise comparison among three LLMs revealed that AtlasGPT and ChatGPT outperformed Gemini. Untrained LLMs have the ability to identify partially correct CPT codes in endovascular neurosurgery. Training these models could further enhance their ability to identify CPT codes and minimize healthcare expenditure., Competing Interests: Declarations. Ethical Approval: Not applicable. Competing Interests: Dr. Jabbour is a consultant for Q’Apel Medical, Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for MicroVention. Dr. Gooch is a consultant for Stryker. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objectives: Body mass index (BMI) is a modifiable risk factor that has been shown to affect outcomes in neurointervention. The impact of BMI on choice of access site (transradial access (TRA) or transfemoral access (TFA), remains undescribed to our knowledge. Our study analyzes outcomes of TRA and TFA stratified by BMI in patients undergoing diagnostic cerebral angiograms in an outpatient setting., Methods: This was a retrospective analysis of a prospectively maintained database of patients who underwent diagnostic cerebral angiograms at a single institution from January 2018-2024. Propensity scores were calculated using a 1:1 optimal match method based on significant covariates derived from a logistic regression model. Patients were grouped into 2 cohorts based on access site (TRA and TFA) and stratified into BMI subgroups: (underweight (BMI <18.5), normal weight (BMI 18.5-25.0), overweight (BMI 25.0-29.9) and obese (BMI >30). Linear regression analysis and chi-square test was used to compare procedure time and post-anesthesia care unit (PACU) time across cohorts., Results: 678 patients were grouped into 2 cohorts (TRA and TFA) of 339 each. The average age of the cohort was 58 years, and 82.4 % was female. TRA significantly shortened procedure times in patients across normal and overweight subgroups of BMI compared to TFA. TRA shortened PACU times across all BMI subgroups compared to TFA. There was no significant association between access site complications or post-operative complications for TRA or TRF across BMI subgroups., Conclusion: TRA is a safe and feasible alternative to TFA in certain subgroups of patients undergoing elective diagnostic angiogram in the outpatient setting. This is evidenced by shorter procedure time across certain BMI subgroups and shorter recovery time in the PACU across all BMI subgroups., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The Woven EndoBridge (WEB) device is frequently used for the treatment of intracranial aneurysms. Postoperative management, including the use of aspirin, varies among clinicians and institutions, but its impact on the outcomes of the WEB has not been thoroughly investigated., Methods: This was a retrospective, multicenter study involving 30 academic institutions in North America, South America, and Europe. Data from 1492 patients treated with the WEB device were included. Patients were categorized into two groups based on their postoperative use of aspirin (aspirin group: n=1124, non-aspirin group: n=368). Data points included patient demographics, aneurysm characteristics, procedural details, complications, and angiographic and functional outcomes. Propensity score matching (PSM) was applied to balance variables between the two groups., Results: Prior to PSM, the aspirin group exhibited significantly higher rates of modified Rankin scale (mRS) mRS 0-1 and mRS 0-2 (89.8% vs 73.4% and 94.1% vs 79.8%, p<0.001), lower rates of mortality (1.6% vs 8.6%, p<0.001), and higher major compaction rates (13.4% vs 7%, p<0.001). Post-PSM, the aspirin group showed significantly higher rates of retreatment (p=0.026) and major compaction (p=0.037) while maintaining its higher rates of good functional outcomes and lower mortality rates. In the multivariable regression, aspirin was associated with higher rates of mRS 0-1 (OR 2.166; 95% CI 1.16 to 4, p=0.016) and mRS 0-2 (OR 2.817; 95% CI 1.36 to 5.88, p=0.005) and lower rates of mortality (OR 0.228; 95% CI 0.06 to 0.83, p=0.025). However, it was associated with higher rates of retreatment (OR 2.471; 95% CI 1.11 to 5.51, p=0.027)., Conclusions: Aspirin use post-WEB treatment may lead to better functional outcomes and lower mortality but with higher retreatment rates. These insights are crucial for postoperative management after WEB procedures, but further studies are necessary for validation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: Endovascular procedures are associated with improved outcomes and patient satisfaction compared to open surgery in selected cases. However, this is at the cost of increased radiation exposure. Robotic procedures are thought to minimize radiation exposure and may confer procedural efficacy due to the lack of operator fatigue. Our systematic review and meta-analysis compares procedural efficacy of robotic versus manual diagnostic and stenting procedures., Methods: PubMed, Embase and Scopus were searched in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Articles reporting comparative outcomes between robotic and manual diagnostic and stenting procedures were included. Articles related to stereotactic radiosurgery and open surgical procedures were excluded. The Newcastle Ottawa Scale was used to assess risk of bias. Effect sizes (mean difference for robotic and manual procedures) and variances were calculated for procedure time. The random effects model was used to calculate pooled estimates for technical success using the "metafor" package in R (R software v4.2.1, Vienna, Austria)., Results: 6465 articles were identified through our search strategy. After 4683 articles were excluded through a title and abstract screen and 30 articles were excluded through a full text review, 3 articles reporting outcomes in 175 patients undergoing robotic procedures and 185 patients undergoing manual procedures were included. These studies reported comparative outcomes for carotid artery stenting, diagnostic cerebral angiograms and transverse sinus stenting. There was no significant difference in procedure time (mean difference: 0.14 min [95% confidence interval (CI): -0.58, 0.86, p = 0.64, I 2  = 68%]. Technical success was 0.05-fold lower for robotic procedures compared to manual procedures [95% CI: 0.00- 0.84), P = 0.04]. One study was considered high quality using the NOS., Conclusions: Robotic procedures confer significantly lower rates of technical success with no significant difference in procedure time. Further studies are necessary to draw conclusions about potential benefits of robotic procedures including lower radiation exposure., Competing Interests: Declarations. Ethical approval: Not applicable. Competing interests: Dr. Jabbour is a consultant for Q’Apel Medical, Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for MicroVention. Dr. Gooch is a consultant for Stryker. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The EXCELLENT registry aimed to evaluate the effectiveness of the EMBOTRAP Revascularization Device in an all-comer population in a real-world setting, with a focus on the composition of retrieved clots., Methods: EXCELLENT is a prospective, global registry of patients with acute ischemic stroke treated with EMBOTRAP as the first-line mechanical thrombectomy device conducted at 34 sites (25 sites contributing clot) from September 2018 to March 2021, utilizing core imaging and central histology laboratories blinded to clinical data, independent 90-day modified Rankin Scale assessment and Clinical Events Committee., Results: After screening 3799 patients, a total of 997 subjects (mean age, 70.0±14.2 years; 51.8% women; 19.7% non-White) were included. The first-pass modified Treatment in Cerebral Infarction (mTICI) ≥2b rate was 64.5% (623/966), first-pass mTICI ≥2c was 39.1% (378/966), and final mTICI ≥2b was 94.5% (931/985). A total of 427/912 (46.8%) patients achieved a 90-day modified Rankin Scale of 0 to 2 or ≤baseline. Embolization to a new territory occurred in 0.2% (2/984), and symptomatic intracranial hemorrhage at 24 hours in 1.6% (16/997). The 90-day mortality was 19.1% (175/918). Device- and/or procedure-related serious adverse events occurred in 5.9% (54/912) through 90 days. The mean RBC percentage of retrieved clots was 45.62±21.372. Among patients who achieved mTICI ≥2b with the first pass, 15.7% (52/331) and 9.7% (32/331), respectively, had RBC-poor (<25%) and RBC-rich (>75%) clots. Patients with no clot retrieved in any procedural pass had a lower percentage of hyperdense or susceptibility vessel sign on baseline imaging (58.9% versus 74.7%; P <0.001), pointing to a potential preprocedure indicator of challenging clot., Conclusions: The EXCELLENT registry informs real-world practices in mechanical thrombectomy and sheds light on the range of clots effectively retrieved by current technology. This is the first report of detailed patient characteristics where mechanical thrombectomy maneuvers failed to remove any clot material. Although the composition of nonretrievable clots cannot be assessed histologically, the results support the notion that no retrieval may be correlated with imaging findings suggesting clots lower in RBC., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03685578., Competing Interests: Dr Nogueira: consulting for Anaconda, Medtronic, Cerenovus, Genentech, Viz-AI, Stryker, Prolong Pharmaceuticals, Perfuze, Biogen, Shanghai Wallaby, Brainomix, Hybernia, RapidPulse, Imperative Care, Corindus, NeuroVasc Technologies, Vesalio, Cerebrotech, Phenox, Astrocyte, Ceretrieve, Philips; grants from Stryker, Cerenovus; data safety monitoring for Synchron; ownership/investment interest in Ceretrieve, Corindus, Brainomix, Perfuze, Truvic, Viz-AI, Reist, Q’Apel, Vesalio, Cerebrotech, Viseon, Piraeus, Brain4Care, Quantanosis-AI. Dr Andersson: consulting for Neuravi, Anaconda, Johnson & Johnson (J&J), Rapid Medical; ownership/investment interest in Ceroflo. Dr Haussen: consulting for Brainomix, Vesalio, Stryker, Poseydon, Chiesi, Cerenovus; ownership/investment interest in Viz-AI; data safety monitoring for Jacobs Institute. Dr Yoo: consulting for Philips, Nicolab, ZOLL Circulation, Vesalio, Rapid Medical; grants and consulting for J&J, Medtronic, Penumbra; grants from Stryker, Genentech; ownership/investment interest in Gravity, Galaxy Therapeutics, Insera, Nicolab; data safety monitoring for NIH; employment with HCA Healthcare; other services for AHA. Dr Hanel: consulting for Balt, MicroVention, Medtronic, Rapid Medical, Stryker, Phenox, Cerenovus, Q’Apel; ownership/investment interest in Cerebrotech, Three Rivers Medical, NTI, Endostream, BlinkTBI, RisT, InNeuroCo, Corindus, eLum, Scientia. Dr Zaidat: consulting for J&J; patent holder. Dr Hacke: consulting for J&J. Dr Jovin: consulting for Contego Medical; grants from Medtronic, Stryker; employment with Cooper University Healthcare; data safety monitoring for Cerenovus; ownership/investment interest in Anaconda, StataDx, Galaxy, Basking, Freeox Biotech, Kandu, Viz-AI, Route92, Gravity. Dr Fiehler: consulting for Stryker, Cerenovus, Penumbra, MicroVention, Roche, Tonbridge, Phenox, TG Medical, Medtronic, Acandis; ownership/investment interest in Vastrax, Eppdata, Tegus; employment with Eppdata. Dr De Meyer: travel support from J&J. Dr Brinjikji: consulting for Cerenovus, MicroVention, Medtronic, Balt, Imperative Care, MIVI; ownership interest in Piraeus, Nested Knowledge, MIVI; research funding from Cerenovus, Brainomix, NIH. Dr Doyle: grants from SFI, Cerenovus. Dr Kallmes: grants from MIVI, Cerenovus, Balt, Vesalio, Stryker, MicroVention, Insera, Medtronic, Brainomix; ownership/investment interest in Superior Medical Experts, Conway Medical, Piraeus, Monarch Biosciences, Marblehead, Nested Knowledge; patent holder. Dr Liebeskind: consulting for Cerenovus, Medtronic, Genentech, Stryker, Rapid Medical. Dr Virmani: grants from Endotronix, L&J Bio, W.L. Gore, Recombinetics, Transverse Medical, Profusa, Lutonix, MicroVention, Envision, Neovasc, Cerus EndoVascular, MedAlliance, Interface Biologics, Biotronik, Mercator MedSystems, Spectrawave, Cook Medical, SoundPipe, Ossio, Bolt Medical, CardioMech, Olympus, Spartan Micro, Intact Vascular, Inc, Whiteswell, Vascudyne, Imperative Care, Biotyx Medical, SMT, Innovative Medical Devices, Cardiovascular Solutions, Dexcom, Emboline, Cooper Health, Children’s National, Concept Medical, Filterlex, eLum Technologies, Protembis, Boston Scientific, Polares, MDS, CeloNova, UCSF Foundation, Croivalve, Canon, Terumo, BD Biosciences, Limflow, Renata, Vetex, Recor, Mayo Clinic, CSI, Ohio Health, UPMC, Regencor, Vesper, Ripple Therapeutics, Polyvascular, Invatin, Innovative Cardiovascular Solutions, TruLeaf, Coramaze, ProKidney, 480 Biomedical, Transmural Systems, Intershunt Technologies, Pi-Cardia, Lyra Therapeutics, Sanofi, Phenox, Qool Therapeutics, Chansu Vascular Technologies, Nyra Medical, Surmodics, Microport, Leducq Foundation, OrbusNeich, Cardiac Implants, Rush University, Edwards Lifesciences, Cardionomic, Restore Medical, Medanex, CRL, Lahav, Pulse Biosciences, Jacobs Institute, Nova Vascular, Nephronyx, Maywell, Innovalve, Elucid Bioimaging, Medtronic, Biosensors International Group, ShockWave Medical, Cardiawave, NIH, Occlutech; consulting for Terumo, Recor Medical, Sino Medical, Medtronic, Cook, W.L. Gore, CSI, Surmodics, CeloNova, Edwards Lifesciences, BARD, Xeltis; other services for Xeltis, Medtronic; employment with CVPath Institute. Dr Kokoszka: employment with Cerenovus. Dr Inoa: consulting for Siemens, Viz-AI, Medtronic, Cerenovus, MicroVention, Penumbra; grants from Medtronic; employment with Semmes Murphey Clinic. Dr Humphries: consulting for Cerenovus. Dr Jabbour: consulting for Medtronic. Dr François: consulting for iVascular. Dr Levy: consulting for Guidepoint, GLG Consulting, Clarion, StimMed, Mosaic; other services for Penumbra, Medtronic, MicroVention; ownership/investment interest in Imperative Care, StimMed, Three Rivers Medical, NeXtGen Biologics, Q’Apel, Claret Medical, Rapid Medical. Dr Dashti: consulting for MicroVention, J&J, Cerenovus. Dr Schirmer: consulting for Balt, Medtronic, Stryker, Viz-AI, MicroVention; grants from Route92, MicroVention, Penumbra, Cerenovus, Balt, MIVI, Medtronic; employment with Geisinger; other services for Werfen, Cerenovus, NIH, Stryker, Neurotechnology Investors; ownership interest in Reist. Dr Hussain: consulting for J&J. Dr De Leacy: consulting for J&J, Imperative Care, Stryker; ownership/investment interest in Vastrax, Q’Apel, Spartan Micro, Synchron, Endostream. Dr Puri: consulting for J&J, MicroVention, Merit Medical, Stryker, Medtronic, Balt. Dr Chitale: grants, consulting, and data safety monitoring for Medtronic; grants from J&J. Dr Siddiqui: consulting for Cerebrotech, Boston Scientific, Rapid Medical, Cordis, W.L. Gore, Peijia Medical, Corindus, StimMed, J&J, Viz-AI, Silk Road Medical, Piraeus, Medtronic, Penumbra, Hyperfine Operations, Cerenovus, Endostream, Minnetronix Neuro, Stryker, Canon Medical Systems, Integra LifeSciences, Imperative Care, Apellis, Amnis Therapeutics, Vassol, IRRAS, Cardinal Health 200, Q’Apel, InspireMD, MicroVention, Serenity Medical; grants from Brain Aneurysm Foundation, NIH; other services for Rapid Medical, MicroVention, MIVI, Medical University of South Carolina, Penumbra, Cerenovus, InspireMD, Medtronic; ownership/investment interest in Willow Medtech, Cognition Medical, Whisper Medical, Spinnaker, Sim & Cure, Hyperion, BlinkTBI, Surgical, Inc, Radical Catheter Technologies, Imperative Care, Code Zero Medical, E8, Truvic, Tulavi, Bend IT, Neurolutions, Q’Apel, Endostream, Cerebrotech, Instylla, Collavidence Medical, Sense Diagnostics, Neurotechnology Investors, Peijia Medical, Synchron, Viseon, Borvo, E8, Galaxy Therapeutics, Piraeus, Adona Medical, NeuroRadial Technologies, NextGen Biologics, Viz-AI, Three Rivers Medical, StimMed, Serenity Medical, Cerevatech, Cvaid, Silk Road Medical, PerFlow Medical, InspireMD, VICIS, QAS.ai, SongBird, Launch NY, Neurovascular Diagnostics, Vastrax, Cognition Medical, Integra LifeSciences, Medtronic; employment with University at Buffalo Neurosurgery, Jacobs Institute; patent holder. The other authors report no conflicts.

Objective: Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exist for patients who have undergone robotic versus manual CAS. In addition, no data exist comparing the costs of manual and robotic CAS., Methods: All robotic CAS cases at two academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration by using time-driven activity-based cost analysis., Results: A total of 24 robotic CAS operations were performed between 2019 and 2023. Comorbidities and baseline procedural characteristics were well matched between robotic and manual cases. Unplanned manual conversion was observed in only 1 robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs 19.2 minutes; p < 0.001). Robotic procedure time (88.9 ± 18.2 minutes) was significantly (p = 0.003) longer than manual time (68.72 ± 22.4 minutes). Health personnel costs ($1589.71 ± $176.92 vs $1375.99 ± $233.39, p = 0.005); supply costs ($3918.25 ± $421.20 vs $2152.74 ± $1030.26, p < 0.001); and total procedure costs ($5306.11 ± $608.95 vs $3437.56 ± $1165.67, p < 0.001) were greater for robotic CAS., Conclusions: In the first multicenter study and largest sample to date, the authors show that robotic CAS, with a low rate of procedural failure and postoperative complications, is safe and feasible. In addition, robotic CAS achieves comparable clinical outcomes to manual CAS. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX system. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Robotic CAS failed to show superiority to manual CAS. These findings set a foundation for randomized controlled trials of robotic CAS, and also highlight the need for further studies to optimize robotic CAS and reduce its associated costs.

Objective: BMI has been shown to affect choice of access site in coronary intervention procedures, with lower complications reported during transradial (TR) access. To the authors' knowledge, the effect of BMI on outcomes in patients undergoing diagnostic cerebral angiography remains undescribed. This study compares outcomes for BMI subgroups based on access site (TR vs transfemoral [TF] access)., Methods: The authors conducted a single-center retrospective study of patients who underwent diagnostic cerebral angiography between December 2019 and January 2024. Propensity score matching was used to create two similar cohorts (TR and TF). These cohorts were subdivided based on BMI: underweight (BMI < 18.5), normal (BMI 18.5-25.0), overweight (BMI 25.1-29.9), and obese (BMI ≥ 30). Linear regression analysis and the chi-square test were used to compare outcomes., Results: Nine hundred thirty-six patients were stratified into two groups of 468 patients each. Procedure time was significantly shorter for TR access for all BMI subgroups, with a 13-minute reduction in procedure time among underweight patients. Patients with normal BMI, overweight patients, and obese patients experienced a reduction in procedure time of approximately 11, 10, and 13 minutes, respectively. Obese patients experienced significantly shorter length of stay (LOS; 1.33 days) with TR access. There were no significant differences between each BMI subgroup in access site complications, postoperative complications, and conversion of access from TR to TF., Conclusions: TR access in diagnostic cerebral angiography is associated with shorter procedure times and no increased risk of complications compared to TF access across all BMI subgroups. Obese patients experienced shorter LOS with TR access. This study adds to the literature on the safety and efficacy of TR access across all BMI subgroups. Further studies are necessary to validate these preliminary results.

Objective: Few studies have reported the impact of telescoping flow diverters (FDs) in intracranial aneurysm treatment. Our study compared aneurysms treated using telescoping FDs to those treated with a single FD and identified predictors of telescoping., Methods: This was a single-center retrospective review of a prospectively maintained database of aneurysms treated with FDs between 2011 and 2023. All patients who were treated with FDs for intracranial aneurysms were included in the study., Results: The study comprised 750 patients with 750 aneurysms treated using 871 FDs. The study cohort was divided into 85 patients requiring telescoping FDs and 655 who did not. Rates of hemorrhage (7.1% vs. 1.8%, P < 0.001), symptomatic stroke (5.9% vs. 2.6, P < 0.001), and asymptomatic stroke (1.2% vs. 0.8%, P < 0.001) were significantly higher in the telescoping cohorts. At final follow-up, the rate of nonocclusion (9.8% vs. 5.1%, P = 0.029) and the rate of complete occlusion (88.5% vs. 81.1%, P = 0.029) were significantly higher in the telescoping cohort. On multivariate analysis, fusiform morphology (odds ratio [OR]: 2.4, 95% confidence interval [CI] 1.0-5.0, P = 0.03), increasing aneurysm height (OR: 1.0, 95% CI 1.0-1.1, P= 0.034), and the use of the Pipeline Embolization Device FD (OR: 2.4, 95% CI 1.3-4.4, P = 0.005) were independent predictors of telescoping., Conclusions: Aneurysms with fusiform morphology, increasing aneurysm height and those that underwent flow diversion using Pipeline Embolization Device had higher odds for telescoping. Significantly higher rates of angiographic occlusion with the use of telescoping FD add to the literature on its efficacy in treating aneurysms of varying morphology., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The Woven EndoBridge (WEB) device is emerging as a novel therapy for intracranial aneurysms, but its use for off-label indications requires further study. Using machine learning, we aimed to develop predictive models for complete occlusion after off-label WEB treatment and to identify factors associated with occlusion outcomes., Methods: This multicenter, retrospective study included 162 patients who underwent off-label WEB treatment for intracranial aneurysms. Baseline, morphological, and procedural variables were utilized to develop machine-learning models predicting complete occlusion. Model interpretation was performed to determine significant predictors. Ordinal regression was also performed with occlusion status as an ordinal outcome from better (Raymond Roy Occlusion Classification [RROC] grade 1) to worse (RROC grade 3) status. Odds ratios (OR) with 95 % confidence intervals (CI) were reported., Results: The best performing model achieved an AUROC of 0.8 for predicting complete occlusion. Larger neck diameter and daughter sac were significant independent predictors of incomplete occlusion. On multivariable ordinal regression, higher RROC grades (OR 1.86, 95 % CI 1.25-2.82), larger neck diameter (OR 1.69, 95 % CI 1.09-2.65), and presence of daughter sacs (OR 2.26, 95 % CI 0.99-5.15) were associated with worse aneurysm occlusion after WEB treatment, independent of other factors., Conclusion: This study found that larger neck diameter and daughter sacs were associated with worse occlusion after WEB therapy for aneurysms. The machine learning approach identified anatomical factors related to occlusion outcomes that may help guide patient selection and monitoring with this technology. Further validation is needed., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Asymptomatic carotid stenosis (ACS) carries a 4.7% risk of ipsilateral stroke if left untreated. Carotid endarterectomy (CEA) is a surgical intervention that has demonstrated efficacy in reducing stroke risk among symptomatic elderly. However, literature on its efficacy in preventing stroke in patients with ACS remains limited. Our systematic review summarizes evidence on the safety and efficacy of CEA in the asymptomatic elderly.PubMed and Scopus were searched to identify articles that described outcomes after CEA for ACS in patients aged ≥ 65 years old. Articles that did not report outcomes specific to the asymptomatic elderly were excluded. Outcomes of interest were technical success, stroke, death, myocardial infarction and post-operative complications. The Newcastle Ottawa Scale (NOS) was used to perform a qualitative assessment for risk of bias and studies with NOS ≥ 6 were considered high quality. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.After a title and abstract screen, followed by a full-text review, 7 studies reporting outcomes in 76,404 patients were included. Five studies were retrospective and two were prospective. Among studies that reported criteria for intervention in ACS patients, 2 studies performed CEA for 70% stenosis and one performed CEA for 60% stenosis. One study reported outcomes for all ranges of stenosis (mild: 0-50%, moderate: 50-79% and severe: 80-99%). Clinical outcomes varied among included studies, with rates of death stroke and myocardial infarction ranging from 0.39 to 6.1%, 0.5-1.2% and 0.9-3%, respectively.The decision to perform CEA in patients with ACS is made after outweighing risks and benefits of surgery based on various factors like age, comorbidities and frailty. At present, evidence is largely limited to retrospective studies that utilized nationwide databases. Prospective studies and randomized controlled trials could help characterize the risk of CEA in this cohort., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: The Woven EndoBridge (WEB) device was approved to treat wide-necked bifurcation aneurysms. The device is designed as an intrasaccular flow disruptor covering aneurysm widths up to 10 mm. Although prior studies combined all aneurysm sizes, it is known that aneurysms behave differently in response to endovascular treatment based on their size. Therefore, the authors' objective was to identify ideal middle cerebral artery (MCA) aneurysm width and neck sizes most suitable for WEB treatment., Methods: The WorldWideWEB consortium is a large multicenter retrospective database that analyzes intracranial aneurysms treated with the WEB device. In this study, all unruptured MCA bifurcation aneurysms with available measurements were included. Cutoff values based on aneurysm width and neck in relation to aneurysm occlusion status were measured using the receiver operating characteristic (ROC) curve. Propensity score matching (PSM) was then used to compare treatment outcomes between aneurysms smaller and larger than the cutoff value for both width and neck size., Results: The ideal cutoff values for MCA bifurcation aneurysm width and neck were 6.1 mm and 4.6 mm, respectively. On PSM, 87 matched pairs were compared based on width size (≤ 6.1 mm and > 6.1 mm), and 77 matched pairs were compared based on neck size (≤ 4.6 mm and > 4.6 mm). There was a significant difference in adequate aneurysm occlusion between aneurysms smaller and larger than those cutoff values for both widths (93% vs 76%, p = 0.0017) and neck sizes (90% vs 70%, p = 0.0026). The retreatment rate was also significantly higher for larger aneurysms in both parameters., Conclusions: This study shows that MCA bifurcation aneurysms ≤ 6.1 mm in width and ≤ 4.6 mm in neck size are significantly better candidates for WEB treatment, leading to improved occlusion status and reduced retreatment rate, which are important considerations when using WEB devices.

Background: Intracranial atherosclerotic disease (ICAD) is one of the most prevalent causes of stroke across the world. Endovascular treatment has gained prominence but remains a challenge with unfavorable results. Recent literature has demonstrated that the Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) is a technically safe option with low complication rates along with 30-day outcomes associated with intracranial stent placement for ICAD with RO-ZES compared to results from the Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Here, we aim to compare outcomes at one year with the SAMMPRIS trial with a multicenter longitudinal study., Materials and Methods: Prospectively maintained databases across seven stroke centers were analyzed for adult patients undergoing RO-ZES placement for ICAD between January 2019 and May 2023. The primary endpoint was composite of one-year stroke, ICH, and/or death. These data were propensity score matched using age, sex, hypertension, diabetes mellitus, smoking status, and impacted vessel for comparison between RO-ZES and the SAMMPRIS percutaneous angioplasty and stenting groups (S-PTAS)., Results: A total of 104 patients were included, mean age ± SD: 64.9 ± 10.9 years, 25.5% female. Propensity score match analysis of the 104 patients with S-PTAS demonstrated one-year stroke, ICH, and/or death rate of 11.5% in the RO-ZES group and 28.1% in the S-PTAS group (odds ratio 4.17, 95% CI 2.06-8.96, p = 0.001)., Conclusion: The RO-ZES system demonstrates strong potential to reduce long-term complications at one year compared with the S-PTAS group. Further prospective multicenter studies are needed to corroborate and build upon these findings., Competing Interests: Declaration of conflicting interestsDr Burkhardt is a consultant for Stryker, Microvention, Q'Apel, Longeviti, Cerenovus, Phenox, and Medtronic. Dr Jabbour is a consultant for Medtronic, Microvention, and Cerus Endovascular. Stavropoula I. Tjoumakaris is a consultant for Medtronic/Microvention. Dr Siddiqui has the following disclosures: Financial Interest/Investor/Stock Options/Ownership: Adona Medical, Inc, Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc, Cerebrotech Medical Systems, Inc, CerevatechMedical, Inc, CognitionMedical, CVAID Ltd, E8, Inc, Endostream Medical, Ltd, Galaxy Therapeutics, Inc, Imperative Care, Inc, InspireMD, Ltd, Instylla, Inc, International Medical Distribution Partners, Launch NY, Inc, Neurolutions, Inc, NeuroRadial Technologies, Inc, NeuroTechnology Investors, Neurovascular Diagnostics, Inc, Peijia Medical, PerFlow Medical, Ltd, Q'Apel Medical, Inc, QAS.ai, Inc, Radical Catheter Technologies, Inc, Rebound Therapeutics Corp (purchased in 2019 by Integra Lifesciences, Corp), Rist Neurovascular, Inc (purchased in 2020 by Medtronic), Sense Diagnostics, Inc, Serenity Medical, Inc, Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, Inc, StimMed, LLC, Synchron, Inc, Three Rivers Medical, Inc, Truvic Medical, Inc, Tulavi Therapeutics, Inc, Vastrax, LLC, VICIS, Inc, Viseon, Inc; Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc, Boston Scientific, Canon Medical Systems USA, Inc, Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc, Cerenovus, Cerevatech Medical, Inc, Cordis, Corindus, Inc, Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc, Peijia Medical, Penumbra, Q'Apel Medical, Inc, Rapid Medical, Serenity Medical, Inc, Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc, VasSol, Viz.ai, Inc; National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFTDIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial. Dr Grandhi is a consultant for Balt, Medtronic Neurovascular, and Cerenovus. Dr Qureshi received consultation fees from AstraZeneca. Dr Hassan is a consultant/speaker for Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, RapidMedical, Imperative Care, and Galaxy Therapeutics; is the principal investigator for the COMPLETE study—Penumbra, and LVOSYNCHRONISE—Viz.ai; is a member of the steering committee/publication committee for SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI; and DSMB for the COMAND trial. Other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Background: Double lumen balloon catheters (DLBCs) have emerged as a potential alternative to single lumen balloon catheters for endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs). This study describes our preliminary experience with the Eclipse 2L DLBC in treating AVMs and dAVFs., Methods: Patients who underwent embolization of cranial dAVFs or AVMs at our institution from August 2021 to March 2024 were included. Spinal vascular malformations were excluded. Descriptive statistics were used to analyze procedural outcomes, technical nuances, and postoperative outcomes on follow-up., Results: Twenty-five patients who underwent 38 embolization procedures (15 AVMs and 23 dAVFs) met criteria for inclusion in this study. The mean age of the cohort was 52.44 (standard deviation = 17.26), and 48% of the overall cohort (n = 13) was female. The average procedure times for AVMs and dAVFs were 80.4 minutes and 96.73 minutes, respectively. There was 1 instance of catheter entrapment. Two patients in the AVM cohort experienced mortality, and 1 experienced postoperative rupture., Conclusions: Our preliminary experience using the Eclipse 2L balloon catheter for Onyx embolization reported procedural outcomes comparable to other DLBCs despite relatively higher procedure times and radiation doses. Further long-term studies on its efficacy as primary modality in treating AVMs and dAVFs are encouraged., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite their asymptomatic occurrence, unruptured intracranial aneurysms (UIAs) account for a significant proportion of hospital charges and healthcare resource utilization in the United States. Hospital length of stay (LOS) is a reimbursement metric utilized to incentivize value-based care. Our study identifies predictors of extended LOS (eLOS) after elective treatment of UIAs., Methods: This was a retrospective study of 525 patients who underwent elective treatment of an UIA at a single institution. Data were collected with regard to demographics, clinical presentation, treatment characteristics, and postoperative outcomes. The primary outcome, eLOS, was defined as hospital stay in the upper quartile of the median (≥75th percentile). Univariate and multivariate analyses were performed to identify factors predictive of eLOS in this cohort., Results: The average age of the cohort was 61.40, standard deviation=11.41. 77.3% of the cohort was female. The median duration of LOS was 2 days (interquartile range: 1-5). 11.6% experienced eLOS (≥5 days). Multivariate logistic regression identified age (OR: 1.04, 95% confidence interval [CI]: 1.01-1.07), coexistent vascular pathology (OR: 21.33, 95% CI: 8.06-56.39), open surgery (OR: 3.93, 95% CI: 1.85-8.34), and postoperative stroke (OR: 11.72, 95% CI: 3.18-43.18) as independent predictors of eLOS., Conclusions: Our study identified predictors of eLOS that could help promote risk stratification prior to treatment of UIAs. Future research that identifies predictors of long-term outcomes based on treatment modality could help identify ways to improve healthcare resource utilization in this cohort., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Endovascular treatment with the woven endobridge (WEB) device has been widely utilized for managing intracranial aneurysms. However, predicting the probability of achieving adequate occlusion (Raymond-Roy classification 1 or 2) remains challenging., Objective: Our study sought to develop and validate a predictive calculator for adequate occlusion using the WEB device via data from a large multi-institutional retrospective cohort., Methods: We used data from the WorldWide WEB Consortium, encompassing 356 patients from 30 centers across North America, South America, and Europe. Bivariate and multivariate regression analyses were performed on a variety of demographic and clinical factors, from which predictive factors were selected. Calibration and validation were conducted, with variance inflation factor (VIF) parameters checked for collinearity., Results: A total of 356 patients were included: 124 (34.8%) were male, 108 (30.3%) were elderly (≥65 years), and 118 (33.1%) were current smokers. Mean maximum aneurysm diameter was 7.09 mm (SD 2.71), with 112 (31.5%) having a daughter sac. In the multivariate regression, increasing aneurysm neck size (OR 0.706 [95% CI: 0.535-0.929], p  = 0.13) and partial aneurysm thrombosis (OR 0.135 [95% CI: 0.024-0.681], p  = 0.016) were found to be the only statistically significant variables associated with poorer likelihood of achieving occlusion. The predictive calculator shows a c -statistic of 0.744. Hosmer-Lemeshow goodness-of-fit test indicated a satisfactory model fit with a p -value of 0.431. The calculator is available at: https://neurodx.shinyapps.io/WEBDEVICE/., Conclusion: The predictive calculator offers a substantial contribution to the clinical toolkit for estimating the likelihood of adequate intracranial aneurysm occlusion by WEB device embolization., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The Woven EndoBridge (WEB) device is primarily used for treating wide-neck intracranial bifurcation aneurysms under 10 mm. Limited data exists on its efficacy for large aneurysms. We aim to assess angiographic and clinical outcomes of the WEB device in treating large versus small aneurysms. We conducted a retrospective review of the WorldWide WEB Consortium database, from 2011 to 2022, across 30 academic institutions globally. Propensity score matching (PSM) was employed to compare small and large aneurysms on baseline characteristics. A total of 898 patients were included. There was no significant difference observed in clinical presentations, smoking status, pretreatment mRS, presence of multiple aneurysms, bifurcation location, or prior treatment between the two groups. After PSM, 302 matched pairs showed significantly lower last follow-up adequate occlusion rates (81% vs 90%, p = 0.006) and higher retreatment rates (12% vs 3.6%, p < 0.001) in the large aneurysm group. These findings may inform treatment decisions and patient counseling. Future studies are needed to further explore this area., (© 2024. The Author(s).)

Objective: The paucity of literature comparing Woven EndoBridge (WEB) embolization to microsurgical clipping for anterior circulation wide-neck bifurcation aneurysms (WNBAs) underscores the need for further investigation into the optimal management of this patient subpopulation. The objective of this study was to compare the rate of endovascular and microsurgical treatment of WNBAs before and after the introduction of the WEB device. In addition, the authors performed a comparison of demographics, aneurysm characteristics, and treatment outcomes in patients before and after the introduction of the WEB device., Methods: This study was a retrospective review of the usage rate of different treatment modalities for WNBAs before and after the WEB device was approved by the US FDA on September 27, 2018., Results: The study cohort comprised 235 patients with anterior circulation WNBAs treated at the authors' institution, including 127 aneurysms treated pre-WEB and 108 treated post-WEB. Generally, the rate of endovascular treatment of anterior circulation WNBAs was significantly higher post-WEB (86.1% vs 46.5%, p < 0.001), while the rate of clipping was significantly lower (13.9% vs 53.5%, p < 0.001). During follow-up, the rate of adequate aneurysm occlusion (Raymond-Roy occlusion classification [RROC] grades 1 and 2) was nonsignificantly higher in the post-WEB cohort (83.9% vs 78.5%, p = 0.34), while the rate of RROC grade 3 was nonsignificantly higher in the pre-WEB cohort (21.5% vs 16.1%, p = 0.34). Additionally, and although nonsignificant, the rates of recurrence (pre-WEB 25.3% vs post-WEB 14.9%, p = 0.12) and retreatment (pre-WEB 22.8% vs post-WEB 14.9%, p = 0.22) were higher in the pre-WEB cohort. Recurrence was assessed before retreatment., Conclusions: After the introduction of the WEB device, the rate of endovascular treatment of WNBAs increased while the rate of microsurgical clipping decreased. It is essential for neurointerventionalists to become familiar with the indications, advantages, and shortcomings of all these different techniques to be able to match the right patient with the right technique to produce the best outcome.

Background and Purpose: Despite the numerous studies evaluating the occlusion rates of aneurysms following WEB embolization, there are limited studies identifying predictors of occlusion. Our purpose was to identify predictors of aneurysm occlusion and the need for retreatment., Materials and Methods: This is a review of a prospectively maintained database across 30 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB who had available intraprocedural data and long-term follow-up., Results: We studied 763 patients with a mean age of 59.9 (SD, 11.7) years. Complete aneurysm occlusion was observed in 212/726 (29.2%) cases, and contrast stasis was observed in 485/537 (90.3%) of nonoccluded aneurysms. At the final follow-up, complete occlusion was achieved in 497/763 (65.1%) patients, and retreatment was required for 56/763 (7.3%) patients. On multivariable analysis, history of smoking, maximal aneurysm diameter, and the presence of an aneurysm wall branch were negative predictors of complete occlusion (OR, 0.5, 0.8, and 0.4, respectively). Maximal aneurysm diameter, the presence of an aneurysm wall branch, posterior circulation location, and male sex increase the chances of retreatment (OR, 1.2, 3.8, 3.0, and 2.3 respectively). Intraprocedural occlusion resulted in a 3-fold increase in the long-term occlusion rate and a 5-fold decrease in the retreatment rate ( P < .001), offering a specificity of 87% and a positive predictive value of 85% for long-term occlusion., Conclusions: Intraprocedural occlusion can be used to predict the chance of long-term aneurysm occlusion and the need for retreatment after embolization with a WEB device. Smoking, aneurysm size, and the presence of an aneurysm wall branch are associated with decreased chances of successful treatment., (© 2024 by American Journal of Neuroradiology.)

Objective: This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates., Methods: A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation., Results: The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19-0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25-0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38-10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26-8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04-0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48-230, p = 0.024)., Conclusions: The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.

Background: The emergence of artificial intelligence (AI) has significantly influenced the diagnostic evaluation of stroke and has revolutionized acute stroke care delivery. The scientific evidence evaluating the role of AI, especially in areas of stroke treatment and rehabilitation is limited but continues to accumulate. We performed a systemic review of current scientific evidence evaluating the use of AI in stroke evaluation and care and examined the publication trends during the past decade., Methods: A systematic search of electronic databases was conducted to identify all studies published from 2012 to 2022 that incorporated AI in any aspect of stroke care. Studies not directly relevant to stroke care in the context of AI and duplicate studies were excluded. The level of evidence and publication trends were examined., Results: A total of 623 studies were examined, including 101 reviews (16.2%), 9 meta-analyses (1.4%), 140 original articles on AI methodology (22.5%), 2 case reports (0.3%), 2 case series (0.3%), 31 case-control studies (5%), 277 cohort studies (44.5%), 16 cross-sectional studies (2.6%), and 45 experimental studies (7.2%). The highest published area of AI in stroke was diagnosis (44.1%) and the lowest was rehabilitation (12%). A 10-year trend analysis revealed a significant increase in AI literature in stroke care., Conclusions: Most research on AI is in the diagnostic area of stroke care, with a recent noteworthy trend of increased research focus on stroke treatment and rehabilitation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Cerebral cavernous malformations are complex vascular anomalies in the central nervous system associated with a risk of intracranial hemorrhage. Traditional guidelines have been cautious about the use of antithrombotic therapy in this patient group, citing concerns about potential bleeding risk. However, recent research posits that antithrombotic therapy may actually be beneficial. This study aims to clarify the association between antithrombotic therapy, including antiplatelet and anticoagulant medications, and the risk of intracranial hemorrhage in patients with cerebral cavernous malformations., Methods and Results: A comprehensive literature search was conducted in PubMed, Web of Science, and Scopus databases, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Nine single-center, nonrandomized cohort studies involving 2709 patients were included. Outcomes were analyzed using random-effects model, and a network meta-analysis was conducted for further insight. Of the 2709 patients studied, 388 were on antithrombotic therapy. Patients on antithrombotic therapy had a lower risk of presenting with intracranial hemorrhage (odds ratio [OR], 0.56 [95% CI, 0.45-0.7]; P <0.0001). In addition, the use of antithrombotic therapy was associated with lower risk of intracranial hemorrhage from a cerebral cavernous malformation on follow-up (OR, 0.21 [95% CI, 0.13-0.35]; P <0.0001). A network meta-analysis revealed a nonsignificant OR of 0.73 (95% CI, 0.23-2.56) when antiplatelet therapy was compared with anticoagulant therapy., Conclusions: Our study explores the potential benefits of antithrombotic therapy in cerebral cavernous malformations. Although the analysis suggests a possible role for antithrombotic agents, it is critical to note that the evidence remains preliminary. Fundamental biases in study design, such as ascertainment and assignment bias, limit the weight of our conclusions. Therefore, our findings should be considered hypothesis-generating and not definitive for clinical practice change.

Background: The Woven EndoBridge (WEB) devices have been used for treating wide neck bifurcation aneurysms (WNBAs) with several generational enhancements to improve clinical outcomes. The original device dual-layer (WEB DL) was replaced by a single-layer (WEB SL) device in 2013. This study aimed to compare the effectiveness and safety of these devices in managing intracranial aneurysms., Methods: A multicenter cohort study was conducted, and data from 1,289 patients with intracranial aneurysms treated with either the WEB SL or WEB DL devices were retrospectively analyzed. Propensity score matching was utilized to balance the baseline characteristics between the two groups. Outcomes assessed included immediate occlusion rate, complete occlusion at last follow-up, retreatment rate, device compaction, and aneurysmal rupture., Results: Before propensity score matching, patients treated with the WEB SL had a significantly higher rate of complete occlusion at the last follow-up and a lower rate of retreatment. After matching, there was no significant difference in immediate occlusion rate, retreatment rate, or device compaction between the WEB SL and DL groups. However, the SL group maintained a higher rate of complete occlusion at the final follow-up. Regression analysis showed that SL was associated with higher rates of complete occlusion (OR: 0.19; CI: 0.04 to 0.8, p = 0.029) and lower rates of retreatment (OR: 0.12; CI: 0 to 4.12, p = 0.23)., Conclusion: The WEB SL and DL devices demonstrated similar performances in immediate occlusion rates and retreatment requirements for intracranial aneurysms. The SL device showed a higher rate of complete occlusion at the final follow-up., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objectives: The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care., Methods: This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study., Results: Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01)., Conclusion: In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH., Methods: Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis., Results: Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0)., Conclusion: Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: Over the past several decades, the number of women applying to medical school has increased significantly. However, parallel recruitment and retention of women in the field of neurosurgery continues to lag. The aim of this study was to identify the ratio and trend of female neurosurgery residents to the total number of residents during the past 7 years across all US neurosurgery residency programs., Methods: The authors conducted a cross-sectional demographic study investigating the ratio of female neurosurgery residents to the total number of neurosurgery residents across US neurosurgical programs from 2016 to 2022. Using the Fellowship and Residency Electronic Interactive Database, all neurosurgical residency programs in the US were collected. Data were further divided into postgraduate years 1-7 to dissect the data collection per residency year. One hundred fourteen programs were included in the study., Results: The number of female neurosurgery residents was 71 (29.8%) in 2022, 58 (25.2%) in 2021, 65 (27.9%) in 2020, 62 (27.3%) in 2019, 46 (21.4%) in 2018, 33 (15.2%) in 2017, and 34 (15.9%) in 2016. The trend line showed a significant increase using the Mann-Kendall test (p = 0.035). The total number of international medical graduate (IMG) female neurosurgery residents was 3 (4.2%) in 2022, 4 (6.9%) in 2021, 3 (4.6%) in 2020, 1 (1.6%) in 2019, 1 (2.2%) in 2018, 1 (3%) in 2017, and 2 (5.9%) in 2016., Conclusions: The number of women matching into neurosurgery residency programs is modestly increasing, especially for IMG women. Future steps toward fewer gender disparities should focus on career advancement and leadership diversification in organized and academic neurosurgery.

Background and Importance: Venous sinus stenosis is believed to play a role in the pathogenesis of idiopathic intracranial hypertension (IIH). Venous stenting has emerged as a promising treatment option for patients with IIH because of venous sinus stenosis refractory to medical management or unsuitable for shunt placement. In this technical note, we present a case of IIH with the highest recorded pressure gradient to date., Clinical Presentation: This technical note presents the successful use of intracranial venous stenting in a patient with IIH because of severe venous sinus stenosis, leading to significant improvement in vision and reduction in intracranial pressure. A meticulous review of the literature revealed that our patient exhibited the highest recorded pressure gradient (70 mm Hg). This remarkable finding underscores the potential effectiveness of venous stenting as a viable treatment approach. The procedure involved the placement of a Zilver stent (Cook Medical) and balloon angioplasty after stenting of the right transverse sinus stenosis, resulting in a substantial decrease in pressure gradient. Following the procedure, another venous manometry showed no more gradient with a uniform pressure in the whole venous system at 18 mm Hg., Conclusion: To our knowledge, this case presents the highest pressure gradient reported in the literature and contributes to the growing evidence supporting venous stenting in patients with IIH and venous sinus stenosis., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background and Objectives: Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms., Methods: This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission., Results: The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission., Conclusion: In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS's have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS's. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS's and were treated with venous stenting., Competing Interests: Declaration of Competing Interest Dr. Gooch is a consultant for Stryker. Dr. Jabbour is a consultant for Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for Medtronic and MicroVention. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort., Methods: Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression., Results: A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression., Conclusions: Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.

Objective: The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity., Methods: This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates., Results: The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts., Conclusions: This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.

Background: Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients., Objective: Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT., Methods: We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT., Results: Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations., Conclusions: MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience., Objective: To assess outcomes of TF vs TR approach for CAS., Methods: This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study., Results: A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts., Conclusion: The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Mechanical thrombectomy is established as standard of care in the management of acute ischemic stroke due to large vessel occlusion and evidence-based guidelines for mechanical thrombectomy have been defined. As research continues to further expand the eligibility criteria for thrombectomy and the number of thrombectomy procedures increase worldwide, there is also growing focus on innovation of thrombectomy devices, procedural techniques, and related outcomes. Thrombectomy primarily involves use of stent retrievers and distal aspiration techniques, but variations and different combinations of techniques have been reported. As this is a rapidly evolving area in stroke management, there is debate as to which, if any, of these techniques leads to improved clinical outcomes over another and there is a lack of data comparing them. In this review, currently published and distinct techniques of mechanical thrombectomy are described methodically along with illustrations to aid in understanding the subtle differences between the techniques. The perceived benefits of each variation are discussed.

Background: Although not a technically difficult operation, cranioplasty is associated with high rates of complications. The optimal timing of cranioplasty to mitigate complications remains the subject of debate., Objective: To report outcomes between patients undergoing cranioplasty at ultra-early (0-6 weeks), intermediate (6 weeks to 6 months), and late (>6 months) time frames. We report a novel craniectomy contour classification (CCC) as a radiographic parameter to assess readiness for cranioplasty., Methods: A single-institution retrospective analysis of patients undergoing cranioplasty was performed. Patients were stratified into ultra-early (within 6 weeks of index craniectomy), intermediate (6 weeks to 6 months), and late (>6 months) cranioplasty cohorts. We have devised CCC scores, A, B, and C, based on radiographic criteria, where A represents those with a sunken brain/flap, B with a normal parenchymal contour, and C with "full" parenchyma., Results: A total of 119 patients were included. There was no significant difference in postcranioplasty complications, including return to operating room ( P = .212), seizures ( P = .556), infection ( P = .140), need for shunting ( P = .204), and deep venous thrombosis ( P = .066), between the cohorts. Univariate logistic regression revealed that ultra-early cranioplasty was significantly associated with higher rate of functional independence at >6 months (odds ratio 4.32, 95% CI 1.39-15.13, P = .015) although this did not persist when adjusting for patient selection features (odds ratio 2.90, 95% CI 0.53-19.03, P = .234)., Conclusion: In appropriately selected patients, ultra-early cranioplasty is not associated with increased rate of postoperative complications and is a viable option. The CCC may help guide decision-making on timing of cranioplasty., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause 10% of strokes annually in the United States. However, treatment remains a challenge with several different stenting options studied in the past with unfavorable results., Objective: To report the 30-day stroke and/or death rate associated with intracranial stent placement for sICAD using Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) and provide a comparison with the results of Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial., Methods: Prospectively maintained databases across 8 stroke centers were used to identify adult patients treated with RO-ZES for sICAD between January 2019 and December 2021. Primary end point was composite of 30-day stroke, intracerebral hemorrhage, and/or death. Propensity score matching was performed using age, hypertension, lipid disorder, cigarette smoking, and symptomatic target vessel to create a matched group for comparison between RO-ZES and the SAMMPRIS medical management and treatment groups (SAMMPRIS percutaneous angioplasty and stenting [S-PTAS])., Results: A total of 132 patients met the inclusion criteria for analysis (mean age: 64.2 years). Mean severity of stenosis was 81.4% (±11.4%). A total of 4 (3.03%) stroke and/or deaths were reported within 30 days of treatment in the RO-ZES group compared with 6.6% in the SAMMPRIS medical management group (OR [odds ratio] 2.26, 95% CI 0.7-9.56, P = .22) and 15.6% in the S-PTAS group (OR 5.9, 95% CI 2.04-23.4, P < .001). Propensity score match analysis of 115 patients in each group demonstrated 30-day stroke and/or death rate of 2.6% in the RO-ZES group and 15.6% in the S-PTAS group (OR 6.88, 95% CI 1.92-37.54, P < .001)., Conclusion: Patients treated with RO-ZES had a relatively low 30-day stroke and/or death rate compared with the S-PTAS group. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine. To compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients., Methods: This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. National Institutes of Health Stroke Scale was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge., Results: The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the modified Rankin scale score was significantly lower in the vaccinated cohort (3[1-4] vs. 4[2-5], odds ratio = 0.508, P = 0.011). At 3 months of follow-up, the median modified Rankin scale score was comparable between both cohorts., Conclusions: Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic., (Copyright © 2022 Elsevier Inc. All rights reserved.)