Microguidewire electrocoagulation, an alternative when microcatheterization is not feasible, has been reported in sporadic cases, almost exclusively limited to tiny, extremely narrow-necked aneurysms.1-10 However, it has not been described for recurrent wide-necked aneurysms following braided stent-assisted coiling.A woman in her 40s presented with Hunt-Hess grade 4 subarachnoid hemorrhage from a ruptured dorsal supraclinoid internal carotid artery aneurysm. Emergency braided stent-assisted coiling was complicated by significant recurrence at 3 weeks. COVID-19 restrictions prevented interhospital transfer and rendered dedicated electrocoagulation devices unavailable. Salvage treatment was performed by connecting a loop-tipped microguidewire to a common 9 volt battery for electrocoagulation, followed by Tubridge flow diverter deployment. Complete aneurysm occlusion was confirmed at 18-month angiography. The patient survived and remained neurologically stable without new deficits, although severely disabled (video 1). This improvised technique achieved durable aneurysm occlusion and may be considered a last-resort bailout in resource-limited emergency scenarios.neurintsurg;jnis-2026-025979v1/V1F1V1Video 1Technical video demonstrating 9-volt battery-powered microguidewire electrocoagulation and flow diversion for salvage of recurrent supraclinoid aneurysm.
BACKGROUND:To evaluate the impact of Woven EndoBridge (WEB) device protrusion on the occurrence and number of postprocedural diffusion-weighted imaging (DWI) lesions in patients with unruptured intracranial aneurysms. METHODS:This retrospective single-center study included all consecutive patients with unruptured intracranial aneurysms treated with the WEB device between January 2019 and May 2026. Postprocedural brain MRI, including DWI, was performed within 24-72 hours after treatment. The presence and number of postprocedural DWI lesions, as well as the WEB protrusion, were independently assessed by two experienced board-certified neuroradiologists. Univariable and multivariable linear regression analyses were performed to identify factors associated with the number of postprocedural DWI lesions. Logistic regression analyses were used to assess factors associated with the occurrence of DWI lesions. RESULTS:WEB protrusion was observed in 26/117 patients (22%). Postprocedural DWI lesions occurred in 51/117 patients (44%), without a significant difference between patients with and without protrusion (13/26 (50%) vs 38/91 (42%), P=0.408). However, the mean number of postprocedural DWI lesions was significantly higher in patients with WEB protrusion compared with those without protrusion (4.6±10.2 vs 1.5±3.2, P=0.013). In the multivariable linear regression model, only WEB protrusion was significantly associated with the number of postprocedural DWI lesions (β=3.03 (0.49-5.57), P=0.02). CONCLUSION:WEB protrusion was independently associated with the number of DWI lesions after treatment of unruptured intracranial aneurysms. In contrast, procedure duration was associated with DWI lesion occurrence, whereas repositioning attempts showed no independent association with either lesion occurrence or lesion burden.
BACKGROUND:Flow diverters have expanded endovascular treatment options, yet large real-world data about their comparative periprocedural safety in the treatment of unruptured intracranial aneurysms are limited. This study aimed to compare the short-term safety of flow diverters with alternative endovascular techniques. METHODS:We analyzed 24 458 procedures for unruptured intracranial aneurysms recorded in the DEGIR (Deutsche Gesellschaft für Interventionelle Radiologie und minimal-invasive Therapie) endovascular registry between January 2018 and December 2025, across 154 German centers. A 1:1 propensity score-matched cohort was derived. The primary outcome was any periprocedural complication within 72 hours. Secondary outcomes were severe complications (permanent neurological deficit or death), hemorrhagic complications, and thromboembolic complications. Temporal trends were assessed using the interaction between flow diverter treatment and treatment year. ORs and 95% CIs are reported. RESULTS:We included 13 576 (6788 flow diverter, 6788 non-flow diverter) 1:1 propensity score-matched procedures in our analysis. Flow diverter treatment was not associated with a significant difference in overall (OR 1.09, 95% CI 0.94 to 1.26), thromboembolic (0.99, 0.81 to 1.21), hemorrhagic (1.30, 0.99 to 1.70), or severe complications (1.38, 0.94 to 2.02). No significant temporal trend was observed for any of the outcomes. Results were robust in sensitivity analyses comparing flow diverters with stent-assisted coiling and restricting the cohort to saccular aneurysms. CONCLUSIONS:In a large national quality assurance registry, flow diverter treatment for unruptured intracranial aneurysms was not associated with a significant increase in periprocedural (≤72 hour) complication risk.
BACKGROUND:Under- or over-inhibition of platelet aggregation by antiplatelets may contribute to ischemic or hemorrhagic complications following flow diversion for intracranial aneurysms. We aimed to describe our institutional practice of adjusting antiplatelet doses based on periprocedural Multiplate Analyzer platelet function testing (PFT) to avoid under- or over-inhibition. METHODS:Patients with an internal carotid artery (ICA) aneurysm treated electively with flow diversion and with antiplatelet doses guided by PFT were included. Patients were classified as having either low-, standard-, or high-dose antiplatelets based on their discharge doses. The primary outcome was major ipsilateral stroke (National Institutes of Health Stroke Scale score (NIHSS) ≥4) or neurological death within 6 months. RESULTS:One hundred and nine (57.4±12.9 years, 94 (86.2%) female) patients met the inclusion criteria. Aspirin (range 25-100 mg/day) was used in 109 (100%), prasugrel (range 1.25-15 mg/day) in 74 (67.9%), clopidogrel (range 37.5-75 mg/day) in 33 (30.3%), and ticagrelor (range 90-180 mg/day) in 2 (1.8%) patients. Low-dose antiplatelets were used in 57 (52.3%), standard-dose in 50 (45.9%), and high-dose in 2 (1.8%) patients. Two (1.8%) patients met the primary outcome (one in each of the standard- and low-dose groups) and 4 (3.7%) patients had symptomatic neurological complications that did not meet the primary outcome. CONCLUSIONS:In a cohort managed with routine periprocedural PFT to avoid under- or over-inhibition of platelet function, low-dose antiplatelets were commonly prescribed, and a low complication rate was observed. These findings support further prospective evaluation of PFT-guided antiplatelet dosing.
BACKGROUND:The CT myelography (CTM)-based Duke CSF-Venous Fistula Confidence Score (DCCS) standardizes diagnostic assessment of suspected CSF-venous fistulas (CVFs) in spontaneous intracranial hypotension (SIH). We evaluated whether confidence categories are associated with response after transvenous embolization (TVE), and whether renal contrast accumulation adds prognostic information in equivocal cases. METHODS:This retrospective, single-center cohort included patients with SIH attributed to suspected or confirmed CVFs who underwent TVE between May 2023 and January 2026. Based on the DCCS, pretreatment CTM studies were categorized as definite, high-probability, or low-probability groups. The primary outcome was overall clinical improvement, defined as complete or partial symptom improvement without additional intervention at 3 months. Renal contrast accumulation was evaluated as an adjunctive marker. RESULTS:Overall clinical improvement occurred in 44/63 patients (69.8%), including complete resolution in 32 (50.8%) and partial improvement in 12 (19.0%). Improvement rates differed by Duke category: 24/30 (80.0%) in the definite, 10/12 (83.3%) in the high-probability, and 10/21 (47.6%) in the low-probability group (p=0.02). High-confidence CTM findings (comprising definite and high-probability) remained independently associated with overall improvement after adjustment for preoperative Bern score (adjusted OR 4.47; 95% CI 1.15 to 20.19; p=0.03). A renal accumulation modified model showed similar discrimination to conventional CTM grading (area under the curve (AUC) 0.691 vs 0.683; p=0.87), but lower corrected Akaike Information Criterion (AICc)/Bayesian Information Criterion (BIC) and higher sensitivity (90.9% vs 77.2%). CONCLUSIONS:The CTM-based DCCS categories were associated with response after TVE. Low-probability cases had less predictable outcomes but improved in nearly half of patients. Renal contrast accumulation may provide adjunctive information in equivocal cases but requires prospective validation.
BACKGROUND AND OBJECTIVES:Cerebrospinal fluid-venous fistula (CVF) is an increasingly recognized cause of spontaneous intracranial hypotension (SIH). We report our single-center retrospective experience with transvenous CVF embolization, focusing on clinical and imaging outcomes, recurrence, and rebound intracranial hypertension (RIH). METHODS:We selected patients who underwent transvenous embolization for CVF between January 2022 and January 2026. Inclusion required a clinical diagnosis of SIH, confirmation of CVF on decubitus myelographic imaging, and completion of transvenous embolization. Brain MRI was scored using the Bern SIH score. Outcomes included immediate post-procedural response, symptom resolution at 3 months, RIH, recurrence, procedural complications, and final clinical outcome. RESULTS:Forty-six patients were included in the primary analysis. Brain MRI features of SIH were present in just over half of patients. Symptom resolution at 3 months was achieved in 80.4%, while overall RIH occurred in 26.1%. Among evaluable patients, recurrence occurred in 18.9%. One procedural complication occurred without lasting clinical sequelae. In patients with available post-treatment MRI, Bern score improved after embolization. DISCUSSION:Transvenous CVF embolization was associated with favorable clinical and imaging outcomes. Brain MRI status showed a consistent directional association with outcome, rebound intracranial hypertension and SIH recurrence.
BACKGROUND:NeoCastTM is a solvent-free, non-adhesive biomaterial engineered to achieve microvascular occlusion. EMBO-01 is the first-in-human trial of NeoCast for the pre-surgical embolization of hypervascular brain tumors supplied by the middle meningeal artery (MMA). METHODS:EMBO-01 was an open-label, multicenter, prospective, externally monitored, and core lab adjudicated clinical trial. The primary safety endpoint was freedom from device-related disabling stroke or neurological death within 30 days of embolization. The primary effectiveness endpoint was successful injection of NeoCast into targeted vessel(s), resulting in complete occlusion at or distal to the point of embolysate injection. Additional assessments included occurrence of microcatheter adhesion and non-target embolization, percent tumor devascularization, extent of resection, estimated intraoperative blood loss, and surgical time. RESULTS:Five subjects were enrolled with an average tumor size of 5.0±1.2 cm. NeoCast achieved occlusion in all targeted vessels for all subjects. There were no adverse events or device deficiencies during embolization. The average NeoCast injection volume was 0.68±0.28 mL with an average injection time of 7.8±6.4 min. There was no microcatheter entrapment or non-target embolization. The average percent tumor devascularization was 89±7%. Tumor resection was complete in all subjects, with an average estimated blood loss of 240±164 mL and average total surgery time of 167±75 min. All subjects successfully met both the primary feasibility and safety endpoints. CONCLUSION:This first-in-human study provides evidence that NeoCast can be used to reproducibly and safely achieve substantial preoperative devascularization of brain tumors supplied by the MMA.
BACKGROUND:Accurate flow diverter (FD) sizing is critical for successful intracranial aneurysm (IA) treatment. We evaluated the predictive performance of the Ankyras FD simulation platform within a standardized simulation based clinical workflow using three-dimensional (3D) DynaCTA centerline analysis as an advanced validation reference standard. METHODS:A retrospective analysis of a prospectively maintained institutional database of Ankyras guided IA treatments between April 2024 and October 2025 was performed. 3D rotational angiography data generated Ankyras simulations for treatment planning, device selection, and intraoperative guidance. Simulated length (SL) and proximal landing zone (PLZ) were compared with post-deployment length (DL) from DynaCTA centerline measurements (3D Slicer). Accuracy was assessed using correlation coefficients, mean absolute error (MAE), and Bland-Altman analysis. RESULTS:54 consecutive patients (48 women, mean age 54.2 years) with 63 IAs underwent 57 pipeline embolization device (PED) treatments. All achieved procedural success without intraoperative complications; two required adjunctive stent placement for malapposition. Mean SL was 21.44±3.53 mm and DL was 21.49±3.52 mm (n=46), with a strong SL-DL correlation (r=0.91), minimal bias (-0.05 mm), and 1.24 mm MAE. PLZ demonstrated a strong correlation (r=0.94), low bias (0.14 mm), and minimal MAE (1.34 mm) between Ankyras and the deployed values (n=45). Bland-Altman analysis showed narrow agreement limits without evidence of proportional error. CONCLUSIONS:Using a robust 3D DynaCTA centerline based validation, Ankyras demonstrated high accuracy for PED deployment length and landing zone prediction within a standardized clinical treatment workflow of pre-procedural planning, intraoperative guidance, and post-deployment assessment.
BACKGROUND:Flat-detector computed tomography (FDCT) is increasingly used for peri-interventional cerebral imaging but is associated with a relatively high radiation exposure. Copper (Cu) filtration may reduce radiation dose. However, its impact on cerebral image quality and intracranial hemorrhage detection remains unclear. METHODS:In this retrospective single-center study, 31 patients undergoing neurointerventional procedures with intraindividual FDCT acquisitions with and without Cu filtration were analyzed. Quantitative image quality was assessed using contrast-to-noise ratio (CNR). Qualitative image analysis and intracranial hemorrhage detection were independently evaluated by two readers blinded to Cu filtration status using five-point scales. RESULTS:Cu filtration resulted in a significant radiation dose reduction of 25.9% for both entrance skin dose (145.19±13.18 mGy vs 195.89±18.05 mGy) and dose-area product (41.52±3.77 Gy·cm² vs 56.01±5.16 Gy·cm²), respectively (P<0.001). No differences in CNR were observed for unfiltered vs Cu-filtered FDCT (basal ganglia: 4.73±2.04 vs 4.37±1.99, P=0.419). Qualitative image ratings were similar between techniques (supratentorial cortex: 2.27±0.66 vs 2.08±0.75, P=0.089), with very good inter-reader agreement (κ=0.86; 95% CI: 0.80 to 0.91). All intracranial hemorrhages were correctly identified by both techniques. Correct exclusion of intracranial hemorrhage was 15/16 with Cu filtration and 14/16 without Cu filtration, without statistically significant difference. Differences were limited to hemorrhage mimics (n=2) and minor variations in diagnostic confidence without affecting binary classification. CONCLUSION:Cu filtration in cerebral FDCT enables substantial radiation dose reduction while preserving image quality and intracranial hemorrhage detection, supporting its clinical implementation as a practical dose optimization strategy for peri-interventional imaging.
BACKGROUND:More high-quality evidence for stent-assisted coiling (SAC) of cerebral aneurysms is needed. Randomized controlled trials have shown lower recurrence with the HydroCoil Embolic System (HES) compared with bare platinum coils, and self-adjudicated LVIS Evo SAC studies have demonstrated favorable safety and technical success. The objective of the SEALANT study is to investigate the safety and effectiveness of this device combination. METHODS:SEALANT is an open-label, prospective, single-arm, multicenter study including patients with aneurysms up to a maximum size of 12 mm. The primary effectiveness endpoint was complete occlusion on digital subtraction angiography (DSA), and the primary safety endpoint was major ipsilateral stroke or neurological death. Adverse events and imaging were independently adjudicated. RESULTS:206 patients were enrolled; 193 had follow-up imaging for outcome assessment; and 164 satisfied all criteria, were treated with both study devices (including ≥90% HES), and had DSA follow-up. The participants' mean age was 56.8±11.6 years; 65% were female. Of 212 aneurysms, 86.3% were bifurcation and 13.2% sidewall; 25.0% were previously treated and 17.9% previously ruptured; 89.6% were anterior circulation, 34.0% at the anterior communicating artery, and 30.7% at the middle cerebral artery; and 84.9% were wide-necked (neck ≥4 mm or dome/neck ratio <2). The primary effectiveness endpoint of complete occlusion was achieved in 82.1% (95% CI 76.4% to 87.9%) of aneurysms. 2.4% (95% CI 0.3% to 4.5%) of patients met the primary safety endpoint of major ipsilateral stroke or neurological death. The primary safety endpoint was significantly associated with baseline modified Rankin Scale and history of previous stroke. CONCLUSION:1-year SEALANT results confirm the safety and effectiveness of SAC using LVIS Evo and HES. TRIAL REGISTRATION NUMBER:NCT04999423.
INTRODUCTION:THUNDER (Acute Ischemic Stroke Study With the Penumbra System Including Thunderbolt Aspiration Tubing) was the first study to evaluate the safety and effectiveness of a proprietary computer assisted vacuum thrombectomy (CAVT) system including modulated aspiration (Penumbra System with Thunderbolt; Penumbra, California, USA) in patients with emergent large vessel occlusion (ELVO). METHODS:THUNDER was a single arm, prospective, multicenter study with core laboratory adjudication and oversight by a Clinical Events Committee and Data Safety Monitoring Board. The primary endpoint was post-Thunderbolt successful revascularization (modified Treatment in Cerebral Infarction (mTICI) 2b-3). Secondary endpoints included first pass mTICI 2b-3, post-Thunderbolt mTICI 2c-3, time to revascularization, symptomatic intracranial hemorrhages (sICH), device/procedure related serious adverse events (SAEs) within 24 hours, 90- day modified Rankin Score (mRS) 0-2, and all cause mortality. RESULTS:216 patients were enrolled across 29 US centers (mean age 64.8 years, 45.4% women, median National Institutes of Health Stroke Scale score 15.0). The predefined performance goal was met, with post-Thunderbolt mTICI 2b-3 revascularization achieved in 87.5% (95% CI 82.3% to 91.6%; P<0.001). First pass mTICI 2b-3 was 64.8%. Post-Thunderbolt mTICI 2c-3 was 70.4%. Median time to revascularization was 20 min. Post-procedure, 83.0% of visualized clots were characterized as ingested. At 90 days, mRS 0-2 was 55.4%. Device/procedure related SAEs occurred in 2.8%, sICH in 0.9%, and the rate of all cause mortality at 90 days was 11.7%. CONCLUSIONS:The Thunderbolt system was safe and effective for the treatment of ELVO, achieving high revascularization and clot ingestion rates, short procedure times, and low complication rates. The first pass effect rate was numerically higher than those previously reported for large bore catheters and approximated those of ultra bore/super large bore devices. TRIAL REGISTRATION:ClinicalTrials.gov NCT05437055.
OBJECTIVES:Arteriovenous malformation (AVM) rupture can be life-threatening, necessitating accurate predictive methodologies. We developed and validated the normalized stasis index (NSI), derived from quantitative digital subtraction angiography (qDSA), for predicting AVM rupture risk. METHODS:In this multicenter, retrospective, observational study, we enrolled consecutive AVM patients who underwent DSA examination between 2017 and 2022. qDSA was used to calculate hemodynamic parameters. We performed univariate and multivariate analyses to assess NSI's association with AVM rupture, evaluated its predictive performance through receiver operating characteristic (ROC) curve analysis, and compared it with existing prediction models using DeLong's test. An independent cohort provided external validation. RESULTS:The study included 663 patients (internal cohort: n=523; external validation cohort: n=140) with 324 ruptured and 339 unruptured AVMs. The ruptured group demonstrated significantly higher NSI values than the unruptured group (median: 9.03 vs 2.11; p<0.001). Across multivariate models, NSI maintained an independent association with AVM rupture after adjusting for vascular structural factors (p=0.009), hemodynamic factors (p<0.001), combined factors (p=0.029), and demographic factors (p=0.027). Integration of NSI into existing R2eD and VALE predictive models significantly enhanced their performance (R2eD: area under the curve (AUC) 0.768; VALE: AUC 0.792; both p<0.001). CONCLUSIONS:NSI demonstrates an independent association with AVM rupture and exhibits robust predictive capability for rupture events, providing valuable insights for clinical risk stratification and therapeutic decision-making.
INTRODUCTION:The Woven EndoBridge (WEB) Embolization System is the first intrasaccular device developed for the treatment of wide-necked bifurcation aneurysms (WNBAs). Here we report the 1-year outcomes for the unruptured aneurysm cohort of the WISE Study (WEB Implant Safety and long-term Effectiveness) database, a pooled analysis of subject-level data from seven prospective WEB trials. METHODS:Individual subject-level data from seven prospective, multicenter, core laboratory adjudicated, externally monitored studies evaluating the WEB device for the treatment of unruptured WNBAs were pooled. The included aneurysms had a mean dome width of 6.5 mm. All studies shared the same core laboratory, and five of the seven shared the same clinical events committee. Subject demographic and aneurysm characteristics, procedural data, and effectiveness and safety outcomes were combined and evaluated as a single population. Adequate occlusion was defined as complete occlusion or residual neck on core laboratory assessment. RESULTS:A total of 449 unruptured aneurysms were successfully treated within WISE. The 1-year rates of complete occlusion and adequate occlusion were 54.7% (223/408) and 82.8% (338/408), respectively. Aneurysm recurrence was 6.4% (19/298) and the retreatment rate was 2.5% (11/449). All-cause morbidity was 1.2% (5/416) and treatment-related morbidity (device- and/or procedure-related) was 0.5% (2/416) at 12 months. No ruptures were observed after WEB treatment through 1 year. Complete occlusion was less likely for anterior circulation aneurysms, larger aneurysm height and width, and wider neck. Complete occlusion was less likely for anterior circulation aneurysms and for aneurysms with larger height, width, and neck size (all p<0.05). Greater WEB lateral compression was associated with higher rates of complete occlusion (OR 1.289 for absolute difference and OR 7.042 for ratio, p≤0.0066), and with higher rates of adequate occlusion (OR 1.288 and 8.846, respectively). Retreatment was associated with larger aneurysm height and width, and smoking history. CONCLUSION:The WEB device is safe and effective for the treatment of unruptured intracranial aneurysms with high rates of adequate occlusion, low rates of recurrence and retreatment, and reliable protection from rupture.
BACKGROUND AND PURPOSE:Cerebral perfusion imaging may help detect the presence of, and infer vessel occlusion location in, anterior circulation stroke, but its value in posterior circulation large vessel occlusion (PC-LVO) is less well defined. We evaluated the accuracy and inter-reader reliability of CT and MR perfusion imaging for occlusion classification and posterior circulation vessel localization. METHODS:We performed a retrospective multicenter diagnostic accuracy study from 11 centers that underwent perfusion imaging for stroke evaluation. The cohort was enriched for posterior circulation stroke. Four blinded readers assigned each case to one of five categories: no occlusion, anterior circulation large vessel occlusion (AC-LVO), basilar artery, posterior cerebral artery (PCA), or vertebral/posterior inferior cerebellar artery (vert/PICA) occlusion. Final classification was determined by majority vote. RESULTS:184 patients were included. Perfusion imaging correctly classified 150/184 cases on the 5-class task (81.5%, 95% CI 75.1% to 86.9%). Across the 3-class task of LVO(-), AC-LVO, and PC-LVO, accuracy was 163/184 (88.6%, 95% CI 83.1% to 92.8%), with sensitivity of 100% for LVO(-), 100% for AC-LVO, and 84.4% for PC-LVO. Within the posterior circulation subgroup, perfusion imaging correctly localized basilar, PCA, and vert/PICA occlusions in 101/135 cases (74.8%, 95% CI 66.6% to 81.9%), including 82/107 basilar (76.6%), 10/12 PCA (83.3%), and 9/16 vert/PICA (56.3%). Fleiss κ was 0.889 for the 3-class task, 0.742 for the 5-class task, and 0.604 for posterior localization. CONCLUSION:Perfusion imaging is moderately accurate for the detection and localization of PC-LVO, but performs less well compared with the detection of AC-LVO.
The purpose of this review is to provide a practical framework for understanding, diagnosing, and managing cerebrospinal fluid-venous fistulas (CVFs), a major cause of spontaneous intracranial hypotension (SIH). First, we summarize current concepts of CSF physiology, including glymphatic pathways, and discuss leading hypotheses for why CVFs occur, including potential roles of pressure gradients and underlying intracranial hypertension in select patients. We then outline a stepwise diagnostic approach and detail contemporary myelographic techniques used to localize CVFs: lateral decubitus digital subtraction and CT myelography, with emphasis on acquisition strategies, interpretive 'pearls and pitfalls', common mimics, reasons for false-negative studies, and escalation pathways when suspicion remains high. Finally, we review and discuss contemporary literature regarding management options across the spectrum of disease severity including conservative measures, epidural blood patching and targeted percutaneous therapies, surgical disconnection, and endovascular treatment. Regarding the latter, we discuss anatomical considerations, access and targeting strategies, expected outcomes, complications, and radioprotection considerations. We then summarize post-treatment issues such as rebound intracranial hypertension and conclude with open questions and future directions to guide research and standardization in this rapidly evolving field.
Intravenous thrombolysis (IVT) has been the mainstay of acute ischemic stroke (AIS) treatment for over three decades. Recently, several studies have evaluated the safety and efficacy of IVT in certain complex clinical scenarios such as bridging IVT with mechanical thrombectomy (MT) versus direct MT, MT in distal medium vessel occlusions (DMVOs), and extended time window reperfusion. Many of these scenarios overlap with neurointerventional treatment strategies. This updated evidence has uncovered certain nuances in AIS treatment (transfer vs non-transfer patients, degree of disability, feasibility of MT) that warrant consideration in medical decision-making in addition to the conventional risks-versus-benefits discussion. Furthermore, as an increasing number of neurologists with diverse subspecialty interests are involved in AIS triage and treatment decision-making across various patient-care models (telestroke, spoke and hub systems, etc), variability in data interpretation may lead to inconsistencies in the administration of these time-sensitive therapies. In this vignette-based narrative review, we focus on evolving 'gray zones' of AIS reperfusion therapy that are particularly relevant to neurointerventional practice: (1) bridging IVT before MT, and (2) reperfusion strategies for DMVOs, with the role of IVT in the extended time window primarily discussed within the second vignette and, to a lesser extent, in the first. This paper is not meant to be a treatment guideline but rather a case-based exercise to provide a better understanding of the new data in this area.
BACKGROUND:Endovascular thrombectomy (EVT) is a cornerstone treatment for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Super large bore (SLB) catheters represent the latest evolution in device design for aspiration technology; however, their benefit over standard large bore (LB) catheters remains uncertain. METHODS:A systematic literature search and proportional meta-analysis were conducted on studies reporting EVT outcomes with LB and SLB aspiration catheters. Both single-arm and comparative studies were included. The primary outcome was first-pass modified treatment in cerebral infarction (mTICI) score ≥2C (FPE2C). Secondary outcomes included safety and procedural measures. Random-effects models generated pooled estimates, with subgroup comparisons between LB and SLB and sensitivity analyses using leave-one-out and outlier exclusion. RESULTS:A total of 3966 patients (39 studies) were included in the primary analyses (SLB n=376; LB n=3590). FPE2C rates were similar between SLB and LB catheters (56% vs 50%; P=0.4). Final successful recanalization rates were high and similar in both groups (92% vs 92%; P=0.9). Procedural time did not differ, with pooled mean times of 27.03 min for SLB and 26.97 min for LB catheters. The need for rescue therapy showed a trend toward lower use with SLB compared with LB catheters (11% vs 20%; P=0.06). Rates of failure to reach the target clot showed a trend toward higher rates in the SLB group (10% vs 5%; P=0.11). Safety outcomes did not differ significantly (P>0.2). CONCLUSION:SLB catheters did not demonstrate a clear advantage over LB catheters in reperfusion outcomes. Limited clinical data prevent conclusions on functional benefit, and further prospective studies are needed.
BACKGROUND:Optimal management of residual stenosis after successful thrombectomy in intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusion (LVO) remains uncertain. We evaluated whether post-thrombectomy angiography-derived fractional flow (FF) was associated with 90-day functional independence in anterior circulation ICAS-LVO and whether FF outperformed anatomic stenosis measures. MATERIALS AND METHODS:This retrospective analysis of a prospectively maintained registry included consecutive patients with anterior circulation ICAS-LVO who achieved successful reperfusion after thrombectomy between October 2024 and June 2025. Post-thrombectomy FF was computed using AccuICAD V1.0 software. Receiver operating characteristic analysis with the maximum Youden index identified the optimal FF cut-off for predicting 90-day functional independence, defined as a modified Rankin Scale (mRS) score ≤2. Patients were dichotomized into two groups: a low-FF (FF ≤0.94) group and a high-FF (FF >0.94) group. Multivariable logistic regression and receiver operating characteristic analyses were performed. RESULTS:Among 105 patients (mean age, 66 years±11; 81 men), 90-day functional was observed in 22 of 48 patients (45.8%) in the low-FF group and 48 of 57 patients (84.2%) in the high-FF group (P<0.001). After full adjustment, high-FF remained independently associated with functional independence (OR, 4.46; 95% CI: 1.5-13.3; P=0.008). FF showed better discrimination than diameter and area stenosis rate (area under the curve (AUC) 0.761 vs 0.657 vs 0.660, respectively; P=0.03 and P=0.04). CONCLUSION:Higher post-thrombectomy FF was associated with better 90-day outcomes in anterior circulation ICAS-LVO and may provide a physiologic marker of residual lesion significance. Further validation is needed.
