Large-format (6 × 50 mm) stent-retrievers may improve first-pass effect (FPE) during thrombectomy, but real-world safety data remain limited. We retrospectively analysed adults with large-vessel-occlusion stroke treated first-line with the fully radiopaque 6 × 50 mm APERIO® Hybrid21 stent-retriever plus aspiration (Sep 2023–Jul 2024). Baseline, procedural, 24-h, and follow-up modified Rankin Scale (mRS) data were collected. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b; FPE was mTICI ≥ 2b after one pass. Multivariable ordinal logistic regression identified predictors of mRS. 127 patients (median age 74; 54

BACKGROUND:Middle meningeal artery embolisation (MMAE) is a potential adjunct/alternative to conventional treatment of chronic subdural haematoma (cSDH) and is associated with reduced rates of recurrence and surgical rescue. However, real world reporting outcomes in older people with frailty have not yet been extensively described. METHODS:We undertook an observational analysis of all cSDH patients requiring intervention between November 2019 and December 2024. Patients received either MMAE (standalone/adjunctive) or burr holes alone. RESULTS:Ninety patients underwent MMAE (median age: 81, IQR: 76-86); 222 underwent burr holes alone (median age: 80, IQR: 74-85). MMAE was adjunctive in 64.4% of cases; these patients had more severe neurological impairment, larger haematoma depth, and greater degree of midline shift than patients undergoing standalone MMAE. 52.2% of MMAE patients had frailty. MMAE was associated with significantly reduced cSDH recurrence (7.8% vs. 19.8%, p = 0.009, OR 0.341 (95% CI 0.136-0.745)), and antithrombotic therapy was resumed earlier in patients treated with MMAE (8.5 vs. 14 days, p < 0.001). Adverse events following MMAE were low (1.1%). CONCLUSIONS:In a real-world UK healthcare setting, including patients with frailty, MMAE is associated with reduced rates of clinically significant cSDH recurrence and may facilitate safer, earlier reintroduction of antithrombotic therapy.

Acute and chronic subdural haematomas are two common but distinct conditions, increasingly encountered by non-neurosurgical medical teams. Although each carries a significant mortality, there have been recent advances in the care of these, typically in older, frail patients. Challenges often arise from cardiovascular or thrombotic disease and with the need for antithrombotic medication. When considering when or whether to restart antithrombotic agents, patients need nuanced, individualised decisions to balance the competing risks of thrombosis against that of progressive or recurrent haemorrhage. Middle meningeal artery embolisation is increasingly used both as an adjunctive intervention and a stand-alone treatment for chronic subdural haematoma. The evidence defining its role is evolving but it appears safe and effective and will likely be increasingly used.

BACKGROUND AND PURPOSE:Acute tandem internal carotid artery (ICA) reocclusion after stenting as part of endovascular stroke treatment is recognized as a complication in a significant minority of patients, and this can be associated with neurological deterioration and worse functional outcomes. Non-contrast CT (NCCT) forms the basis of initial follow-up imaging in this setting. We aimed to assess the sensitivity and specificity of asymmetrical hyperdensity within the superior cervical ICA (HD-CICA) on cranial NCCT for tandem ICA reocclusion. METHODS:This was a retrospective review of a prospectively acquired database (of cases performed January 2022-December 2024 inclusive) at a regional thrombectomy center. The frequency of HD-CICA on 12-24 h NCCT was compared to contemporaneous vascular imaging (CT angiography or carotid Doppler ultrasound) in patients with patent and reoccluded ICAs. RESULTS:A total of 148 patients underwent thrombectomy with ICA stenting for tandem occlusion. Stent occlusion was associated with lower rates of early neurological improvement and reperfusion and higher rates of neurological deterioration. A total of 99 patients were acutely investigated for stent patency, and HD-CICA was assessable in 92. The frequency of HD-CICA with stent occlusion was 18/19 (94.7%) versus 0/73 (0%) in patent stents (p < 0.0001). HD-CICA was both a sensitive (18/19, 94.7%, 95% confidence interval: 74.0%-99.9%) and specific sign (73/73, 100%, 95% confidence interval: 95.1%-100%), with high positive and negative predictive value for stent reocclusion. CONCLUSION:HD-CICA on acute follow-up cranial NCCT is a reliable acute marker of tandem carotid reocclusion.

Chronic subdural haematoma (cSDH) is a common subtype of traumatic brain injury, typically affecting older people living with frailty and multimorbidity. Until now, no published guideline has existed internationally to guide management, perhaps explaining why the care of the older cSDH patient varies between neurosurgical centres. The Improving Care in Elderly Neurosurgery Initiative guideline is the first guideline dedicated to the care of patients with cSDH across the entire patient pathway, from initial presentation through to rehabilitation and discharge after surgery. It includes specific recommendations for those patients not requiring surgery who, in the UK, are mostly managed in satellite hospitals away from the tertiary neurosurgical centre. It therefore has relevance to clinicians across the entire UK and also potentially to a broader international audience. In this guideline commentary we summarise the key points for geriatricians and those allied specialties such as acute medicine who deliver care to a large proportion of patients with cSDH. We discuss issues and limitations relating to guideline development, in particular in the rapidly evolving field of Middle Meningeal Artery Embolisation. We also comment on factors which may influence guideline implementation and future service development. Finally we call for some form of national registry in older people sustaining SDH, which may need to be supported by financial incentives to drive investment in services for this historically neglected patient group.

BackgroundWe report our initial experience on the use of the Walrus, a new generation balloon guide catheter (BGC) capable of accommodating large bore aspiration catheters for patients undergoing endovascular stroke thrombectomy for large vessel occlusion with a particular focus on procedural aspects related to the vascular anatomy, recanalisation efficacy and complications.MethodsThis is a retrospective, site-adjudicated, two-centre study on consecutive patients with anterior circulation large vessel occlusion treated with the Walrus BGC. Baseline characteristics and procedural and clinical outcomes were analysed.ResultsBetween July 2023 and January 2024, we recruited 300 participants (mean age 69.5 ± 15 years; 132 (44%) females). The mean admission NIHSS was 15.8 ± 6.5, and the mean ASPECTS was 7.6 ± 1.9. Combined stent-retriever and aspiration first-line thrombectomy technique was performed in 235 patients (79%). The Walrus BGC was successfully navigated to the ICA in 99.7% of patients. Near complete-complete recanalisation (eTICI2c-3) was achieved in 75.4% of patients, and the eTICI2b-3 rate was 92.2%. First-pass effect (eTICI2c-3) was achieved in 49% of patients, and the modified first-pass effect (eTICI2b-3) was 65.9%. No significant difference in the arterial puncture-to-guide catheter placement time across the three different arch types (P = .52) or between the favourable and unfavourable ASMETS score (P = .085) was observed. Any intracranial haemorrhage (ICH) occurred in 14.9% of patients, and symptomatic ICH in 3.9%.ConclusionUse of the Walrus large bore BGC during endovascular stroke thrombectomy appears effective in reaching the target vessel without a significant time penalty across various anatomical configurations and tortuosity, whilst maintaining a satisfactory safety profile.

BackgroundComplications following mechanical thrombectomy (MT) are common and impact on clinical outcome. However, unless complication reporting is standardised, there is scope for significant variation in results across multiple centres, potentially undermining both inter and intra unit comparisons and multicentre national quality improvement audit programmes. We therefore sought to achieve consensus amongst interventional neuroradiologists (INRs) in England and Wales for reporting of MT complications as part of national audit.MethodsWe conducted a two-round electronic Delphi survey with initial invitation to forty INR panellists representing each neurointerventional centre in England and Wales with questions covering timing, staffing and mode of data entry, specific MT complications (vessel perforation, intracerebral and subarachnoid haemorrhage, vessel dissection, vasospasm and distal or new territory embolisation) and topics for future content inclusion.ResultsThere were 22 and 21 respondents in round one and two, respectively. Consensus was achieved in methods of data entry and in reporting of specific complications (strongly supportive of symptomatic haemorrhagic complication reporting rather than non-clinically relevant changes with clear definitions of when to report distal, new territory embolic or vasospastic complications or arterial dissection). There was also agreement to include tandem lesion, access site and procedural-related physiological complications in future.ConclusionIn this exercise, we have achieved accordance and developed guidance with an emphasis on reporting of clinically relevant/outcome impacting post-MT complications, which will allow for a better standardised and more meaningful national audit process going forward.

BACKGROUND:Early identification and quantification of core infarct is of importance in stroke management for treatment selection, prognostication, and complication prediction. Non-contrast computed tomography (CT) (NCCT) remains the primary tool, but it suffers from limited sensitivity and inter-rater variability; CT perfusion is inconsistently available and commonly blighted by movement artefact. We assessed the performance of a standardised form of CT angiographic source imaging (CTASI) obtained through addition of a delayed phase at 40 seconds post-contrast injection (DP40) following fast-acquisition CT angiography. METHODS:Contrast resolution between ischaemic and normal grey matter (GM) was compared qualitatively and quantitatively to NCCT. Using Alberta Stroke Program Early CT Score (ASPECTS), DP40 low density was compared to NCCT and venous phase CT perfusion source images (CTPSI) and to 24-hour NCCT ASPECTS in patients with timely endovascular recanalisation (Thrombolysis In Cerebral Infarction 2C/3). RESULTS:Seventy-four patients with a proximal middle cerebral artery or terminal internal carotid artery occlusion were included. The mean attenuation difference between ischaemic and normal GM increased from 4.86+/-3.12 HU (NCCT) to 9.30+/-3.14 HU (DP40) (p < 0.0001). Subjective assessment by two raters revealed that DP40 improved ischaemic tissue conspicuity in 39 to 41 (78-82%) of cases (kappa 0.805, standard error 0.108, 95% confidence interval: 0.593-1.000). The correlation between ASPECTS on baseline imaging and eventual 24-hour ASPECTS improved from R = 0.7197 for NCCT to R = 0.9875 for DP40 (z = 7.89, p < 0.0001). The correlation between DP40 and venous phase CTPSI ASPECTS was 0.9681, p < 0.0001. CONCLUSION:DP40 CTASI represent a simple technique for improving detection and estimation of extent of ischaemia over NCCT and show close correlation with surrogate measures of infarct core.

OBJECTIVES:To create a nationwide consortium to gather all the data related to advanced devices used for aneurysm treatment and conduct pragmatic real-world studies despite the variations among all centres. The strength of this study will be in pooling data of the less commonly used recent devices where there is less evidence. The study will be prospective and retrospective where the initial recruitment figure is expected to be around 5000 patients. METHODS:To assess how endovascular techniques vary among different UK centres, we illustrate the results of initial surveys that were sent to those centres across the United Kingdom using a single device, the pipeline embolization device with vantage technology (PEDV). RESULTS:Although the centres were using the same device, the antiplatelet protocol varied from one centre to another as well as follow-up protocols according to the local experience, patient clinical status or even according to the adjuncts uses (e.g., adjunct coiling). CONCLUSIONS:The illustrated results show that although the centres were using the same device, the antiplatelet protocol varied from one centre to another. Also, follow-up protocols vary from one centre to another according to the local experience, patient clinical status or even according to the adjuncts used (e.g., adjunct coiling). This exemplar serves to illustrate that a nationwide consortium can pool and analyse data of any recent endovascular device. ADVANCES IN KNOWLEDGE:Obtaining nationwide data regarding safety, efficacy as well as risk factors for aneurysm recurrence when using recent devices. This study will add valuable data regarding the less commonly used recent devices where there is less evidence.

Cerebral blood flow (CBF) is under homeostatic control via cerebral autoregulation, maintaining a constant blood supply to brain parenchyma by integrating myogenic, metabolic, and neurogenic inputs across the neurovascular unit to stabilise perfusion despite physiological variations in cerebral perfusion pressure. While the mechanisms that underpin the control of CBF have been extensively investigated, this narrative review aims to holistically synthesise key findings for clinicians and researchers across healthy and diseased states. We first summarise autoregulatory inputs, cellular effectors, and typical stimuli/responses (with practical caveats including non-linearity, frequency dependence, and pressure-passivity). We then discuss monitoring approaches for assessing CBF and contrast cross-sectional techniques with portable bedside modalities, highlighting what each primarily measures (perfusion, velocity, oxygenation proxy, or flow index), their typical applications, and key constraints (radiation exposure, invasiveness, operator dependence, penetration depth, quantification). For historical context, we briefly note invasive monitors that remain selectively indispensable within multimodal neurocritical care. Looking forward, we outline emerging directions that prioritise non- and minimally-invasive solutions, including photoacoustic imaging, functional ultrasound, diffuse optical methods, speckle-based optics, and machine learning-enhanced post-processing, alongside hybrid multimodal integration. Collectively, these developments aim to improve accuracy, repeatability, and scalability of CBF monitoring and to support individualised decision-making across the clinical neurosciences.

BackgroundBalloon guide catheters (BGCs) are adjunctive devices that may be used during mechanical thrombectomy (MT) to induce flow arrest and improve clot retrieval and reperfusion outcomes for acute ischemic stroke. As the cost-effectiveness of BGC use remains uncertain, this study assessed short- and long-term direct healthcare costs associated with BGC use versus standard guide catheters (SGC) during MT.MethodsA decision tree model estimated the short-term costs (index hospitalization), long-term costs (one year after index hospitalization), and total costs for patients undergoing MT + BGC versus MT + SGC from a healthcare system perspective in the United States (US), Canada, United Kingdom (UK), Sweden, Germany, Italy, Spain, Belgium, and The Netherlands. Average device costs were sourced from public tender prices and market research data. Weighted average healthcare costs for modified Rankin Scale scores were sourced from published literature for the respective countries. A 2024 meta-analysis supporting improved outcomes with BGC provided input parameters to model treatment effects for BGC and SGC. Deterministic one-way and probabilistic sensitivity analyses evaluated the robustness of model parameters and accounted for uncertainty.ResultsAcross all countries, long-term and total per-patient costs were lower with MT + BGC, yielding total per-patient cost savings of $6297 (US), CAD 3006 (Canada), £1828 (UK), 28,950 kr (Sweden), €1077 (Germany), €709 (Italy), €3678 (Spain), €2259 (Belgium), and €3344 (The Netherlands). The probability of MT + BGC yielding cost savings ranged 0.356-0.911 (short term), 0.962-0.975 (long term), and 0.838-0.935 (total costs). While long-term and total costs consistently favored MT + BGC, short-term cost savings showed more variability across countries.ConclusionThis study demonstrates that BGC use is associated with total one-year per-patient cost savings for inpatient and postdischarge stroke care across the US, Canada, and seven European healthcare systems. Balloon guide catheters can potentially reduce post-stroke care costs and should be considered more broadly, despite the additional cost incurred by the device.

Objective The objective of this scoping review is to understand the extent and type of evidence in relation to the use of glucagon-like peptide-1 receptor agonists (GLP1-RA) for neuroprotection in aneurysmal subarachnoid haemorrhage (aSAH). Introduction The individual and societal costs of aSAH remain high. Effective neuroprotection would reduce morbidity and mortality but there are uncertainties around both established and emerging therapies. GLP1-RA show promise as neuroprotective drugs in other forms of acute and chronic brain injury and could be repurposed for aSAH. Inclusion criteria Animal and human studies of the use of GLP1-RA for aSAH will be included. Key exclusions are traumatic or non-aneurysmal subarachnoid haemorrhage, or the use of multi-agonist drugs. Methods Searches will conducted in Embase (Ovid), Medline (Ovid), Cochrane Central Register of Controlled Trials (Wiley) and the World Health Organisation's International Clinical Trials Registry Platform with no limits applied. Studies for data extraction will be identified by two independent reviewers after screening of titles and abstracts then full text review of potentially relevant articles against inclusion criteria. Data will be extracted by two independent reviewers using a charting tool based on the Joanna Briggs Institute template. A narrative review and summary of findings will be presented. Keywords cortical spreading depressions; critical care; neurosurgery; stroke; vasospasm, intracranial ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data that will be produced in the work described in this protocol will be contained in the review manuscript

BACKGROUND AND PURPOSE:M2 middle cerebral arterial (MCA) occlusions present a greater radiological challenge when compared to more proximal occlusions and additional signs aiding detection could be helpful. We routinely image patients with a dual-phase CT angiography (CTA) protocol, encompassing a bolus-tracked arterial/early and then delayed-phase (40-s post contrast injection) acquisition. We screened a 12-month period of our local thrombectomy database as a preliminary investigation into additional signs that can be gleaned to aid M2 occlusion diagnosis when imaged using this technique. METHODS:We reviewed the CTA and digital subtraction angiographic (DSA) imaging in 10 consecutive patients with M2 MCA occlusions who subsequently underwent thrombectomy. RESULTS:All patients showed the presence of hyperattenuating M3 and M4 vessels distal to the occlusion on delayed-phase but not early-phase CTA (despite venous opacification evident on the latter). Compared to the contralateral side, attenuation values were significantly elevated in these vessels (202.3 [23.9] vs. 108.5 [16.4] Hounsfield units [HU]; 95% confidence interval [CI] of difference: 69.7-117.9, p < 0.0001). Eight of 10 patients also showed associated ipsilateral hyperattenuating cortical veins; the attenuation difference compared to contralateral cortical veins was 263.5 (58.3) vs. 151 (16.7) HU, 95% CI: 69.0-156.0, p = 0.0005. Collateral appearance and washout were much brisker on DSA suggesting that the signs on delayed-phase CTA represent the retrograde accumulation of contrast material distal to the occlusion after multiple contrast passes with slowed resultant venous flow accounting for an accumulation on the venous side. CONCLUSION:An additional phase at 40-s displays hyperattenuating distal arteries and cortical veins that could aid in occlusion detection.

Chronic subdural haematoma (cSDH) is a common neurosurgical disorder in older people and projected to become the most common cranial neurosurgical pathology by 2030. Incidence of cSDH has risen in recent years as a consequence of improved access to brain imaging, and the increased prescribing of antithrombotic medication for both primary and secondary prevention of vascular disease. Chronic SDH typically presents with an insidious onset of broad-ranging symptoms including impaired cognition, gait, balance and mobility, often with headache. It progresses to more fulminant symptoms of hemiplegia, dysphasia and eventually coma. Although the established standard of care for clearly symptomatic cSDH is burr hole trephination, Middle Meningeal Artery Embolisation (MMAE) has emerged as a minimally invasive treatment option for some patients with cSDH. This is a rapidly evolving field: recently published randomised control trials have provided an evidence-base supporting the use of MMAE not only as an adjunct to burr hole trephination, but also in patients in whom trephination is contraindicated, or in patients with mild symptomatology who are not considered appropriate for immediate burr hole trephination. This article provides practical, real-world guidance on current best practice based on our experience and the published evidence available to date. We use case studies and treatment algorithms from the UK's highest volume MMAE centre to illustrate collaborative care pathways for patients with cSDH between neurosurgery, interventional neuroradiology and trauma geriatricians.

We describe the use of direct superficial temporal artery puncture to access the left middle meningeal artery for embolization of a recurrent chronic subdural hematoma in a patient with a type A aortic dissection, involving the origin of the left common carotid artery which precluded conventional access from a radial or femoral approach.

Background Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. With the move to 24/7 provision, we aimed to assess (1) the change in referral and procedural frequency and timing, (2) reasons referrals did not proceed to MT, and (3) nocturnal procedural efficacy and safety.Methods This was an observational study comparing 12-month data for an extended daytime service (2021/2022, hours, 0800-2000) to that for a 12-month period delivering 24/7 cover (2023-2024). Nocturnal and daytime outcomes (rate of recanalisation using modified TICI scoring), extent of postprocedural infarction (using ASPECTS grading), rate of early neurological improvement (using 24-h NIHSS change), 90-day mortality, and complicating symptomatic intracranial haemorrhage (SICH) in the latter period were compared.Results Both referrals (432 to 851) and procedural caseload (191 to 403) approximately doubled with the move to 24/7 cover; 36% of procedures occurred overnight (n = 145). The dominant reasons for referrals not proceeding to MT were a large core infarct (n = 144) or absence of a large vessel occlusion on baseline imaging (n = 140). There were no significant differences in successful recanalisation (TICI 2B/3: 85.5% vs 87.1%, P = .233), rates of postprocedural ASPECTS >= 7 (74.9% vs 75.8%, P = .987), early neurological improvement (NIHSS reduction >= 30%: 43.4% vs 42.4%, P = .917), 90-day mortality (19.6% vs 18.6%, P = .896), or SICH (1.9% vs 4.1%, P = .214) obtained for daytime vs nighttime hours.Conclusion 24/7 MT provision has resulted in a rapid rise in the number of patients who may benefit from MT. This service can be provided with an acceptable safety profile during nighttime hours in a high-volume comprehensive UK centre. Key messages What is already known on this topic? Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. What this study adds? Implementation of a 24/7 mechanical thrombectomy service was associated with a doubling of the number of referrals relative to an extended daytime service. Thrombectomy activity increased by over 100%. Over one-third of procedures were performed overnight. No significant differences in case mix, recanalisation rate, measures of early neurological improvement, or serious complication rate were demonstrated for cases performed during nighttime versus daytime hours. How this study might affect research, practice, or policy? The study raised further research questions. Does our practice relate to other UK centres and have other units had a similar experience? Will imaging interpretation tools alter the speed of referral and ratio of referrals to procedures? Will inclusion of more patients with large core infarcts at baseline significantly alter the procedural workload?

Recurrence rates following surgical management of chronic subdural haematoma (CSDH) range from 5 to 33 %. There is growing evidence which suggests middle meningeal artery embolisation (MMAe) may reduce recurrence rates when used as surgical adjunct or standalone treatment. In this study we described our experience of this new procedure in the our UK institution. Patients with recurrent CSDH or CSDH at high risk of recurrence were selected for MMAe on a case -by -case basis following MDT discussion. A departmental database was used to identify patients treated. 26 CSDH were embolised in 20 patients; 9 CSDH were de-novo and 17 were recurrent. 10/26 CSDH were treated with MMAe only. No procedural mortality, access site or thrombo-embolic complications occurred. One patient experienced symptomatic collection growth 12 h following MMAe and required surgical drainage. 15 (75 %) of patients were living at home at follow-up (mean 14 months). On imaging followup 15/18 showed CSDH volume reduction or resolution, 1/18 remained stable requiring no further treatment, 2/ 18 patients suffered recurrent CSDH requiring treatment. In both recurrent cases incomplete embolisation was noted on procedural imaging (posterior division of MMA not embolised). Persistent posterior MMA division filling was significantly associated with collection recurrence (p = 0.002). Our results suggest MMAe as a standalone or adjuvant therapy can be performed safely in a UK neuroscience setting and is associated with high rates of symptomatic CSDH size reduction or resolution in problematic CSDH that have either recurred or are prone to recurrence.

Background The Pipeline Vantage Embolization Device (PEDV) is the fourth-generation pipeline flow diverter for intracranial aneurysm treatment. There are no outcome studies for the second PEDV version. We aimed to evaluate safety and efficacy outcomes. Primary and secondary objectives were to determine outcomes for unruptured and ruptured cohorts, respectively. Methods In this multicenter retrospective and prospective study, we analyzed outcome data from eight centers using core laboratory assessments. We determined 30-day and ≥3-month mortality and morbidity rates, and 6- and 18-month radiographic aneurysm occlusion rates for procedures performed during the period July 2021–March 2023. Results We included 121 consecutive patients with 131 aneurysms. The adequate occlusion rate for the unruptured cohort at short-term and medium-term follow up, and also for the ruptured cohort at short-term follow up, was >90%. Two aneurysms (1.5%) underwent retreatment. When mortality attributed to a palliative case in the unruptured cohort, or subarachnoid hemorrhage in the ruptured cohort, was excluded then the overall major adverse event rate in respective cohorts was 7.5% and 23.5%, with 0% mortality rates for each. When all event causes were included on an intention-to-treat basis, the major adverse event rates in respective cohorts were 8.3% and 40.9%, with 0.9% and 22.7% mortality rates. Conclusions For unruptured aneurysm treatment, the second PEDV version appears to have a superior efficacy and similar safety profile to previous-generation PEDs. These are acceptable outcomes in this pragmatic and non-industry-sponsored study. Analysis of ruptured aneurysm outcomes is limited by cohort size. Further prospective studies, particularly for ruptured aneurysms, are needed.