Heart failure (HF) is a common comorbidity in patients undergoing carotid artery stenting (CAS), but its impact on outcomes by HF phenotype is unclear. This is the first study to compare short-term CAS outcomes between patients with heart failure with reduced ejection fraction (HFrEF) and those with preserved ejection fraction (HFpEF). This multicenter, prospective observational study started by screening 889 patients from the CASSH registry. After applying predefined criteria, 105 patients with heart failure undergoing CAS were included (69 HFpEF, 36 HFrEF). Baseline demographics, comorbidities, and procedural details were compared. The primary outcome was a composite of 30-day procedure-related mortality, stroke, or myocardial infarction. Secondary outcomes included disability, measured by the modified Rankin Scale (mRS), at 30 days and at 90 days. Multivariable ordinal regression was used to assess the independent association between HF phenotype and poor functional outcome. Baseline characteristics were similar between groups. The primary outcome occurred in 5.6
Vestibular schwannomas (VS) are monitored for growth after stereotactic radiosurgery (SRS) using serial MRI. Conventional measurements often miss internal regrowth within necrotic/cystic tumor components—a subtle and difficult-to-detect imaging scenario that may indicate treatment failure. We evaluated a custom AI-based segmentation tool to detect internal tumor regrowth after SRS, comparing it with expert segmentation for spatial agreement, volumetric change, and radiographic failure classification (≥ 20
Language processing is organized in brain networks, generally lateralized to the left hemisphere. In clinical routine, task-based functional MRI (fMRI) is the gold standard for non-invasive evaluation of language lateralization. However, standard fMRI does not account for the individual heterogeneity of language networks. fMRI-based functional connectivity analysis (FCA) has addressed this shortcoming by identifying correlates of dysfunctional language networks in epilepsy patients. In order to individualize FCA, translation of group-based network analysis to individual epilepsy patients is necessary. Here, we introduce the functional connectivity laterality index (LIFC) as a potential clinical parameter. This retrospective study included adults with unilateral temporal lobe epilepsy (TLE) who underwent task-based fMRI and a control group. To account for individual variations, fMRI was performed at a 3T scanner and processed entirely in native space. Laterality indices were computed from both activation maps and seed-based functional connectivity across frontal, temporal, and combined language regions. Group comparisons and associations with neuropsychological language performance were analysed. Forty patients with unilateral TLE and 25 healthy controls were included. Groups were comparable in terms of sex, handedness, imaging findings, and epilepsy duration, although the controls were younger. Classical LI showed predominantly left-lateralization, while LIFC showed mostly bilateral language lateralization. Neuropsychological performance did not differ between TLE-left and TLE-right patients. While a difference in semantic fluency was initially observed, it did not survive correction for multiple comparisons. However, analyses based on functional network organization revealed a critical pattern: Patients with language networks lateralized to the seizure side—as quantified by LIFC—showed significantly poorer semantic fluency and lower composite language scores. This potential clinically relevant result was exclusive to FCA and was not captured by activation data alone. Our findings suggest an individual vulnerability of language networks to seizure burden, although this uncorrected, exploratory finding requires replication in larger, independent samples. Incorporating functional connectivity measures into presurgical clinical fMRI analysis may enhance our ability to predict and protect language function in patients with TLE by prioritizing further therapies or surgical interventions for those at higher risk of language decline.
Unfavorable outcome is not uncommon after endovascular thrombectomy (EVT) in patients with acute basilar artery occlusion (BAO) presenting with mild symptoms, but predictors remain unclear. This study aimed to identify clinical and imaging predictors of unfavorable outcome in patients with BAO and mild symptoms. We retrospectively analyzed 71 patients with acute BAO and baseline NIHSS ≤ 10 who underwent EVT. Patients were classified by 90-day modified Rankin Scale (mRS) scores into favorable (0–2) and unfavorable (3–6) outcome groups. Clinical and imaging variables, including perfusion parameters, were compared. Independent predictors for unfavorable outcome were assessed using multivariable logistic regression. Subgroup analyses were performed according to onset-to-puncture time (early ≤ 6 h vs. late > 6 h) and door-to-puncture time (immediate ≤ 120 min vs. delayed > 120 min). Of 71 patients, 25 (35.2
The learning curve for interventional neuroradiologists starting independent mechanical thrombectomy (MT) remains insufficiently understood. This study investigated associations between operator experience, procedural performance, and clinical outcomes to estimate the number of procedures for expert-level performance. We retrospectively analyzed MT procedures from our stroke registry (2020–2024). Operators with low-to-intermediate prior neurovascular experience were followed during their first 20–50 independent cases. Procedural outcomes included procedure duration, number of passes, door-to-groin-puncture time, first-pass success, reperfusion success (modified treatment in cerebral infarction (mTICI) ≥ 2b–3), and complications. Learning curves were benchmarked against expert operator performance. Associations between operator experience and outcomes were evaluated with mixed-effects models. Clinical outcomes were assessed using changes in the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) from admission to discharge and at 3‑month follow-up. 295 MT procedures were performed by seven operators (median 50 each; interquartile range 25–50). Procedure duration decreased significantly with experience (β = −0.7 min per procedure; 95
Wilson disease is an autosomal recessive disorder of copper metabolism that results in toxic copper accumulation in the liver and brain, thereby causing neurological injury. Previous reports have described astrocyte dysfunction, oxidative stress, glial pathology, and impaired aquaporin-4-mediated water transport in Wilson disease, suggesting a potential disruption of glymphatic fluid dynamics. However, glymphatic function has not been quantitatively assessed in this population using diffusion tensor imaging analysis along the perivascular space (DTI-ALPS). This retrospective single-center study aimed to quantify glymphatic system function in pediatric patients with Wilson disease using the DTI-ALPS index. Brain MRI/DTI data (30 directions, b = 1000 s/mm2) from 43 patients younger than 18 years diagnosed according to the Leipzig criteria (2018–2025) were analyzed and compared with 43 age- and sex-matched healthy controls. Neuro-Wilson status was defined by MRI involvement plus neurological symptoms. ALPS indices were derived from regions of interest in the corona radiata and superior longitudinal fasciculus on color-FA maps. The analyses included group comparisons, correlations with clinical variables, and a secondary sensitivity ANCOVA adjusted for age and sex to confirm the robustness of group differences despite demographic matching. Right-, left-, and mean ALPS indices were significantly lower in patients with Wilson’s disease than in controls, with this group effect persisting after demographic adjustment (F = 13.90, p < 0.001; adjusted means: controls 1.51, WD 1.34, NWD 1.38). ALPS indices did not differ between the WD and NWD subgroups despite higher liver severity scores in the latter. ALPS values did not correlate with liver severity scores, urinary copper, ceruloplasmin or sex. These findings suggest that the DTI-ALPS index may reflect glymphatic system-related processes, as well as disease-related microstructural and perivascular alterations, in pediatric Wilson disease. The DTI-ALPS index may provide complementary, non-invasive imaging information regarding early perivascular microstructural alterations. Prospective multicenter longitudinal studies are warranted to clarify the temporal relationships among ALPS index changes, neurological progression, and treatment response.
To evaluate the feasibility of a locally deployable large language model (LLM) system for automated MRI protocol selection addressing data privacy, annotation burden, and scalability limitations. This retrospective study included 598 German-language MRI order entries from three neuroradiology domains (brain, head/neck, spine) between June 2018 and January 2023. A radiologist labeled entries for 27 protocol classes based on institutional standard operating procedures (SOP). An SOP-grounded AI system using MedGemma 27B was developed to predict the MRI protocol from the order entry. The system was optimized using Stochastic Introspective Mini-Batch Ascent (SIMBA), a self-reflective prompt optimization algorithm, and compared with a hierarchical system that first classified the body region and then the MRI protocol. Data efficiency was evaluated using training subsets of 10–119 examples across 3 optimization runs per subset size. The flat zero-shot model achieved 73.07
To evaluate the diagnostic capability and vessel visibility of Pointwise Encoding Time Reduction with Radial Acquisition MR angiography (PETRA-MRA) in a large cohort of patients with clipped intracranial aneurysms. This retrospective single-center study included patients who underwent surgical clipping and follow-up MRI with PETRA-MRA sequence between January 2021 and August 2024. Two radiologists independently assessed PETRA-MRA and TOF-MRA for vessel visibility and recurrent aneurysms. Diagnostic performance was evaluated using DSA or CTA as reference standards. A total of 368 patients with 546 clipped intracranial aneurysms were evaluated (mean age, 64 ± 10.6 years; median follow-up, 8.9 years). Twenty recurrent aneurysms (3.7
Hemorrhagic transformation after endovascular thrombectomy (EVT) for acute ischemic stroke is associated with poor outcomes. Dual-energy CT (DECT) iodine maps may predict hemorrhagic transformation. Therefore, we investigated the predictive value of DECT for hemorrhagic complications and evaluated whether DECT can be adopted in clinical practice. We retrospectively analyzed 306 patients with anterior circulation stroke who underwent DECT after EVT (July 2017–March 2025). Maximal ROI values were measured bilaterally, and an ipsilateral-to-contralateral ratio was calculated. Analyses were focused on DECT within 1 h and DECT between 2–3 h after EVT. The association between the ROI ratio and hemorrhagic complications was evaluated using multivariable logistic regression. Predictive performance of DECT for any hemorrhage and parenchymal hematoma (PH) on follow-up MRI was assessed using AUC, sensitivity, specificity, and accuracy. Mean age was 70.3 years; 85.6
Clopidogrel (CPG)-based dual antiplatelet therapy (DAPT) is widely used prior to endovascular treatment of intracranial aneurysms to prevent procedural thromboembolic complications (TECs). Recently, newer-generation P2Y12 inhibitors – prasugrel and ticagrelor (PSG/TCG) – have emerged as potential alternatives. This meta-analysis aimed to evaluate the utility of PSG and TCG as first-line agents for DAPT by directly comparing their safety and efficacy with conventional CPG-based therapy. Relevant studies were extracted from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials by two independent reviewers. A random-effects model was used to compare the risk of TECs and hemorrhagic complications (HECs) between PSG/TCG-based and CPG-based DAPT, expressed as risk ratios (RRs) with 95 unit (PRU) values, between the two groups. Six studies encompassing 1,071 patients were included. Compared with CPG-based DAPT, PSG/TCG-based DAPT was associated with a significantly lower risk of TECs (RR, 0.46; 95 CPG group (p =0.01). This meta-analysis shows that PSG/TCG-based DAPT offers superior thromboembolic protection without increased hemorrhagic risk, compared to conventional CPG-based regimens in endovascular treatment of intracranial aneurysms. These results suggest that PSG/TCG-based DAPT is worth considering as a treatment option in this setting, and prospective randomized trials are needed to confirm these results and to evaluate its role as a first-line option.
The benefits and risks of intravenous thrombolysis (IVT) with alteplase for acute ischemic stroke (AIS) beyond 4.5 h are unclear. Decision-making is further limited by the lack of comparisons between imaging strategies used for patient selection, including magnetic resonance imaging with diffusion-weighted imaging (MRI/DWI) and perfusion-guided approaches such as MRI with perfusion-weighted imaging (MRI/PWI) or computed tomography perfusion (CTP). This study aims to evaluate the efficacy and safety of alteplase administered beyond 4.5 h and to compare MRI/DWI- and perfusion-guided IVT. Databases were searched for RCTs enrolling AIS patients treated with alteplase beyond 4.5 h. Efficacy outcomes included excellent (mRS 0–1) and favorable (mRS 0–2) functional outcomes at 90 days, and major neurological improvement up to 72 h. Safety outcomes included any intracranial hemorrhage (aICH), symptomatic ICH (sICH), parenchymal hemorrhage (PH), and 90-day mortality. Seven RCTs comprising 1685 patients were included. There were no differences between imaging strategies in any efficacy or safety outcome. Alteplase administered beyond 4.5 h was associated with higher rates of excellent (RR 1.24; 95
Assessing generalizability and performance of machine learning models in clinical settings is crucial. In this study, we aimed to test our models’ performance on an external validation real-world clinical dataset and to evaluate the impact of magnetic field strength and brain volume normalization on the classification. We validated two previously published models trained on public datasets (Alzheimer’s disease [AD], mild cognitive impairment [MCI] and cognitively normal [CN] subjects) on a real-world clinical dataset from UK memory clinics (SLaM-BRC: 255 non-AD [subjects without cognitive complaints], 281 MCI and 711 AD). Our ‘CN vs. AD’ model showed similar performance when tested at different magnetic fields (1.5T vs. 3.0T: 87.1
Thrombectomy (TE) is the standard of care for stroke patients with large vessel occlusion. While TE achieves high recanalization rates, a subset of clots requires three or more thrombectomy maneuvers (“challenging or tough clots”) which is associated with increased complication rates and poor clinical outcome. The underlying biological properties of tough clots are poorly understood, and it remains unclear whether these have distinct structural characteristics or etiology that might contribute to their resistance to TE. We performed a prospective, single-center study which analyzed clot composition in 33 consecutive ischemic stroke patients. This included 16 tough clots (48
The 5th edition of the WHO Classification of Tumors of the Central Nervous System (CNS) introduced new additional tumor predisposition syndromes (TPS) that were not included in the 2016 version of the WHO Classification. It is essential for neuroradiologists to be familiar with these novel TPS entities, as accurate imaging interpretation and clinical evaluation often depend on recognising patterns of peripheral and central nervous system findings. Such identification should lead to genetic testing to confirm the suspected TPS diagnosis. Generally, neuroradiological features of brain tumors arising in these TPS are not distinctly different from those observed in sporadic forms of the same tumors. Even in uncommon cases such as meningiomas with aggressive behaviour, often seen in BAP1 syndrome, imaging and clinical evaluations can only suggest TPS; a definite diagnosis cannot be made from phenotype and imaging alone. This review discusses all new TPS in detail and presents their phenotypic spectrum known today. Knowledge of the genetic aspects of each TPS provides additional support to neuroradiologists due to the certainty of the clear distinguishability of TPS. For example, in conditions such as DICER1 syndrome and Fanconi anaemia, the diversity of genetic mutations contributes directly to the broad spectrum of phenotypic manifestations. As a result, genetic knowledge is essential not only for diagnosis but also for appreciating the complexity and heterogeneity of these syndromes in clinical practice. Finally, this discussion includes other TPS that, while not yet classified as distinct entities in the current edition of the WHO Classification of Tumors of the CNS, remain relevant to the field of neuro-oncology.
This post-hoc subanalysis of the TENSION trial evaluated the association between anesthesia strategy and neurological outcomes in patients with large-core infarcts undergoing mechanical thrombectomy (MT). We analyzed patients from the interventional arm of the TENSION trial who underwent MT under general anesthesia (GA) or conscious sedation (CS). Anesthesia strategy was not prespecified and was selected by the local stroke team. Key outcomes included early neurological improvement (ENI) or deterioration (END), modified Rankin Scale (mRS) at 90 days, procedural metrics, and safety outcomes. Multivariable logistic regression was performed to assess the independent association between anesthesia strategy and ENI, END, and favorable functional outcome, defined as mRS 0–3 at 90 days. Sensitivity analyses were conducted in patients with successful reperfusion. A total of 117 patients were included, of whom 50 were treated under GA and 67 under CS. No significant differences were observed between GA and CS for ENI (46.0
In the early phase after mechanical thrombectomy, differentiating between intracranial hemorrhage and contrast medium extravasation on CT imaging remains a major diagnostic challenge. Both can appear hyperdense on standard CT scans, however, they have significantly different clinical implications, particularly regarding anticoagulation decisions. The Virtual Non-Contrast (VNC) technique using photon-counting computed tomography (PCCT), offers the potential to reliably distinguish between blood and iodine-based contrast material in a single scan by virtually removing the iodine component. To evaluate the clinical feasibility and diagnostic performance of the VNC technique in patients after thrombectomy, with focus on the differentiation between hemorrhage and contrast extravasation. In this retrospective study, we analyzed hyperdense areas of 36 patients who underwent PCCT imaging shortly after mechanical thrombectomy. Two experienced neuroradiologists independently assessed the presence of intracranial hemorrhage and residual contrast extravasation using the VNC datasets. Findings, including measured volumes, were compared to follow-up scans. VNC imaging enabled reliable differentiation between hemorrhage and contrast staining. The sensitivity for detecting hemorrhage was 0.93 (25 of 27 patients, confidence interval 0.77–0.98), with a specificity of 100
