Background: Neuroendovascular devices can achieve immediate angiographic success yet fail at the site that ultimately matters: the healing vessel wall. Durable therapeutic benefit depends on stable endothelialization, organized thrombus remodeling, and resolution of inflammation rather than progression to thrombosis, restenosis, or recanalization. Summary: This review reframes vascular healing as the primary therapeutic target and synthesizes evidence supporting three complementary strategies for biologically directed device integration. Among these, bioresorbable scaffolds and surface-modified implants currently have the strongest neurovascular device evidence, though this evidence derives from extracranial animal models, demonstrating improved hemocompatibility, more favorable vascular integration, and reduced long-term foreign material exposure. Extracellular vesicles, including exosomes, combined with ultrasound microbubble-mediated delivery represent promising approaches for concentrating pro-repair signals at the device interface. However, supporting evidence remains largely extracranial, and clinical translation will require rigorous control of vesicle identity and manufacturing standards, evaluation under clinically relevant antiplatelet conditions, standardized acoustic dosing, and careful assessment of branch vessel and perforator safety. No published intracranial platform has yet integrated a biological payload, focal delivery, and temporary scaffolding into a single therapeutic system. We therefore propose a stepwise translational framework that evaluates each component incrementally using endpoints aligned with clinically relevant failure mechanisms. Key Messages: Future neuroendovascular therapies should be evaluated not only by immediate angiographic success but also by their ability to promote durable vascular healing. Key translational endpoints include surface thrombogenicity, endothelial coverage and function, quality of vascular remodeling, and preservation of branch vessel patency. A biologically directed approach to device integration may improve the long-term durability and safety of intracranial endovascular therapies.
Background and Purpose: Artificial intelligence‑assisted perfusion imaging can support selection and coordination in acute ischemic stroke (AIS). This study assessed institutional changes in access to reperfusion therapies and workflow metrics before and after RapidAI® implementation. Methods: We retrospectively analyzed consecutive AIS admissions (July 2014–October 2024) at a single comprehensive stroke center, comparing pre‑implementation and post‑implementation periods (RapidAI® introduced June 2018). Primary outcomes were utilization of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT), mRS 0–1 at discharge, and decompressive craniectomy (DC). Secondary outcomes were 90‑day mRS, door‑to‑needle (DTN) time, and hospital length of stay (LOS). Analyses were adjusted for key confounders and sensitivity analyses were made. Results: Among 2,144 patients, adjusted analyses showed no significant differences in IVT (adjusted OR 0.93; 95% CI 0.52–1.69; p = 0.822) or MT (adjusted OR 2.73; 95% CI 0.70–10.61; p = 0.147) between periods. Rescue decompressive craniectomy was lower in the post period (adjusted OR 0.15; 95% CI 0.03–0.82; p = 0.029) and hospital length of stay was reduced (adjusted B −2.33 days; 95% CI −3.62 to −1.03; p < 0.001). No significant adjusted differences were observed for door to needle time (B −0.56 minutes; 95% CI −32.44 to 31.32; p = 0.972), discharge mRS 0–1 (adjusted OR 1.47; 95% CI 0.90–2.39; p = 0.126), discharge mRS ordinal (B −0.29; 95% CI −0.62 to 0.05; p = 0.091), or 90 day mRS ordinal (B −0.26; 95% CI −0.64 to 0.12; p = 0.174). Sensitivity analyses after multiple imputation produced consistent results. Conclusions: RapidAI® implementation coincided with improved metrics in hospital length of stay and the need for decompressive craniectomy. Given low software utilization and potential secular trends, findings should be interpreted cautiously.
Background: Acute ischemic stroke (AIS) is a time-critical emergency in which the benefit of reperfusion depends not only on treatment speed but also on accurate large-vessel occlusion (LVO) recognition, destination selection, and coordination between prehospital and hospital teams. Mobile stroke units (MSUs) move imaging, laboratory testing, specialist assessment, and thrombolysis into the prehospital setting, but their effect on thrombectomy depends substantially on onboard vascular-imaging capability and local routing protocols. Summary: This narrative review evaluates MSUs through the broader construct of thrombectomy efficiency, encompassing LVO identification, destination accuracy, avoidance of secondary transfer and duplicate imaging, in-hospital parallel processing, puncture and reperfusion times, and downstream clinical outcomes. Evidence for earlier intravenous thrombolysis is retained as an important upstream benefit but is distinguished from thrombectomy-specific efficiency. The available literature indicates that non-contrast-CT–based MSUs can accelerate hospital workflows through early diagnosis and prenotification, whereas CTA-enabled models can additionally confirm LVO in the field and support direct routing to a thrombectomy-capable center or, in selected systems, direct-to-angiography pathways. The magnitude of benefit is therefore configuration- and system-dependent. Economic evaluations likewise show that value is highly sensitive to annual patient volume, catchment population, staffing model, operating hours, analytic time horizon, and baseline patient disability. Key Messages: MSUs should not be treated as a uniform intervention. Their thrombectomy value is determined by how effectively prehospital imaging and specialist assessment are linked to destination decisions, interfacility-transfer avoidance, and receiving-center activation. CTA-enabled pathways provide the clearest mechanism for thrombectomy-specific time savings, while non-contrast-CT-based models may still improve in-hospital efficiency. Implementation is most defensible when local geography, case volume, workforce, dispatch integration, downstream thrombectomy capacity, and cost-effectiveness are considered together.
Introduction: Intravenous thrombolysis (IVT) rates for acute ischemic stroke (AIS) remain suboptimal in Brazil, largely due to limited access to specialized stroke teams. Telestroke (TS) has emerged as a potential strategy to overcome geographic and structural barriers to timely stroke care, particularly in countries with continental dimensions such as Brazil. However, robust evidence regarding the effectiveness and safety of telestroke in the country remains scarce. The primary aim was to compare access to IVT before and after the implementation of a mobile TS program in the municipality of Matão, São Paulo. Secondary objectives included comparing treatment metrics, safety outcomes—specifically, intracranial hemorrhage and mortality—and functional independence at 90 days. Methods: We conducted a retrospective analysis of a prospectively collected stroke registry, using an uncontrolled before-and-after (pre/post-implementation) design at Carlos Fernando Malzoni Hospital (Matão-SP), including patients with confirmed AIS between September 1, 2016, and August 31, 2022. Patients were divided into two groups: pre-TS (36 months before implementation) and post-TS (36 months after implementation). The TS platform used was the JOIN® app (Allm Inc., Tokyo, Japan). Results: Of 379 patients diagnosed with AIS during the 72-month period, the mean age was 69.8 ± 13.6 years, and 59.1% were male. The most common risk factors were hypertension (76.8%), diabetes mellitus (38.5%), and smoking (26.1%). Although 65.4% of patients arrived within 4.5 hours from symptom onset, only 58 (15.3%) received IVT. Nevertheless, the number and proportion of patients receiving IVT increased from 11 (6.7%) in the pre-TS period to 47 (22.0%) in the post-TS period (p < 0.001). Among thrombolysed patients, median door-to-needle time was significantly reduced from 145.0 minutes (IQR 119.0–265.0) pre-TS to 92.0 minutes (IQR 66.0–129.0) post-TS (p = 0.004). There were no significant differences in symptomatic intracranial hemorrhage (p = 1.000), 90-day mortality (p = 0.729), or 90-day functional outcomes (p = 0.742). In multivariable analysis, post-TS period (OR 5.65; 95% CI 2.68–11.93; p < 0.001) and higher NIHSS score at admission (OR 1.05; 95% CI 1.02–1.08; p = 0.002) were independently associated with IVT. Conclusion: In this single-center before-and-after study, implementation of a mobile telestroke program was associated with higher rates of intravenous thrombolysis and shorter treatment times. No statistically significant differences were observed in symptomatic intracranial hemorrhage, 90-day mortality, or functional outcomes. These findings support further evaluation of mobile telestroke strategies in low- and middle-income settings.
Introduction: Remote ischemic conditioning (RIC) is delivered by a transient (5 min) pressure increase in the arm BP cuff by a variable 30-50 mmHg above systolic BP to a maximum of 200 mmHg. This inconsistency in pressure application may affect the fidelity of intervention delivery. We tested the hypothesis that monitoring remote ischemic conditioning (RIC) with an adjunct forearm skin tissue reflectance sensor (STRS) device may be feasible in patients with acute ischemic stroke (AIS) and cerebral small vessel disease (cSVD). Methods: We screened patients with AIS within 7 days of symptom onset for moderate-to-severe cSVD. Eligible patients were randomized 2:1 to receive intervention RIC or sham RIC. The primary outcome measure was a composite feasibility of the forearm STRS (patient-level comfort and technical aspects measured by IOx1 and IOx2). The secondary outcome was changes in forearm STRS-derived tissue reflectance responses during the pressure-on phase (5 min) and the early pressure-off phase (1 min) of RIC. Multivariable linear regression analysis assessed the relationship between IOx1 and intervention allocation. We also used receiver operating characteristic curve analysis to propose candidate thresholds for classifying the magnitude of the tissue oxygenation response to RIC. Results: Fifty-one [34 intervention (68 RIC sessions), 17 sham (29 RIC sessions)] patients with mean ± SD age of 69±12.8 years, 24(47.1%) were females, were enrolled at a median (IQR) 42(26-78) hours after symptom onset, and median baseline National Institute of Health stroke Scale of 5(3-7). STRS-derived median relative IOx1(β = 0.33, p = 0.002) and median relative IOx2 (β = 0.23, p = 0.04) slopes during the pressure-on phase were different in the intervention arm compared to the sham arm. A percent IOx1 change of 4- 13.7% can be considered a threshold to differentiate between intervention and sham treatment. The median Likert scale score was similar: 3.5 (3-4) in the intervention group and 4 (4-5) in the sham group. Conclusion: RIC monitoring with forearm STRS is feasible in patients with AIS. Clinical trials evaluating the efficacy of RIC interventions can use STRS to assess fidelity. Clinical Trial Registration Number: ClinicalTrials.gov ID: NCT05408130 (https://clinicaltrials.gov/study/NCT05408130)
