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Background Flow diversion (FD) has emerged as an effective treatment option for intracranial aneurysms. However, there is limited evidence regarding its safety and efficacy specifically for distal and small‐artery aneurysms of the posterior circulation. This study aimed to investigate the outcomes of FD for aneurysms arising from the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and the P2 and P3 segments of the posterior cerebral artery. Methods This is a subanalysis of the Post‐FD (Posterior Circulation Aneurysms Treated With Flow Diversion) registry, highlighting distal aneurysms in the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and the P2 and P3 segments of the posterior cerebral artery treated with FD. Aneurysm characteristics and patient outcomes were described for the total series, and a more focused analysis comparing fusiform/dissecting versus saccular aneurysms was performed. The primary treatment outcome was complete aneurysm occlusion (Raymond–Roy class 1). Primary safety outcome was major ischemic/hemorrhagic stroke following FD. Secondary outcomes included functional outcome, aneurysm retreatment, and in‐stent stenosis. Results Overall, 36 patients with 36 aneurysms were treated with FD, with a median age of 60.0 years (interquartile range [IQR], 52.8—65.3 years). Of those, 13 were fusiform/dissecting, while 23 were saccular aneurysms. Complete occlusion was achieved in 78.1% for all aneurysms at a median follow‐up of 14.0 months (IQR, 9.3–48.6 months). There was a nonsignificant trend in rates of complete occlusion between fusiform/dissecting (91.7%) and saccular aneurysms (70%; P = 0.151). Major stroke was reported in 2 cases (5.6%) and in‐stent stenosis in 4 (11.1%), and retreatment was required for 4 aneurysms (11.4%) There was no difference in rates of major stroke, in‐stent stenosis, or retreatment between fusiform/dissecting and saccular aneurysms. Conclusion This study suggests the safety and feasibility of FD for distal aneurysms of the posterior circulation, particularly fusiform/dissecting aneurysms. Further larger‐scale studies are warranted to confirm these findings.

Background Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large‐bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large‐bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN [Society of Vascular Interventional Neurology] Registry) treated with stand‐alone contact aspiration for the first pass in the middle cerebral artery M1 or intracranial internal carotid artery occlusions from 2012 to 2021. Catheters were stratified on the basis of construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first‐pass effect (first‐pass eTICI 2c–3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first‐pass technique. First‐pass effect was observed in 34% and associated with age (odds ratio [OR], 1.02 [95% CI, 1.01–1.03]), cardioembolic stroke pathogenesis (OR, 1.69 [95% CI, 1.77–2.41]), middle cerebral artery M1 (OR, 2.74 [95% CI, 1.09–1.87]), nongeneral anesthesia (OR, 0.55 [95% CI, 0.39–0.767]), as well as with 0.070‐inch (OR, 2.04 95% CI, 1.01–3.78]), and 0.088‐inch (OR, 3.90 [95% CI, 1.58–9.61]) distal catheter inner diameter in the adjusted analysis. Mean time from arterial access to clot contact was 17 minutes, with faster times observed in younger patients (OR, 0.99 [95% CI, 0.98–0.996]) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18–30 cm) on multivariable regression (OR, 0.30 [95% CI, 0.11–0.82]). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of first‐pass effect. Aspiration catheter construction components were found to influence times from arterial access to clot contact.

Introduction Choice of anesthesia for endovascular thrombectomy in large vessel occlusion of the anterior circulation has been well studied, although practice patterns may still be variable. Anesthesia choice for distal vessel occlusions (DVO) presents unique challenges, however. General anesthesia (GA) may offer advantages over conscious sedation (CS) due to reduced patient movement facilitating catheter navigation, but concerns persist about potential delays and hypotension impacting collateral circulation. In our study, we aim to explore this question further. Methods In our prospectively maintained stroke registry from December 2014 to July 2023, we identified patients with DMVO defined as M2, M3, M4 occlusion, ACA occlusion, and PCA occlusion, who underwent MT for AIS. We compared patients who received CS to those who GA. Our primary outcome measures were length of procedure defined as time from entering angiography suite until final recanalization, access time to recanalization, CS to GA conversion rate, number of passes to reach TICI2b or better and first pass effect. Our secondary outcomes were length of stay, and modified Rankin Scale (mRS) at 5 days, 30 days, and 90 days. Results Total of 290 patients with DVO were identified, the median age was 73 (IQR 19). Of these, 86 patients (29.7%) underwent GA, and 200 (69.0%) received CS. CS to GA conversion was required in 36 patients (12.4%). Females accounted for 47.5% of the CS group and 38.4% of the GA group. No significant differences were found between the two groups in the racial and gender composition (p>0.1). The mean admission NIHSS was significantly higher in the GA group (16.86) compared to the CS group (12.44) as was the rate of IV thrombolysis in the CS (36.2%) group compared to GA (31.4%) group (p

Introduction Tandem Lesions (TLs) pose unique challenges in the endovascular management of acute ischemic stroke.(1) The absence of anterograde blood flow in the carotid occluded segment may limit the effectiveness of endovascular interventions, resulting in delayed reperfusion or suboptimal recanalization.(2,3) Thus, the presence of unpaired blood flow through the ICA in the context of TLs is believed to exacerbate the extension of ischemic lesions. (4,5) This study compared the clinical and procedural outcomes of patients with TLs and extracranial internal carotid artery occlusion versus those with stenosis. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups: those with extracranial ICA stenosis and those with occlusion. Clinical outcomes, including functional independence, hemorrhagic events, and procedural time metrics including puncture to reperfusion time were assessed. Sensitivity analyses were conducted to evaluate these differences segregating patients according to varying degrees of stenosis, and in pre‐specified subgroups. Results A total of 513 patients with TLs were included in the study. 281 (54.8%) presented with ICA occlusion, and 232 (45.2%) presented stenosis >=70% (Table 1). The comparison between the stenosis and occlusion groups revealed no significant differences in the main outcomes, including mTICI 2c‐3 (47.5% vs. 50.6%, aOR 1.07, 95% CI 0.70‐1.64, p=.751) (Figure 1), mRS 0‐2 at 90 days (43.6% vs. 48.9%, aOR 0.79, 95% CI 0.52‐1.20, p=.271), sICH rates (4.7% vs. 5.6%, aOR 0.72, 95% CI 0.31‐1.71, p=.458), and puncture to reperfusion time (58 [40‐80.5] vs. 52.5 [35.2‐80], ratio 1.04, 95% CI 0.88‐1.23, p=.64). Similar analyses performed comparing different degrees of stenosis and occlusion, and in patients treated with the antegrade approach only, did not show significant differences either. Conclusion Our findings indicate that although more severe degrees of stenosis or occlusion of the ICA prolong the time from puncture to reperfusion, no significant differences in clinical outcomes exist. The clinical implications of these findings need to be further evaluated to fully comprehend the specific needs of patients affected by TLs.

Introduction Flow diverters have demonstrated reliable safety and effectiveness for the treatment of selected anterior circulation intracranial aneurysms. However, posterior circulation aneurysms comprise around 10‐15% of all aneurysms, and they frequently present atypical morphological and anatomical characteristics. Furthermore, these lesions have an increased risk of rupture (compared to those in the anterior circulation) with respect to size and higher treatment risks (regardless of the technique). Flow diversion in posterior circulation aneurysms has been described previously with inconsistent clinical and radiological results. Hence, we aimed to compare the safety and effectiveness of FDs in fusiform/dissecting vs. saccular aneurysms located in the vertebrobasilar vessels. Methods We performed a multicenter, retrospective cohort study including 9 centers. All patients treated with FDs for aneurysms located in the posterior circulation (vertebral and basilar arteries) between 2015 and 2022 were included. Patients were divided into two groups according to the morphology of the aneurysm (fusiform/dissecting vs. saccular). The effectiveness outcome was complete aneurysm occlusion (Raymond‐Roy Class 1) at the latest follow‐up. Safety outcomes included the incidence of ischemic/hemorrhagic and mortality. After adjusting for confounders multivariable logistic regressions were performed to compare outcomes of interest. Results A total of 147 patients with 147 aneurysms were included. The fusiform/dissecting group included 85 cases, while the saccular group 62. The saccular group had older patients (median age: fusiform/dissecting, 55 years [45‐64] vs. saccular, 63 years [51‐70.0]; p=.02). The number of female patients was not different between groups (fusiform/dissecting, 42% vs. saccular, 58%; p=.05). Clinical presentation, comorbidities, modified Fisher, and Hunt and Hess were similar. Baseline modified Rankin Score (mRS) was different (mRS 0‐2: fusiform/dissecting, 84% vs. saccular, 98%; p=.030). Previous endovascular treatment (p=.396) was similar. Aneurysm location (most were in the vertebral artery: fusiform/dissecting, 60% vs. saccular, 42%; p=.009) was different. Median aneurysm size (fusiform/dissecting, 10.0 mm [6.5‐18.8] vs. saccular, 5.9 [3.0‐10.0]; p=1 FD: fusiform/dissecting, 36% vs. saccular, 10%; p=

Introduction Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN Registry) treated with stand‐alone contact aspiration for the first pass in the MCA M1 or intracranial ICA occlusions from 2012‐2021. Catheters were stratified based on construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first pass effect (FPE ‐ first‐pass eTICI2c‐3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first pass technique. FPE was observed in 34% and associated with age (OR:1.016;95%CI:1.006‐1.027), cardioembolic stroke etiology (OR:1.685;95%CI:1.77 ‐2.41), MCA M1(OR:2.737;95%CI:1.091 ‐1.867), non‐general anesthesia (OR:0.546;95%CI:0.389 ‐0.767), as well as with 0.070” (OR:2.038;95%CI:1.099 ‐3.779) and 0.088” (OR:3.899;95%CI:1.582 ‐9.606) distal catheter inner diameter in the adjusted analysis. Median time from arterial access to clot contact was 17 minutes with faster times observed in younger patients (OR:0.986;95%CI:0.975 ‐0.996) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18‐30cm) on multivariable regression (OR:0.303; 95%CI:0.113‐0.816). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of FPE. Aspiration catheters with reduced distal tip hydrophilic coating were associated with faster arterial access to clot contact time.

Introduction There has been a growing body of literature in recent years suggesting the safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) from distal vessel occlusion (DVO). Limited data is available regarding the risks and benefits of EVT in this patient population, especially when comparing the early window (6 hours from LKW) to the extended window (6‐24 hours from LKW). We aim to study this further. Methods We queried our stroke registry, a prospectively maintained database of AIS patients who presented from December 2014 to July 2023, and isolated patients with DVO who underwent EVT. DVO was defined as M2, M3, M4 occlusion, ACA occlusion, and/or PCA occlusion. We then further subdivided this into two groups, patients within the early window, and patients within the extended window. We compared characteristics between these groups using univariate analysis. We additionally performed a multivariable logistic regression analysis adjusted for Alberta Stroke Program Early CT Score (ASPECTS), National Institutes of Health Stroke Scale (NIHSS) score, age, sex, and use of intravenous (IV) thrombolysis to investigate whether or not extended window thrombectomy was associated with worse outcome. Our primary outcomes were modified Rankin Score (mRS) at discharge and at 90 days. Results Total of 290 patients had DVO and underwent EVT. Of these, 214 had all relevant data. 147 (68.7%) underwent EVT in the early window and 67 (31.3%) received EVT in the extended window. Mean age was 72.3 (±14.4). There were more women in the extended window 51.5% vs 44.8% (χ² = 20.57, p‐value < 0.001). No significant difference was observed in the average NIHSS between early (13.7) and extended (13.9) windows (t=‐0.44, p=0.66). Similarly, the median ASPECTS score was comparable between early (9.3) and extended (9.0) windows (t=1.41, p=0.16). As expected, there was a striking difference seen in patients receiving IV thrombolysis between early (54.5%) and extended (4.5%) windows (χ²=48.48, p

Introduction Previous studies did not show a difference in terms of safety and efficacy among first‐line stent retriever (SR), contact aspiration (CA), or combined techniques for proximal large vessel occlusion strokes. However, the optimal reperfusion therapy in patients with primary distal medium vessel occlusion (DMVO) strokes is uncertain. We aimed to compare the clinical and procedural outcomes among first‐line SR, CA and combined techniques in patients with primary DMVO. Methods This is a retrospective analysis of a prospectively maintained database from 14 comprehensive stroke centers in the US and Europe. Patients were included if they had a primary DMVO stroke due to MCA‐M3/M4, ACA‐A1/A2‐3, or PCA‐P1/P2‐3 and underwent mechanical thrombectomy with first‐line SR, CA, or combined technique. The primary outcome was FPE defined as eTICI 2c/3 on the first pass. Secondary outcomes included mFPE defined as eTICI 2b/3 on the first pass, successful reperfusion defined as eTICI 2b/3 at the end of the procedure. Clinical outcomes included 90‐day mRS0‐1 and 90‐day mRS0‐2. Safety measures included procedural complications, symptomatic intracranial hemorrhage (sICH), and 90‐day mortality. The secondary analysis aimed to identify the procedural and clinical outcomes in 3 matched cohorts: (SR vs. CA), (SR vs. combined technique), and (CA vs. combined technique). Results A total of 365 patients were eligible for analysis; 38.1% were female, with a mean age of 69.3 years and a median NIHSS score of 11 [7‐18]. The first‐line SR group consisted of n=74 (20.3%), CA group n=142 (38.9%), and combined technique group n=149 (40.8%). Patients with first‐line SR or combined technique had a lower median NIHSS score, less frequent MCA‐M3 segment occlusion, and less usage of the rescue strategy compared to those with first‐line CA, P

Introduction Tandem lesions (TLs) are present in up to 15% of patients with stroke due to acute large vessel occlusions.(1) Nevertheless, published research on endovascular treatment outcomes in this population is scarce. Although TLs are most commonly of atherosclerotic etiology, some patients present with dissection of the ICA.(2, 3) In this study, we compared the clinical outcomes of TL patients with the two etiologies. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups according to the etiology of the ICA lesion: atherosclerosis and dissection. Patients were matched by baseline characteristics. Clinical outcomes, including recanalization success, functional independence and hemorrhagic events were assessed with multivariable analyses. Results Of 691 patients from the database, 526 met the inclusion criteria of this study. 467 (88.8%) patients presented with atherosclerosis of the ICA, and 59 (11.2%) patients presented dissection. Univariable differences were found in median age (69 y. [IQR 61 ‐ 76] vs. 52 y. [IQR 44 ‐ 63], p

Background Procedural intravenous cangrelor has been proposed as an effective platelet inhibition strategy for stenting in acute ischemic stroke. We aimed to compare the safety profile of low‐dose intravenous cangrelor versus dual oral antiplatelet therapy (DAPT) loading in patients with acute cervical tandem lesions. Methods We retrospectively identified cases from an international multicenter cohort who underwent intraprocedural administration of intravenous cangrelor (15 μg/kg followed by an infusion of 2 μg/kg per min) or DAPT loading during acute tandem lesions intervention. Safety outcomes included rates of symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, and in‐stent thrombosis. Inverse probability of treatment weighting matching was used to reduce confounding. Results From 691 patients, we included 195 patients, 30 of whom received intravenous cangrelor and 165 DAPT. The DAPT regimens were aspirin+clopidogrel (93.3%) or aspirin+ticagrelor (6.6%). After inverse probability of treatment weighting, the patients treated with cangrelor were not at greater odds of symptomatic intracranial hemorrhage (odds ratio [OR], 1.30 [95% CI, 0.09–17.3]; P=0.837), symptomatic intracranial hemorrhage–parenchymal hematoma type 2 (OR, 0.54 [95% CI, 0.05–4.98]; P=0.589), or petechial hemorrhage (OR, 1.11 [95% CI, 0.38–3.28]; P=0.836). Similarly, the rate of in‐stent thrombosis was not significantly different between the 2 groups (1.8% versus 0%; P=0.911). Conclusion Cangrelor at the half dose of the myocardial infarction protocol showed a similar safety profile compared with the commonly used DAPT loading protocols in patients with acute tandem lesions. Further studies with larger samples are warranted to elucidate the safety of antiplatelet therapy in tandem lesions.

Introduction: Artificial intelligence (AI) software is increasingly applied in stroke diagnostics. Viz LVO (large vessel occlusion) is an AI-based software that is FDA-approved for LVO detection in CT angiography (CTA) scans. We sought to investigate differences in transfer times (from peripheral [spoke] to central [hub] hospitals) for LVO patients between spoke hospitals that utilize Viz LVO and those that do not. Methods: In this retrospective cohort study, we used our institutional database to identify all suspected/confirmed LVO-transferred patients from spokes (peripheral hospitals) within and outside of our healthcare system, from January 2020 to December 2021. The “Viz-transfers” group includes all LVO transfers from spokes within our system where Viz LVO is readily available, while the “Non-Viz-transfers” group (control group) is comprised of all LVO transfers from spokes outside our system, without Viz LVO. Primary outcome included all available time metrics from peripheral CTA commencement. Results: In total, 78 patients required a transfer. Despite comparable peripheral hospital door to peripheral hospital CTA times (20.5 [24.3] vs. 32 [45] min, p = 0.28) and transfer (spoke to hub) time (23 [18] vs. 26 [13.5], p = 0.763), all workflow metrics were statistically significantly shorter in the Viz-transfers group. Peripheral CTA to interventional neuroradiology team notification was 12 (16.8) versus 58 (59.5), p < 0.001, and peripheral CTA to peripheral departure was 91.5 (37) versus 122.5 (68.5), p < 0.001. Peripheral arrival to peripheral departure was 116.5 (75.5) versus 169 (126.8), p = 0.002, and peripheral arrival to central arrival was 145 (62.5) versus 207 (97.8), p < 0.001. In addition, peripheral CTA to angiosuite arrival was 121 (41) versus 207 (92.5), p < 0.001, peripheral CTA to arterial puncture was 146 (53) versus 234 (99.8), p < 0.001, and peripheral CTA to recanalization was 198 (25) versus 253.5 (86), p < 0.001. Conclusion: Within our spoke and hub system, Viz LVO significantly decreased all workflow metrics for patients who were transferred from spokes with versus without Viz.

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = < 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Introduction Introduction The role of platelet function testing in patients with intracranial aneurysms undergoing flow diversion remains controversial with limited evidence of its influence on thrombotic outcomes. We report an observational cohort analysis evaluating the association of P2Y12 assay testing with thrombotic events in patients undergoing flow diversion. Methods We performed a retrospective review of our prospectively maintained procedural database to identify patients who underwent flow diversion between January 2020 and July 2022. One physician within our practice never performs P2Y12 assay testing. All other physicians utilize P2Y12 assay testing as part of routine practice. These two different patient cohorts were compared. Acute thrombotic events were our primary outcome. Secondary outcomes included delayed intracerebral hemorrhage, intimal hyperplasia without clinical sequalae, and transient neurologic deficits. Results We identified 150 patients who underwent flow diversion at our institution between January 2020 and July 2022. Median age was 59 years old (Interquartile range (IQR) 49–67), with 113 females (82.5%) and 24 males (17.5%). Out of 150 patients, 93 (62.0%) patients were treated by physicians who performed routine pre and postoperative testing of aspirin and Plavix assays, with subsequent adjustment of antithrombotic dosing accordingly, while 57 patients (38.0%) were treated by the single physician who prescribes aspirin and clopidogrel pre‐operatively without testing. In all, seven out of 150 patients (4.7%) had an acute thrombotic event requiring intraarterial anti‐thrombotic infusion or urgent thrombectomy, or both. Of these, six where from the 93 patient testing cohort (6.5%), and one in 57 patients non‐testing cohort (1.8%) (p = 0.2). Patients who had a thrombotic event were more likely to have underlying atrial fibrillation (28.6% vs 4.9%, p = 0.01) but otherwise had similar demographics, vascular risk factors, maximal aneurysmal diameter, and parent vessel diameter (Table 1). In a multivariable analysis adjusting for age, maximal aneurysm diameter, ruptured aneurysms, and atrial fibrillation, P2Y12 sensitivity assay testing was not significantly associated with acute thrombotic events in aneurysm patients undergoing flow diversion (Odds Ratio (OR) = 0.15, 95% Confidence Interval (CI) = 0.01‐2.67), p = 0.2). Secondary outcomes were also comparable between both groups; transient neurologic deficits were noted in 4/93 in the testing group (4.3%), and 6/57 in the non‐testing group (10%) (p = 0.14), intracranial hemorrhage occurred in only 2 patients, both in the testing group (p = 0.3), and mild intimal hyperplasia was observed in 18.3% in the testing group versus 12.3% in the non‐testing group (p = 0.33). Conclusions Platelet function testing showed no significant correlation with thrombotic events or outcomes in our cohort. The role of platelet function testing remains controversial, albeit widely used in patients undergoing flow diversion of intracranial aneurysms.

Introduction Despite the irrefutable benefit of mechanical thrombectomy for patients with isolated intracranial large vessel occlusions (LVO), the effect of endovascular treatment in patients with tandem lesions remains unclear. In this study from the multi‐center PICASSO registry, we compare efficacy and safety outcomes in TLs patients treated in the early versus late window. Methods In this study, we used the data from the multi‐center PICASSO (Proximal Internal Carotid Artery Acute Stroke Secondary to Tandem Occlusion Thrombectomy) registry. PICASSO collaboration is a retrospective observational registry from 17 stroke centers. We compared efficacy and safety outcomes in TLs patients treated in the early versus late window. Patients were divided into two groups depending on last known well (LKW) to puncture time: Early time‐window group (

Introduction There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Methods Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. Results 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR = 0.57, 95%CI: 0.25‐1.29, p = 0.18), parenchymal hematoma type 2 (OR = 0.61, 95%CI: 0.3‐1.22, p = 0.16), and all‐cause mortality at 90 days (OR = 1.22, 95%CI: 0.66‐2.26, p = 0.52). However, the median puncture‐to‐reperfusion time was higher in AA compared with RA [59 minutes (IQR: 38–92) vs 53.5 minuntes (IQR: 37–87)]. Conclusions The AA and RA approaches for the treatment of tandem occlusions seem to achieve similar efficacy and safety outcomes. These results are consistent with those of a previous multi‐center study. Additionally, and in line with previous research, there is a puncture‐to‐reperfusion time difference between both approaches, which suggests a potential benefit when using the RA. However, further prospective randomized studies are needed to elucidate its benefit in achieving better clinical outcomes.

Introduction The MAGIC Catheter (Balt, Montmorency, France) is a commonly used flow‐directed microcatheter for neuro‐interventions. Despite the MAGIC catheter not having FDA approval for use in pediatric and neonatal populations, our institution has used this catheter off‐label for numerous cases of pediatric arteriovenous malformation (AVM), vein of Galen malformation (VOGM), dural arteriovenous fistula (dAVF), and pial AVF (pAVF). Herein, we outline our practice’s experience with the MAGIC catheter for pediatrics. Methods We reviewed our institutional, quality‐control database for all cases of pediatric, vascular malformation that utilized the MAGIC catheter since its original use in pediatrics at our practice (March 1999) and July 2022. We describe the disease and demographic characteristics of this cohort, frequency of MAGIC catheter use, adjunct supplies, complications, smallest vessels catheterized, and clinical outcomes. Results Over the review period, 99 pediatric patients with AVM(45), VOGM(49), dAVF(3), and pAVF(2) were identified for detailed review. This cohort has collectively undergone 194 procedures. The average age at first procedure with the MAGIC catheter was 4.42 years with a wide variation (SD: 4.56; Range: 0–17.64). The majority of cases using the MAGIC catheter were cerebral angiograms with embolization (190 – 97.9%), though occasionally it was employed for angiography alone (4 – 2.1%). A 4‐Fr Berenstein Catheter was the most common adjunct catheter used during the study period (156/194; 80.4%), though the 5‐Fr Envoy appeared often as well (30/194; 15.5%). Every embolization in the series led to interval‐decrease or cure of the malformation, though five intraprocedural complications were noted in the form of transient decrease neuromonitoring evoked potentials, epidural hematoma due to vessel perforation, and three cases of vessel perforation without long‐term consequence. Periprocedural complications occurred in one patient involving an intraventricular hemorrhage requiring a ventriculoperitoneal shunt. The most common liquid embolic agent used with the MAGIC catheter was nBCA (179/190; 94.2%) with occasional use of Onyx 18, Fibered Coils, Surgi‐Flo, STS, and Ethanol. Of the 67 patients who had a follow‐up available for review, 30 (44.8%) are neurologically intact and clinically well, 19(28.4%) are clinically well with mild symptoms (mild autism spectrum disorder, mild hemiparesis, headaches, mild weakness, post‐hemorrhage/stroke excellent recovery), 9 (13.4%)have experienced moderate to severe symptoms (limb weakness, cranial neuropathies, cognitive delay/deficit, inability to ambulate, seizures), 3 (4.5%) have passed away, and 6 (9.0%) have been lost to follow‐up. Selective catheterization of small vessels was performed among the anterior choroidal, thalamoperforator, posterior choroidal, middle meningeal arteries and superior cerebellar, posterior cerebral, and deep external/internal carotid artery branches, and many others by the MAGIC microcatheter for contrast injection or delivery of embolic agents. Conclusions Flow‐directed microcatheters are a quintessential tool used in the endovascular treatment of cerebrovascular diseases, but few have regulatory approval for use in pediatric populations. The off‐label use of the MAGIC microcatheter has been shown to be safe and effective in pediatric embolization procedures. However, there still remains a technology gap in the development of flow‐directed catheters specifically designed and proportioned for use in pediatric patients.

Introduction: Stroke is a leading cause of morbidity and mortality worldwide, with hemorrhagic strokes accounting for 10–20% of all strokes. Patients presenting with intracerebral hemorrhage (ICH) often face higher rates of mortality and poorer prognosis than those with other stroke types. As ICH treatment relies on in‐hospital neuroimaging findings, one potential barrier in the effective management of ICH includes increased time to ICH detection and treatment, particularly due to delays in imaging interpretation in busy hospitals and emergency departments. Artificial Intelligence (AI) driven software has recently been developed and become commercially available for the detection of Intracranial Hemorrhage (ICH) and Chronic Cerebral Microbleeds (CMBs). Such adjunct tools may enhance patient care by decreasing time to treatment and diagnosis by helping to adjudicate diagnoses in difficult cases. This systematic review aims to describe the current literature surrounding all currently existing AI algorithms for ICH detection with either non‐contrast computed tomography (CT) scans or CMBs detection with magnetic resonance imaging (MRI). Methods: Following PRISMA guidelines, MEDLINE and EMBASE were searched for studies published through March 1st, 2021, and all studies investigating AI algorithms for hemorrhage detection in non‐contrast CT scans or CMBs detection on MRI scans were eligible for inclusion. Any studies focusing on AI for hemorrhage segmentation only, including studies that enrolled patients with hemorrhages only as their study group, were excluded. Extracted data included development methods, training, validation and testing datasets, and accuracy metrics for each algorithm, when available. Meta‐analysis was not conducted due to heterogeneity in reported accuracy metrics and highly variant algorithmic development. The completed protocol is available for review in the PROSPERO registry. Results: After the removal of duplicates, a total of 609 studies were identified and screened. After an initial screening and full text review, 40 studies were included in this review. Of these, 18 tested a 2‐Dimensional (2D) convolutional neural network (CNN) AI algorithm, 3 used a purley 3‐Dimension (3D) CNN, and 2 utilized a hybrid 2D‐3D CNN. Of note, one software was able to identify ICH in the setting of ischemic stroke using MRI scans. Included papers noted the following challenges when developing these AI algorithms: extensive time required to create suitable datasets, the volumetric nature of the imaging exams, fine tuning the system, and focusing on the reduction of false positives. Diagnostic accuracy data was available for 21 of these studies, which reported a mean accuracy of 94.37% and a mean AUC of 0.958. Conclusions: As reported in this study, many AI‐driven software tools have been developed over the last 5 years. These tools have high diagnostic accuracy on average and have the potential to contribute to the diagnosis of ICH or CMBs with expert‐level accuracy. With time to treatment often dependent on time to diagnosis, this AI software may increase both the speed and accuracy of adjudicating diagnoses. Although there have been several obstacles faced by the developers of these algorithms, AI‐driven software is an important frontier for the future of clinical medicine.

Introduction: Flow diversion has established itself as standard treatment of wide complex intracranial aneurysms (IA). Its recognition has been validated with positive occlusion rates and favorable clinical outcomes. The Surpass Streamline (SS) flow diverter (FD) is a braided cobalt/chromium alloy implant with 72 or 96 wires approved by the FDA in 2018. The aim of this study is to determine the safety and efficacy of the SS in a post‐marketing large US cohort. Methods: We performed a multicenter, retrospective study for consecutive patients treated with the SS FD for IA between January 2018 and June 2021 in the United States. Inclusion criteria for participants were: 1. Adults (≥ 18 years) and 2. Treatment with SS FD for IA. Primary safety end point was a major ipsilateral stroke (increase in National Institutes of Health Stroke Scale Score of ≥ 4) or neurological death within 12 months. Primary efficacy was assessed using the 3‐point Raymond‐Roy (RR) occlusion scale on digital subtraction angiography (DSA) at 6‐12‐month follow‐up. Results: A total of 276 patients with 313 aneurysms were enrolled. The median age was 59 years and 199 (72%) were females. The most common comorbidities included hypertension in 156 (57%) subjects followed by hyperlipidemia in 76 (28%) patients. One hundred and twenty‐two (44%) patients were asymptomatic while subarachnoid hemorrhage was present in only 10 (4%) patients. A total of 143 (46%) aneurysms were left‐sided. Aneurysms were located as follows: 274 (88%) were in the anterior circulation with paraophthalmic being the most common in 120 (38%) followed by petrocavernous ICA in 81 (26%); 33 (11%) aneurysms were located in the posterior circulation with basilar trunk being the most common in 14 (5%). The mean maximum aneurysm dome width was 5.77 ± 4.7 mm, neck width 4.22 ± 3.8 mm and dome to neck ratio was 1.63 ± 1.3 mm. The mean number of SS FD implanted per aneurysm was 1.06 (range 1–3) with more than one SS FD implanted in 21 (7%) aneurysms. Modified Rankin Scale (mRS) of 0–2 was present in 206/213 (97%) patients at 6–12 month follow‐up. The complete aneurysm occlusion (RR 1) rate was 145/175 (83%) among subjects who had angiographic follow‐up at 6–12 months. Major stroke and death was encountered in 7 (2%) and 5 (1.8%) of the patients respectively. Conclusions: Our data represent the largest real‐world study using SS FD. These results corroborate its post‐marketing safety and efficacy for the treatment of intracranial aneurysms showing more favorable rates to the initial experience during SCENT trial.