Middle meningeal artery embolization (MMAE) is a promising new treatment for chronic SDH (cSDH). We conducted an international multi-disciplinary survey among physicians involved in the care of cSDH patients to understand the perceived safety profile and efficacy of MMAE in real-world clinical practice. The survey was distributed via several neurointerventional society mailing lists. We collected data on participant demographics, practice patterns, volumes and experience, perceived MMAE safety, complication tolerance, and decision-making. Data were analyzed using descriptive statistics, non-parametric tests and multi-variable regression. Five-hundred-seventy-seven physicians completed the survey between November 20th, 2024 and May 1st, 2025 (median age 42.0 years, 489 [84.7
BACKGROUND:Patients with extensive ischaemic change are often excluded from endovascular thrombectomy. We aimed to synthesise the evidence from recent trials in these patients by performing a systematic review and individual patient data meta-analysis to estimate treatment benefit, including within clinical and imaging subgroups. METHODS:In this systematic review and meta-analysis, we searched PubMed and Embase for randomised trials published between March 1, 2018, and March 1, 2025, that evaluated efficacy and safety of endovascular thrombectomy compared with medical management in patients with large-core ischaemic stroke (based on an Alberta Stroke Program Early CT Score [ASPECTS] of ≤5 or estimated ischaemic core ≥50 mL) presenting within 24 h of onset. Individual patient-level data from all eligible trials were obtained. A central imaging core laboratory readjudicated ASPECTS and reanalysed ischaemic core volume. A two-stage meta-analysis with random-effects model was used to evaluate the distribution of 90-day modified Rankin Scale (mRS) scores (the primary outcome) using adjusted pooled generalised odds ratios (aGenORs). Missing data were handled by multiple imputation. Safety outcomes were all-cause mortality within 90-day follow-up and neurological worsening within 24-48 h of randomisation, reported as adjusted pooled relative risk (aRR); and symptomatic intracerebral haemorrhage within 36 h of randomisation (reported as risk difference). Subgroup analyses based on clinical and imaging characteristics were done, including subgroups defined by ischaemic core volume, ASPECTS, and time window from onset to randomisation. The meta-analysis was registered with PROSPERO (CRD420251058584). FINDINGS:We included 1886 patients (944 assigned to endovascular thrombectomy and 942 assigned to medical management) from six trials. Baseline characteristics were similar between treatment groups. At day 90, the distribution of mRS scores was improved in patients in the endovascular thrombectomy group (median score 4 [IQR 3-6]; n=940) versus those in the medical management group (5 [4-6]; n=931; aGenOR 1·63 [95% CI 1·42-1·88], p<0·0001). The endovascular thrombectomy group also had reduced mortality (292 [31·1%]) compared with the medical management group (347 [37·3%]; aRR 0·82 [95% CI 0·70-0·97], p=0·022). No significant differences were observed in symptomatic intracranial haemorrhage (ten [1·1%] of 944 vs nine [1·0%] of 942 patients; pooled unadjusted risk difference -0·17 percentage points [95% CI -1·01 to 0·67], p=0·69) or neurological worsening (197 [22·0%] of 896 patients vs 161 [17·9%] of 899; aRR 1·19 [0·87-1·62], p=0·27). Improved functional outcomes with endovascular thrombectomy were consistent across clinical and imaging subgroups, except for those with an estimated ischaemic core volume of 150 mL or greater, in whom point estimates favoured endovascular thrombectomy, particularly in the early time window (0-6 h), but wide 95% CIs limited interpretation. INTERPRETATION:Endovascular thrombectomy was associated with improved functional outcomes and reduced mortality versus medical management in patients with large-core ischaemic stroke presenting within 24 h of onset. With the exception of very extensive ischaemic changes (core volume ≥150 mL) presenting beyond 6 h, where evidence remains limited, benefit was sustained across ASPECTS and ischaemic core strata for patients presenting up to 24 h after onset. FUNDING:None.
BACKGROUND:Endovascular thrombectomy (EVT) has demonstrated benefits in patients with ischemic stroke and large-vessel occlusions, but its efficacy and safety in patients with the largest baseline infarcts (Alberta Stroke Program Early Computed Tomography Score [ASPECTS] 0-2), remain controversial. This study aimed to evaluate the efficacy and safety of EVT in early presenting patients with ASPECTS 0 to 2 compared with medical care alone. METHODS:This post hoc analysis of the multicenter, randomized LASTE trial ([Large Stroke Therapy Evaluation]; patients ≤80 years, ASPECTS 0-5, proximal anterior circulation large-vessel occlusion, randomization within 6.5 hours of last known well) evaluated the subgroup with ASPECTS 0 to 2, representing those with large baseline infarcts without an upper size limit, randomized to receive EVT plus medical care or medical care alone. Primary outcomes included the distribution of the modified Rankin Scale score at 90 days. Secondary outcomes included mortality, infarct volume growth at 24 hours, the incidence of symptomatic intracranial hemorrhage and modified Rankin Scale score at 180 days. The LASTE trial was conducted and reported in accordance with the CONSORT guidelines (Consolidated Standards of Reporting Trials). RESULTS:Median age was 72 years and 55.8% were women. Among the 181 patients with ASPECTS 0 to 2 (median core volume 156 mL [25th-75th percentiles, 121-204 mL]), at 90 days after randomization, EVT improved functional outcomes (generalized odds ratio, 1.81 [95% CI, 1.32-2.47]) and reduced mortality (38.4% versus 59.6%; relative risk, 0.64 [95% CI, 0.47-0.89]), which translated predominantly into an increase in the proportion of modified Rankin Scale score of 0 to 3 in the EVT group (31.4% versus 8.5%; relative risk, 3.69 [95% CI, 1.77-7.68]). A significant reduction in infarct growth volume was observed in the EVT group compared with medical care (mean difference, -70.3 mL [95% CI, -94.2 to -46.3]). Rates of symptomatic intracranial hemorrhage were 12.9% versus 4.5%, respectively (relative risk, 2.85 [95% CI, 0.94-8.60]). CONCLUSIONS:EVT improves functional outcomes and reduces mortality in patients with ASPECTS 0 to 2. These findings support the concept that in patients aged <80 years presenting within early time window (6.5 hours) with unlimitedly large infarct (predominantly selected using magnetic resonance imaging), the infarct size in isolation should not be used to disqualify patients from endovascular treatment. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03811769.
Background and ObjectivesDevelopmental and epileptic encephalopathies (DEEs) with early burst-suppression EEG (EIDEE-BS) are among the most severe neonatal epileptic syndromes, typically presenting in the first months of life with refractory seizures and profound neurodevelopmental impairment. Although variants in the KCNQ2, STXBP1, and SCN2A genes are recognized as major causes, the full genetic spectrum remains uncertain. We aimed to delineate the electroclinical characteristics, genetic etiologies, and long-term outcomes in a large MRI-negative EIDEE-BS cohort.MethodsWe retrospectively analyzed 110 patients with BS EEG enrolled from a database of 1,540 individuals with suspected genetic epilepsies (2008-2023). Clinical, EEG, and genetic data were systematically collected. Patients were stratified into 4 groups: KCNQ2, STXBP1, "other pathogenic variants," and "without a genetic diagnosis." EEG traces were reviewed independently, and outcomes were assessed through long-term follow-up.ResultsPathogenic or likely pathogenic variants were identified in 62.7% of patients and involved 23 genes, including 2 copy number variants. KCNQ2 (n = 24) and STXBP1 (n = 16) accounted for one-third of diagnoses, whereas SCN2A (n = 3) and KCNT1 (n = 2) were less frequent. In KCNQ2 cases, seizures and BS onset occurred earlier than in STXBP1 cases: mean 2 days vs 6 weeks for seizures and 3 days vs 2 months for BS, respectively. A typical BS pattern (bursts longer than suppressions) strongly correlated with KCNQ2 and STXBP1 variants. Novel associations were found with DPM1, GRIN2A, KCNT2, PIGO, PURA, WWOX, and candidate genes (KMT2E, SNAP25, and SYT1). Most variants were de novo heterozygous; however, recessive and X-linked inheritance patterns were also observed. Mortality was high (25%), primarily from status epilepticus and complications of severe disability. Most patients (72.5%) had persistent seizures at follow-up (a mean of 6.5 years), as well as profound intellectual disabilities, irrespective of genotype.DiscussionThis large series highlights the strong monogenic basis of EIDEE-BS. KCNQ2, STXBP1, and SCN2A were the most commonly affected genes. Early EEG features, particularly BS timing and morphology, can help anticipate the underlying genotype and guide precision therapy, including the early use of sodium channel blockers in selected cases. These findings support recent ILAE reclassification efforts and underscore the importance of comprehensive genomic testing for improved diagnosis and counseling.
