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Introduction Indications for flow diversion for the treatment of cerebral aneurysms have increased remarkably in recent years.1 This has been particularly useful for aneurysms that are difficult to treat via endosaccular or open approaches, such as pseudoaneurysms.2 Flow diversion, however, typically requires dual antiplatelet therapy (DAPT), which can contribute to greater morbidity particularly in patients with ruptured aneurysms or other comorbidities.3 The third‐generation iteration of the Pipeline Embolization Device (PED) incorporates Shield technology, a phosphorylcholine coating designed to reduce thrombogenicity via mimicry of native cell membranes.4 In light of this reduced thrombogenicity, there have been reports of early transition to single antiplatelet therapy (SAPT), or other variations on DAPT, in patients treated with PED Shield. We therefore aim to characterize the antiplatelet regimens, and associated thromboembolic/hemorrhagic outcomes, utilized in patients with aneurysms treated with PED Shield. Methods Factors including demographics, comorbidities, rupture status, devices placed, and antiplatelet regimen, among others, were collected. Follow‐up data including aneurysm thromboembolic complication, hemorrhagic complication, new neurological deficit, aneurysm occlusion, and in‐stent thrombosis were also recorded. Results One‐hundred and eighty patients were included in analysis, 18 of which were acutely ruptured. One hundred and sixty‐two patients had a single device placed, while the remaining had two devices placed. Three patients were maintained on SAPT post‐procedurally (aspirin or clopidogrel), with two additional patients treated with SAPT plus an anticoagulant for other purposes. One hundred and seventy‐two patients were maintained on DAPT, most commonly aspirin/clopidogrel (115), followed by aspirin/ticagrelor (40), and aspirin/prasugrel (16). Seven patients had strokes of any kind, three of which were unrelated to the treatment territory, and two of the remaining 4 were non‐compliant with antiplatelet therapy. One patient had a new intraparenchymal hemorrhage, but no appreciable deficit. Of the 135 patients with 6‐month follow‐up, 77 had complete aneurysm occlusion, and 116 demonstrated no in‐stent thrombosis. Conclusion We demonstrate herein the similar safety profile and efficacy of PED Shield with varying antiplatelet regimens, including SAPT in isolated cases.

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=

This manuscript provides a comprehensive review of intracranial atherosclerosis (ICAS)‐related large‐vessel occlusion (ICAS‐LVO) and its mimics, focusing on the challenges in diagnosis and the need for precise diagnostic methodologies, particularly in the context of endovascular therapy. ICAS‐LVO is a significant contributor to acute ischemic stroke, with varying prevalence rates across regions. ICAS‐LVO is characterized by the presence of residual focal fixed stenosis or reocclusion following endovascular treatment or evidence of distal hypoperfusion or watershed infarction on follow‐up imaging. Despite digital subtraction angiography being the gold standard, diagnosing ICAS‐LVO is complicated by similarities with other occlusive conditions, leading to misdiagnosis and inappropriate interventions. The review explores angiographic mimics of ICAS‐LVO, such as intracranial vasospasm, intracranial dissection, partially occlusive thrombus, and rare vasculopathies like Moyamoya disease, reversible cerebral vasoconstriction syndrome, and vasculitis. Each mimic is meticulously examined, providing insights into their distinctive features, diagnostic considerations, and potential interventions. The manuscript emphasizes the importance of early identification of these mimics to guide appropriate interventions and prevent complications. Future perspectives include the incorporation of advanced imaging tools such as integration of artificial intelligence for automated image analysis, and deployment of advanced imaging techniques such as intravascular ultrasound and optical coherence tomography for a more comprehensive radiographical characterization of ICAS‐LVO. Improved diagnostic criteria and ongoing research will play a pivotal role in addressing the challenges of distinguishing ICAS‐LVO from its mimics.

Background: Chordomas are rare, slow growing, locally aggressive malignant bone tumors that arise from remnants of the embryonic notochord with variable presenting symptoms depending on tumor location. Methods: All patients with craniospinal chordoma managed at our institution between 1982 and 2023 were retrospectively reviewed. Demographics, tumor characteristics, clinical course and treatment, and long-term neurological and survival outcomes were collected. Adjuvant radiotherapy (RT) was stratified into standard dose fractionated radiotherapy (standard XRT) for doses of 50 to 60 Gy at 1.8 Gy fractions or high dose hyperfractionated stereotactic radiotherapy (HD-FSRT) for doses of 60 to 81 Gy at 1.2-1.5 Gy fractions per treatment. Descriptive statistics, univariate analysis, Log-rank test, and Kaplan-Meier survival analysis were performed. Results: A total of 37 patients were included in our cohort (mean age 46.0 ± 20.8 years; 22 male). Clival chordomas accounted for the majority of patients (56.8%), followed by vertebral (27%) and sacral (10.8%) chordomas. Thirty-five patients (94.6%) underwent gross total resection (GTR) or subtotal resection (STR), and 2 patients underwent excisional biopsy only. Postoperatively, functional status trended towards improvement (KPS: Preop- 80 [range 40–100] vs. Post op- 90 [60–100], p = .0911) and all patients either maintained or improved their neurological function. Median overall survival (OS) after diagnosis was 16.5 years. Age < 65, clival tumor location, post-operative Frankel grade E, and administration of adjuvant RT following initial STR significantly improved OS. OS of GTR patients was not significantly affected by adjuvant RT treatment. Conclusions: Our results show the best long-term survival outcomes for chordoma patients undergoing GTR of tumor tissue. Higher postoperative neurological function was significantly associated with OS, highlighting the importance of maximal but safe total tumor resection. Moreover, adjuvant RT improved long-term survival for patients that underwent STR but had no effect on survival outcomes for patients that underwent GTR.

Background and Purpose Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours. Methods This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (

Background When mechanical thrombectomy (MT) fails to achieve successful reperfusion, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess clinical outcomes. We aimed to compare the safety and efficacy of RS versus routine medical management in patients with failed MT using an aggregated meta‐analysis. Methods A systematic review was performed from inception to July 2022 of all studies using RS after failed MT. Outcomes of interest included a modified Rankin scale score of 0–2 at 90 days, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3) after RS and symptomatic intracranial hemorrhage. A random‐effects meta‐analysis between the RS and medical treatment arms was performed to calculate pooled odds ratios (OR) for each outcome. We assessed the certainty of evidence using the Grading of Recommendation, Assessment, Development, and Evaluation approach. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 12 studies included 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a significantly higher proportion of patients with a modified Rankin scale score of 0–2 at 90 days (RS: 41% versus 21%; OR,3.27; [95% CI 2.08–5.16]; I2=64%; moderate‐certainty evidence) and a decreased risk of mortality at 90 days (RS: 22.5% versus 33.8%; OR, 0.47; [95% CI 0.32–0.69]; I2=45%; low‐certainty evidence), compared with medical treatment after failed MT. The pooled rate of successful reperfusion after RS was 87% (95% CI 82–91; I2=57%; low‐certainty evidence). The rate of symptomatic intracranial hemorrhage did not differ between groups (RS: 8.5% versus 11.7%; OR, 0.85; [95% CI 0.59–1.20]; I2=7%; low‐certainty evidence). Conclusion RS is a promising strategy for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, randomized trials using a standardized approach/technique and MT failure definition are warranted to confirm these results.

Introduction The management of wide‐necked bifurcation aneurysms can be challenging due to multiple factors. Intrasaccular flow disruption with the Woven EndoBridge (WEB) has demonstrated a safe and effective profile. Current microemboli data after the WEB device placement is non‐existent. We evaluated the rate of embolic signals (MES) after WEB device implantation. Methods We performed a retrospective analysis of a prospectively maintained database including patients who underwent WEB device implantation for the treatment of unruptured intracranial aneurysms between 2021 and 2022. Variables studied included patient demographics, modified Rankin Scale (mRS) before and 3 months post‐treatment, comorbidities, aneurysm characteristics, platelet inhibition tests, and activated clotting time. All patients were on aspirin and a P2Y12 inhibitor and had therapeutic levels on platelet aggregation assays. Intraoperative heparin was given in all cases to keep a therapeutic ACT. P2Y12 drugs were stopped after the procedure. In all patients, MES monitoring was performed in the immediate postoperative period and >12 hours after the procedure. Results 34 patients with 34 aneurysms were analyzed. Mean age was 67.4 years and 85% were females. Mean aneurysm size was 13.1 ± 2.0 mm and mean neck size 4.4 ± 1.5 mm. Locations were middle cerebral artery bifurcation and M1‐M2 segment (n = 13), basilar artery tip (n = 10), anterior communicating artery (n = 8), internal carotid artery terminus (n = 2) and pericallosal artery (n = 1). A single WEB was implanted in 100% of the cases. MES were negative in all cases. 3‐month mRS remained stable or improved in all cases. No procedure‐related complications were seen. Conclusions Our findings reinforce the safety profile of intrasaccular flow disruption. These findings differ from a previous analysis of unruptured aneurysms in our institution where a 7.7% incidence of MES was reported after endovascular treatment of unruptured aneurysms with primary or assisted coiling.

Introduction Actual guidelines offer little guidance for endovascular treatment of patients with acute ischemic stroke (AIS) and pre‐morbid disability (PMD). Often, patients with a mRS >2 are not considered for mechanical thrombectomy (MT) and might not be given the best chance of achieving recovery. Three recent meta‐analysis have showed conflicting results regarding the benefit of MT, while persistently showing a significant increase in mortality. Methods We conducted a systematic search in Embase, Medline, and Web of Science for studies of patients with AIS and PMD who were treated with MT or MM. We included all definitions of PMD, main outcomes were favorable functionality at 90‐days (mRS 0–2 or return to baseline mRS), symptomatic ICH, and mortality. We performed meta‐analyses using a random‐effect model, and I2 to evaluate heterogeneity. Subgroup analyses were used when appropriate. Results 2 studies contained data comparing PMD patients treated with MT versus MM, 14 studies contained data only of patients treated with MT, and 10 only of patients treated with MM; they provided data of 1071 patients in the MT group and 4547 in the MM group. Pooled rates in the MT group were 28% (95% CI 0.24‐0.32) for favorable functionality, 7% (95% CI 0.04‐0.12) for sICH, 43% (95% CI 0.36‐0.51) for 90‐days mortality, 18% (95% CI 0.14‐0.23) for intra‐hospital mortality, and pooled reperfusion rate (mTICI 0–2) of 80% (95% CI 0.72‐0.86). In a meta‐analysis of proportion with the treatments modalities as subgroups, including only studies with a similar definition of PMD, we obtained: for favorable functionality, MT = 26% (95% CI 0.23‐0.30) vs. MM = 35% (95% CI 0.22‐0.51); for sICH, MT = 6% (95% CI 0.05‐0.08) vs. MM = 6% (95% CI 0.05‐0.08); for 90‐days mortality, MT = 48% (95% CI 0.44‐0.52) vs. MM = 34% (95% CI 0.27‐0.41); and for in‐hospital mortality, MT = 18% (95% CI 0.14‐0.23) vs. MM = 22% (95% CI 0.17‐0.28). Additionally, meta‐analysis for 90‐days mortality in MT studies, showed a pooled rate of 49% (95% CI 0.45‐0.53) for the high tPA rate subgroup, and 30% (95% CI 0.19‐0.44) for the low tPA rate subgroup. Conclusions Up to one third of PMD patients who undergo MT might achieve favorable functionality, without increasing the risk of sICH and with rates similar to those obtained with MM. Furthermore, we observed a high 90‐day mortality rate, in both MT and MM groups. In subgroups exploration, there is trend of high tPA rates to be associated with the increased mortality. It is urgent to identify PMD patients who will benefit from MT and factors associated with poor outcomes.

Introduction Improvements in the safety and efficacy of curative embolization for brain arteriovenous malformations (bAVMs) have allowed to achieve comparable results to microsurgical resection and radiosurgery, especially for low‐grade bAVMs (Spetzler Martin [SM] grade I and II). However, whether this treatment modality is beneficial in the pediatric population remains unknown. Hence, we assessed the safety and efficacy of curative embolization for low‐grade bAVMs in children. In addition, we determined predictors of intraprocedural complications and predictors of complete occlusion in one embolization session. Methods Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for low‐grade bAVMs was conducted at two institutions. Demographic data, clinical presentation, SM grade, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Multivariable logistic regression analysis was performed to identify potential predictive factors of intraprocedural complications and complete occlusion in one session. For selected variables, odds ratios (OR) with 95% confidence intervals (CI) and p value of the likelihood‐ratio test were presented. Results Sixty‐eight patients (41 females; mean age 12.9 ± 3.6 years) underwent a total of 102 embolization sessions. Fifty‐one bAVMs (75%) presented ruptured, and headache was the most common clinical presentation (50%). There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Onyx was the most used embolic agent (33%) and the transarterial approach was the most common (93%). The mean volume of embolic agents in each patient was 2.4 ml (range 0.2 to 7.5 ml). Fourteen intraprocedural complications (14% of procedures) were observed and no deaths were reported. The most common complication was microcatheter‐related vessel perforation (6%). Single venous drainage decreased the risk of intraprocedural complications (OR = 0.19; 95% CI 0.04 – 0.78). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (52%) the bAVM was occluded with a single session. A small bAVM size was predictor of complete occlusion in one session (OR = 0.42; 95% CI 0.21 – 0.73). Conclusions Curative embolization in pediatric low‐grade bAVMs can be performed with an acceptable complete occlusion rate but with a high rate of intraprocedural complications. The risk of intraprocedural complications was low in bAVMs with a single venous drainage. The odds of complete occlusion in one session are high in small bAVMs. Curative embolization should be selected on an individual basis in order to achieve optimal results.

Introduction The safe and effective profile of flow diverters (FD) has allowed neuro‐interventionalists to consider them as a versatile tool for the treatment of aneurysms with different morphologies, locations, and characteristics. Optimal deployment with complete wall apposition affects FD performance. However, few devices are suitable for aneurysms in large caliber vessels. Herein, we aimed to describe the safety and efficacy of a large caliber (5 mm) FD for the treatment of intracranial aneurysms. Methods We performed a retrospective, multi‐center cohort study of adult patients in whom a 5 mm Surpass Streamline FD was implanted between 2018 and 2021 in the United States. Efficacy outcome was complete occlusion at final follow‐up. Safety outcomes were ischemic/hemorrhagic events and mortality up to 30 days following the procedure. Secondary safety was assessed by the rate of adjunctive devices/treatments to overcome technical complications and improve wall apposition. Results A total of 29 patients harboring 29 aneurysms were treated with 39 FDs (36 large‐diameter devices). Mean age was 57.8 ± 15.7 years. Aneurysm morphologies were saccular (n = 15), pseudoaneurysm (n = 7), fusiform (n = 6), and dissecting (n = 1). Locations were internal carotid artery (ICA) petro‐cavernous segment (n = 15), ICA paraophthalmic (n = 5), ICA cervical (n = 4), basilar artery (n = 3), and vertebral artery (n = 2). Aneurysm size mean was 11.4 ± 6.7 mm, and neck size mean 6.5 ± 3.9 mm. Proximal FD landing zone vessel diameter was 4.8 ± 1.3 mm and distal 4.5 ± 1.2 mm. At a mean final follow‐up of 12 ± 6 months, 18 (65%) aneurysms were completely occluded. Ischemic/hemorrhagic events occurred in 2 (7%), and 1 patient died during hospitalization. Balloon‐assisted angioplasty was performed in 19 (66%) cases, adjunctive stenting in 8 (28%), and coiling in 1 (3%). Patients who received an adjunctive device/treatment had an 82% (14/17) complete occlusion compared to 66% (4/6) in those who did not. Conclusions The use of large caliber FDs to treat complex intracranial aneurysms located in large‐diameter dysplastic vessels is technically feasible and safe. The use of adjunctive devices and techniques to achieve optimal wall apposition seems crucial to optimize treatment outcomes. Comparative studies with devices specially designed for this patient population might provide further insights into the best device selection.

Introduction Posterior communicating artery (PComA) aneurysms are common and have a high risk of rupture. Flow diverters (FD) have demonstrated a safe and effective profile. However, the use of FD in PComA aneurysms has shown controversial results with high rates of recurrence and a high risk of potential ischemic complications. There, we aimed to evaluate the safety and efficacy of flow diversion for the treatment of PComA aneurysms with a meta‐analysis of the literature. Methods We performed a systematic search in Scopus, Embase, Medline, and Web of Science from inception until May 2022 for all the studies that reported the safety and effectiveness of FD for the treatment of intracranial aneurysms located in the posterior communicating artery. The primary effectiveness endpoint was a complete aneurysm occlusion rate at final follow‐up. The primary safety endpoint was a composite measure of cumulative events that occurred during and after the procedure. Events included death and ischemic/hemorrhagic complications. Random‐effects meta‐analysis was used to calculate proportions. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 13 studies with 397 patients harboring 403 aneurysms were included in our analysis. Mean age was 48 years and mean aneurysm size was 5.3 mm. Complete aneurysm occlusion at final follow‐up was 74% (95% CI 66–81%; I2 = 54%). The primary safety composite outcome was 5% (95% CI 3–9%; I2 = 0%). The mortality rate was 1% (95% CI 0–2%; I2 = 0%). Subgroup analysis showed that patients with a non‐fetal PComA had a higher rate (76%; 95% CI 62%‐86%; I2 = 53%) of complete aneurysm occlusion compared to those with a fetal PComA (36%; 95% CI 21%‐54%; I2 = 0%). Conclusions Our findings show that flow diversion for the treatment of aneurysms located in the PComA is effective and safe. However, the same treatment for aneurysms located in a fetal‐type PComA did not show the same efficacy profile suggesting that these cases might require an alternative treatment to achieve permanent occlusion rates.

Introduction Following the favorable clinical and radiographical results of flow diversion, its use has continually expanded for the treatment of complex intracranial aneurysms. The high metal surface of flow diverters (FD) increases the risk of thromboembolic complications. Current emboli monitoring data after FD placement is limited. Transcranial doppler (TCD) offers a non‐invasive evaluation of microembolic signals and might be a valuable tool to prevent ischemic complications. We evaluated the rate of embolic signals and their management after FD implantation. Methods We performed a retrospective, single‐center evaluation of adult patients who underwent a FD procedure with the Pipeline Embolization Device (PED) for unruptured intracranial aneurysms between 2012 and 2016. Covariates included patient demographics, comorbidities, aneurysm characteristics, procedure characteristics, and post‐procedure TCD emboli monitoring (immediate and >12 hours post‐operative). TCD emboli signals were classified as positive (< 15 microembolic signals) and strongly positive (>15 signals). The primary outcome was the rate of symptomatic stroke at 2 and 12 weeks in these patients. Results 105 patients with 132 aneurysms were analyzed. Mean age was 59.7 years, and 78% were females. Mean aneurysm size was 7.8 ± 6.4 mm. Most of them were located in the paraclinoid region (40%). Two PEDs were implanted in 12 (11%) cases and adjunctive coiling was performed in 15 (14%) cases. Microemboli were detected in 11.4% of cases (12/105 patients) after PED deployment. In 5/12 patients, the emboli resolved upon repeat testing with no intervention. In 6/12 patients, further heparinization, additional clopidogrel administration, or change in antiplatelet agents were needed. These treatments reduced the microembolic events. In 1 patient who was clopidogrel‐resistant and a ticagrelor super‐responder, mechanical thrombectomy was necessary due to acute in‐stent thrombosis. There were no symptomatic strokes at 2 and 12 weeks. Conclusions TCD emboli monitoring can be a powerful non‐invasive tool for the early identification and prevention of thromboembolic events after FD implantation. Early detection of microembolic signals offers the possibility to modify postoperative management, avoid silent emboli, and potentially avoid symptomatic strokes.

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 Paraclinoid aneurysms (PAs) have traditionally been treated with clipping. However, with the emergence of new techniques, endovascular treatment (EVT) has supplanted surgical treatment in recent years. We aimed to determine the safety and efficacy of EVT and microsurgical clipping for PAs. Methods A systematic review was performed in Scopus, Embase, Medline, Web of Science, and Cochrane from inception to March 2022 for all studies that tested the safety and efficacy of EVT or microsurgical clipping of PAs. Efficacy outcomes included complete aneurysm occlusion at last follow‐up, immediate complete occlusion, and an mRS 0–2 at last follow‐up. Safety outcomes included mortality, intraoperative and postoperative complications. We performed a random‐effects meta‐analysis of proportions and assessed the statistical heterogeneity across studies with I2 statistics. Results Eighty‐nine studies included 6496 patients, 3682 treated with EVT and 2814 with microsurgical clipping. Immediate complete occlusion rates were 92% (95% CI 88 – 96%; I2 = 60%) and 46% (95% CI 34 – 59%; I2 = 93%) for clipping and EVT, respectively. The rate of complete occlusion at last follow‐up was 94% (95% CI 91 – 96%; I2 = 0%) and 69% (95% CI 63 – 74%; I2 = 79%) for microsurgical clipping and EVT, respectively. Among EVT studies, the rate of complete occlusion was 54% (95% CI 48 – 59%; I2 = 50%), 52% (95% CI 39 – 64%; I2 = 73%), and 77% (95% CI 54 – 91%; I2 = 91%) for primary coiling, stent‐assisted coiling, and flow diversion, respectively. Among clipping studies, the rate of last follow‐up mRS 0–2 was 86% (95% CI 76 – 92%; I2 = 72%). Among EVT studies, the rate of last follow‐up mRS 0–2 was 94% (95% CI 86 – 98%; I2 = 93%). Mortality rate was 4% (95% CI 3 – 7%; I2 = 57%) and 1% (95% CI 0 – 3%; I2 = 0%) for clipping and EVT, respectively. Among EVT studies, the mortality rate was 3% (95% CI 1 – 6%; I2 = 0%) and 3% (95% CI 1 – 9%; I2 = 39%) for primary coiling and flow diversion, respectively. Intraoperative and postoperative complications were present in 9% (95% CI 6 – 14%; I2 = 68%) and 21% (95% CI 17 – 26%; I2 = 87%) among clipping studies, respectively. Intraoperative and postoperative complications were present in 6% (95% CI 4 – 9%; I2 = 64%) and 9% (95% CI 6 – 13%; I2 = 72%) among EVT studies, respectively. Conclusions In conclusion, microsurgical clipping and EVT for PAs are both safe and effective treatment modalities. Treatment via either approach should be determined on a case‐by‐case basis and according to institutional experience and resources.

Introduction The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature. Methods We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion. Results Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion. Conclusions The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.

Introduction Flow diverters (FDs) have demonstrated a safe and effective profile for the treatment of intracranial aneurysms with complex morphologies and variable anatomic locations. However, aneurysmal persistence after flow diversion still presents in up to 25% of treated aneurysms. Herein, we aimed to perform a pooled analysis of two large studies (SCENT [Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Neck Wide Neck Aneurysms] and SESSIA [Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms]) to evaluate the predictors of occlusion at final follow‐up after treatment with a 72–96 wire device. Methods We pooled all data from the SCENT (prospective) and SESSIA (retrospective) studies that included patients treated with the Surpass Streamline. From the studies, a subset of patients with unruptured saccular aneurysms located in the internal carotid artery (ICA) up to its terminus were included. The authors collected baseline demographics, comorbidities, aneurysm dimensions, and procedural and follow‐up characteristics for each patient. For our analysis, the outcome was complete aneurysm occlusion, as reported by the studies. We performed a multivariable logistic regression to identify the predictors of complete occlusion. Next, we performed a mediation analysis framework to identify the causal relationship of the predictors with the outcome. Finally, we calculated the predicted probability of occlusion for the continuous predictors. Results A total of 348 patients with 348 aneurysms were included, 394 devices were implanted (1.13 per patient). Median age was 61 [22‐85] years, and 83.6% were females. Hypertension was the most common comorbidity (57%) followed by hyperlipidemia (36%). The ICA paraophthalmic segment was the most common location (45%), followed by the petrocavernous (29%) and supraclinoid (25%). Median aneurysm size was 7.5 [1‐29] mm, and neck size was 4.3 [1‐23] mm. At the final follow‐up, the complete occlusion rate was 73% (255/348). After adjusting for confounders and accounting for collinearity, the multivariable analysis identified aneurysm size (OR 0.89; 95% CI 0.85‐0.93;p< .001), procedural technical events (OR 0.31; 95% CI 0.15‐0.65;p = .002), and first device length (OR 0.98; 95% CI 0.96‐1.00;p = .036) as predictors of complete occlusion. Age had a non‐significant direct effect on complete occlusion (p = .091) but a significant indirect effect mediated through aneurysm size (p< .001) and technical events (p< .02). Using our model, the predicted probability of occlusion is≥ 75% in aneurysms measuring < 10 mm when no technical events are encountered. However, when technical events are encountered, the probability decreases to 50–75%. Conclusions Successful aneurysm occlusion after flow diversion is associated with aneurysm size, procedural technical events, and FD length. Age does not directly affect occlusion, but its influence is mediated through the aneurysm size and technical events. Therefore, a priori knowledge of the patient and aneurysm characteristics might guide FD selection to favor the best treatment outcomes.

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 The incidence of ruptured cerebral arteriovenous malformations (AVMs) has increased as a consequence of the publication of the ARUBA trial. In the setting of ruptured AVMs, target embolization of high‐risk features can be considered to decrease the risk for recurrent hemorrhage. However, embolization with the intention to cure has not been well studied in ruptured AVMs. Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization for ruptured AVMs in pediatric patients. Methods Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for ruptured AVMs was conducted in two institutions. Demographic data, clinical presentation, Spetzler‐Martin (SM) grade, associated high‐risk vascular structures, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Results Sixty‐eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. The most frequent clinical presentation was headache (79%). There were 15 (22%) SM grade I lesions, 34 (51%) grade II, 14 (21%) grade III, and 4 (6%) grade IV. In 21 patients, twenty‐three high‐risk structures were observed (3 prenidal aneurysms, 12 intranidal aneurysms, 3 venous aneurysms, 2 varicose veins, 3 arteriovenous fistulae). Decompressive craniectomy with intracerebral hemorrhage evacuation was performed in 15 patients (22%). The mean number of sessions per patient was 1.6 (range 1 to 6) and n‐butyl cyanoacrylate was the most used embolic agent (30%). The transarterial approach was the most common (91%). The mean volume of embolic agents in each patient was 2.1 ml (range 0.1 to 6 ml). Seventeen intraprocedural complications (16% of procedures) were observed and no deaths were reported. In patients with high‐risk structures the rate of intraprocedural complications was 24%. The most common complication was microcatheter‐related vessel perforation (7%). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. The rate of complete obliteration in patients with high‐risk structures was 62%. Conclusions Curative embolization of ruptured pediatric AVMs shows a high rate of intraprocedural complications, especially when high‐risk associated vascular structures are present. In addition, acceptable complete obliteration rates were found. Appropriate long‐term follow‐up in prospective studies tailored to the pediatric population are required to determine the best therapeutic approach.

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.

Flow diversion is an evolving endovascular modality for treating intracranial aneurysms. Although rare, serious adverse events following flow diversion may include ischemic stroke, intracranial hemorrhage, or delayed rupture of the treated aneurysm. This dataset describes 141 flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, or Surpass Streamline on 126 subjects with intracranial aneurysms [1]. The retrospective data were collected from electronic medical records at two large tertiary centers. Baseline patient data included age, sex, and medical comorbidities. The dataset also describes aneurysm characteristics including laterality, anatomic location, morphology, dome height, and neck width. In addition, digital subtraction images showing the internal carotid artery tortuosity were included for aneurysms in the anterior cerebral circulation [2]. Procedural data include case duration, radiation exposure, number of flow diverters deployed, and complications encountered during deployment. In addition, data related to the duration of hospitalization and postoperative adverse events are included. Finally, time to follow up and rates of total aneurysm obliteration at first and second postoperative visits are included. This data is propensity score matching are included. This data is presented as a starting point for future prospective comparisons in the safety and efficacy of flow diverters as more devices become approved and commercially available.

In stroke care, the extent of irreversible brain injury, termed infarct core, plays a key role in determining eligibility for acute treatments, such as intravenous thrombolysis and endovascular reperfusion therapies. Many of the pivotal randomized clinical trials testing those therapies used MRI Diffusion-Weighted Imaging (DWI) or CT Perfusion (CTP) to define infarct core. Unfortunately, these modalities are not available 24/7 outside of large stroke centers. As such, there is a need for accurate infarct core determination using faster and more widely available imaging modalities including Non-Contrast CT (NCCT) and CT Angiography (CTA).Prior studies have suggested that CTA provides improved predictions of infarct core relative to NCCT; however, this assertion has never been numerically quantified by automatic medical image computing pipelines using acquisition protocols not confounded by different scanner manufacturers, or other protocol settings such as exposure times, kilovoltage peak, or imprecision due to contrast bolus delays. In addition, single-phase CTA protocols are at present designed to optimize contrast opacification in the arterial phase. This approach works well to maximize the sensitivity to detect vessel occlusions, however, it may not be the ideal timing to enhance the ischemic infarct core signal (ICS).In this work, we propose an image analysis pipeline on CT-based images of 88 acute ischemic stroke (AIS) patients drawn from a single dynamic acquisition protocol acquired at the acute ischemic phase. We use the first scan at the time of the dynamic acquisition as a proxy for NCCT, and the rest of the scans as a proxy for CTA scans, with bolus imaged at different brain enhancement phases. Thus, we use the terms “NCCT” and “CTA” to refer to them. This pipeline enables us to answer the questions “Does the injection of bolus enhance the infarct core signal?” and “What is the ideal bolus timing to enhance the infarct core signal?” without being influenced by aforementioned factors such as scanner model, acquisition settings, contrast bolus delay, and human reader errors. We use reference MRI DWI images acquired after successful recanalization acting as our gold standard for infarct core.The ICS is quantified by calculating the difference in intensity distribution between the infarct core region and its symmetrical healthy counterpart on the contralateral hemisphere of the brain using a metric derived from information theory, the Kullback-Leibler divergence (KL divergence). We compare the ICS provided by NCCT and CTA and retrieve the optimal timing of CTA bolus to maximize the ICS.In our experiments, we numerically confirm that CTAs provide greater ICS compared to NCCT. Then, we find that, on average, the ideal CTA acquisition time to maximize the ICS is not the current target of standard CTA protocols, i.e., during the peak of arterial enhancement, but a few seconds afterward (median of 3 s; 95% CI [1.5, 3.0]). While there are other studies comparing the prediction potential of ischemic infarct core from NCCT and CTA images, to the best of our knowledge, this analysis is the first to perform a quantitative comparison of the ICS among CT based scans, with and without bolus injection, acquired using the same scanning sequence and a precise characterization of the bolus uptake, hence, reducing potential confounding factors.

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.

Introduction: Chronic internal carotid occlusion is responsible for 10–15% ischemic strokes or transit ischemic attacks (TIA). Subsequent ipsilateral ischemic stroke rate is 5.9% per year. However, this risk can increase up to 23% in two years in a subgroup of patients with poor collaterals regardless of medical therapy with antiplatelet or anticoagulant agents. Prevention of subsequent stroke in patients with carotid artery occlusion remains a difficult challenge. Carotid artery stenting (CAS) has recently been considered in its management. However, there is ambiguity on its safety. We aim to evaluate the safety and feasibility of CAS and compared it with medical management. Methods: We performed a systematic review and meta‐analysis to compare long‐term outcome (stroke recurrence) of current carotid occlusion treatments (CAS vs medical therapy). Two independent reviewers performed the screening, data extraction, and quality assessment. A random effects model was used for analysis. Results: A total of 5720 studies were screened. Of these, 11 studies were included in our systematic review and meta‐analysis of proportions. The CAS group has lower proportions of recurrent strokes (5% vs 30%,) after 30 days than medical therapy alone. Additionally, the proportion of periprocedural intracranial hemorrhage was 4.4% (95% CI 2.5 to 6.8) in the CAS group. Conclusions: CAS of the chronically occluded cervical ICA seems to be a safe procedure with lower rates of recurrent stroke in clinical follow up. Future randomized studies are warranted to guide the optimal management of this complex disease.