Abstract Background and aims Randomised trials have not shown a clear benefit on function outcome of bridging IV thrombolysis (IVT) over direct endovascular thrombectomy (EVT). However meta-analyses and observational data suggest better technical success with bridging, particularly when IVT is ongoing during EVT. We aimed to evaluated whether IVT still infusing at groin-puncture and shorter IVT-to-groin-puncture times are associated with better angiographic reperfusion after EVT. Methods We analysed consecutive EVT-treated patients from the ASTRAL registry (Lausanne, Switzerland). IVT was considered as ongoing during EVT if groin-puncture occurred ≤65 minutes from IVT start. The primary outcome was successful angiographical reperfusion (TICI-score≥2b). Analyses were adjusted for age, sex, vascular risk factors, baseline NIHSS and ASPECTS, onset-to-puncture time, occlusion site, and care organisation (“drip-and-ship” vs “mothership”). Results Of 1732 consecutive patients (mean/SD age 70.8/14.6, 45% female) undergoing EVT, 714 (41.2%) were EVT-only, 623 (36.0%) had IVT completed before groin puncture, and 395 (22.8%) had ongoing IVT at EVT start. eTICI≥2b was achieved in 1562 (90.2%) patients. Ongoing IVT at puncture was associated with higher odds of TICI≥2b (aOR=2.12, 95%CI=1.34–3.38), with no increased risk of haemorrhage (aOR=0.97, 95%CI=0.73-1.28). In bridging patients, longer IVT-to-EVT intervals were associated with lower odds of TICI≥2b (per additional hour: aOR=0.58,95%CI 0.44–0.76). Conclusions IVT still ongoing at groin puncture and shorter IVT-to-puncture intervals were associated with more near-complete angiographic reperfusion. These findings complement prior work showing time-dependent effects of thrombolysis-to-puncture interval on reperfusion and functional outcome, and provide mechanistic support for adjunct thrombolysis after suboptimal EVT reperfusion. Conflict of interest Davide Strambo: advisory board for Boehringer Ingelheim

Background/Objectives: MRI-guided neurovascular interventions could benefit from lower-field systems due to reduced magnetic and radiofrequency hazards. However, safety and practical visibility of commonly used neurointerventional devices at 0.55 T remain insufficiently characterized. We evaluated magnetic field interactions, RF-induced heating, and qualitative device visibility in 11 commercially available and commonly used neurovascular devices on a 0.55 T MRI system. Methods: Eleven devices, including stent retrievers, guidewires, catheters, and one embolization implant, were tested at 0.55 T. Magnetostatic interactions were quantified using the American Society for Testing and Materials (ASTM)-guided deflection methods for translational force (ASTM-F2052) and a two-string suspension apparatus for torque (adapted from Stoianovici et al.). RF-induced heating was measured in an in vitro perfused cerebral vessel phantom using a 15 min high-specific absorption rate spin echo sequence under static and flow conditions. Qualitative device visibility was assessed using a turbo spin echo (TSE) and balanced steady-state free precession (bSSFP) imaging on each device individually. Results: Eight of eleven devices passed the translational force test, while three devices (D, E, and G), containing significant ferromagnetic components, failed with deflection angles > 45°. Eight devices passed torque testing, remaining below the critical threshold in all rotation positions; three devices (D, G, and J) failed by exceeding the 54° criterion, including one guidewire and two devices with braided/coiled metallic structures. Under static conditions, RF-induced heating ranged from negligible to 10.4 °C (maximum in device D) and generally decreased under flow; in the flow configuration, temperature rise remained below 2 °C for 6/11 devices. Qualitative imaging performance differed by sequence, with bSSFP enabling improved delineation of device structure (best for devices A, C, and H), whereas devices D, E, F, and J produced extensive signal voids that precluded reliable visualization in both sequences. Overall, three devices satisfied all safety criteria while remaining clearly visible under MRI. Conclusions: Devices that pass safety thresholds at 0.55 T can serve as candidates for further sequence optimization and preclinical workflow development, enabling the design of low-SAR, device-compatible imaging protocols tailored for neurointerventional workflows. These results provide key safety data supporting the feasibility of MR-guided neurovascular procedures at 0.55 T.

BACKGROUND:The optimal management of isolated posterior cerebral artery occlusion (iPCAO) remains unclear. We investigated whether baseline perfusion imaging parameters are associated with clinical outcomes and whether they modify the association between endovascular therapy (EVT) and outcomes in iPCAO. METHODS:This prespecified secondary analysis of the international, multicenter, observational PLATO (Posterior Cerebral Artery Occlusion) registry (35 centers, 10 countries, 2015-2025) included consecutive adults with unilateral iPCAO and baseline perfusion imaging (computed tomography or magnetic resonance imaging) with reconstructed parameters. The primary end point was an excellent 90-day outcome (modified Rankin Scale score, 0-1). Perfusion parameters included hypoperfusion volume, infarct core volume, and mismatch ratio. The primary analysis used multivariable mixed-effects regression models (center as random effect) to assess associations between perfusion parameters and outcomes, adjusting for age, sex, treatment year, prestroke modified Rankin Scale score, baseline National Institutes of Health Stroke Scale score, diabetes, stroke cause, posterior circulation Acute Stroke Prognosis Early Computed Tomography Score, occlusion site, intravenous thrombolysis, and onset-to-door time. To test whether the association between EVT and outcomes varies according to baseline perfusion parameters, we evaluated treatment-by-perfusion interactions by including interaction terms (treatment×perfusion parameter) in inverse probability of treatment weighting-adjusted models, with results expressed as ratios of odds ratios (ORs). RESULTS:Of 1811 patients with iPCAO, 443 met inclusion criteria (median age, 74 years; 41.8% female). Larger hypoperfusion volume was associated with lower odds of excellent outcome (adjusted OR, 0.72 [95% CI, 0.58-0.89] per 1-unit increase in natural logarithm-transformed volume). No interaction between perfusion parameters and EVT was observed for the primary outcome. However, increasing core volume was associated with a progressively less favorable modified Rankin Scale score shift (ratio of OR, 0.66 [95% CI, 0.48-0.90]; Pinteraction=0.009) and higher mortality (ratio of OR, 1.82 [95% CI, 1.10-3.03]; Pinteraction=0.021) with EVT compared with medical management. Increasing hypoperfusion volume was associated with a higher risk of symptomatic intracranial hemorrhage with EVT (ratio of OR, 10.15 [95% CI, 1.06-96.93]; Pinteraction=0.044). CONCLUSIONS:In iPCAO, perfusion imaging provides independent prognostic information but does not identify patients with potential benefit from EVT and may instead indicate those at higher procedural risk. REGISTRATION:URL: https://osf.io/62mwt; Unique identifier: NCT05291637.

Retinoblastoma is the most common and intrusive intraocular cancer in children. Intra‐arterial chemotherapy is an effective method of delivering concentrated doses of cancer‐killing medicine to the affected area of the eye. The conventional clinical procedure entails positioning the microcatheter tip at the ostium of the ophthalmic artery (OA), as catheterizing the OA carries a high risk of serious complications. Here we present a microrobotic platform that allows teleoperated and autonomous navigation of flow‐driven microcatheters into the OA for superselective infusion of chemotherapy. The platform integrates real‐time imaging, closed‐loop control, and miniaturized instrumentation to achieve submillimeter precision in catheter placement. Computational fluid dynamics models of pediatric vascular anatomy inform the development of effective navigation strategies. Extensive benchtop validations with patient‐derived biomimetic phantoms demonstrate the versatility and clinical relevance of the platform. The proposed microrobotic approach has the potential to improve treatment outcomes and broaden the accessibility of state‐of‐the‐art therapies for children in developing countries suffering from a life‐threatening condition.

OBJECTIVES:Rescue stenting (RS) has emerged as a bailout strategy after failed reperfusion during endovascular treatment (EVT). Optimal blood pressure (BP) management after RS remains unclear. Our aim is to evaluate the association of BP levels and blood pressure variability (BPV) during the first 24 h after RS with short-term and long-term patient outcomes. METHODS:We performed a retrospective analysis of an international registry where data from adult patients who underwent either RS or rescue angioplasty after failed EVT were collected. Patients who received RS with large vessel occlusion and at least 4 BP measurements in the first 24 h were included. RESULTS:RS was performed in 437 patients (40.5% female, mean age 67.1 ± 13 years). Admission median National Institutes of Health Stroke Scale score was 12 (IQR 7-18) and history of hypertension was present in 74.2% of patients. Μean Systolic BP (SBP) in the first 24 h was 137.4 ± 14.6 mmHg. Higher values of BPV (coefficient of variation, standard deviation, average real variability and successive variation) were associated with lower odds for Modified Rankin Scale score 0-2 at 90 days (adjusted odds ratio ranging 0.55 [0.38, 0.79] to 0.99 [0.98, 0.99] per 10 units increase). No associations were found between any SBP measure and death, sICH as well as neurological deterioration at 24 h. CONCLUSION:In our study, higher BPV was associated with worse clinical outcomes in stroke patients treated with RS as bailout therapy after failed reperfusion. No association was shown between mean, maximum, minimum and delta SBP and clinical outcomes.

Background and Purpose: Intra-arterial thrombolysis as an adjunct to mechanical thrombectomy is increasingly being considered to enhance reperfusion in acute ischemic stroke patients. Intra-arterial thrombolysis may increase the risk of post-thrombectomy intracerebral hemorrhage (ICH) in certain patient subgroups. Methods: We analyzed acute ischemic stroke patients treated with mechanical thrombectomy in a multicenter registry. The occurrence of any (asymptomatic and symptomatic) post-thrombectomy ICH was ascertained using standard definition requiring serial neurological examinations and computed tomographic scans. We determined the risk of ICH in subgroups defined by clinical characteristics, and use of intravenous (IV) thrombolysis. Results: A total of 146 (7.5%) patients received intra-thrombolysis among 1953 acute ischemic stroke patients who underwent mechanical thrombectomy. The proportion of patients who developed any ICH was 26 (17.8%) and 510 (28.2%) among patients who were and were not treated with intra-arterial thrombolysis (p=0.006). Among patients who received IV thrombolysis (n=1042), the proportion of patients who developed ICH was 9 (16.7%) and 294 (30.7%) among patients who were and were not treated with intra-arterial thrombolysis (p=0.028). The risk was not different in strata defined by age, gender, location of occlusion, pre-procedure National Institutes of Health Stroke Scale score, time interval between symptom onset and thrombectomy, Alberta Stroke Program Early CT score, systolic blood pressure, and serum glucose concentrations. Conclusions: In patients undergoing mechanical thrombectomy, the risk of any ICH and sICH was not increased with intra-arterial thrombolysis, including in those who had already received IV thrombolytics.

Background Reversible cerebral vasoconstriction syndrome (RCVS) is a transient cerebrovascular disorder characterized by multifocal segmental narrowing of cerebral arteries, often presenting with thunderclap headaches. Known triggers include physical exertion, emotional stress, vasoactive substances, and sexual activity. However, the role of sexual devices in precipitating RCVS has not been documented. Case We describe a 50-year-old woman with well-controlled hypertension and noninsulin-dependent diabetes mellitus who experienced recurrent thunderclap headaches triggered by an orgasm following the use of a sexual device. Neurological examination and lumbar puncture were unremarkable. Magnetic resonance imaging and digital subtraction angiography revealed multifocal arterial narrowing, consistent with RCVS. The patient was treated with oral Nimodipine, leading to complete symptom resolution. A one-year follow-up angiography demonstrated full recovery. Conclusions This case highlights the potential for intense sexual stimulation via a device to act as a previously unrecognized trigger for RCVS. Given the widespread use of sexual devices, healthcare providers should consider this association when evaluating patients with orgasm-induced thunderclap headaches. Further research is needed to understand the mechanisms underlying this phenomenon and to improve patient counseling and management.

Background:Rescue stenting (RS) is a bailout strategy for failed thrombectomy. Optimal platelet inhibition strategy after RS remains unclear. Objectives:We aimed to describe and compare different platelet inhibition strategies during/after RS. Design:Retrospective cohort study across 34 international centers. Methods:Patients with large vessel occlusion and RS after failed thrombectomy (2019-2023) were included. Periprocedural and postprocedural platelet inhibition strategies were described and compared, focusing on glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, single antiplatelet therapy (SAPT), and dual antiplatelet therapy (DAPT). We assessed the effects of platelet inhibition strategy and potentially covariates on the primary outcome of 90-day modified Rankin Scale (mRS) using ordinal shift analysis with proportional odds models. Results:RS was performed in 589 patients (mean age 67.9 years, 60.8% male). Numerous combinations of platelet inhibitors were administered. Periprocedural GPIIb/IIIa inhibitors were used in 61.5% of patients. Postprocedural DAPT was administered to 80.5% and SAPT to 13.3%. Functional independence (mRS 0-2) was achieved in 40.7%, while 26.3% died within 90 days. Stent occlusion occurred in 20.5%, with 67.6% of these occlusions within 24 h. Postprocedural stent-occlusion was independently associated with worse functional outcome at 90 days (OR 4.1, 95% CI 2.3-7.2, p < 0.001). No significant association between periprocedural GPIIb/IIIa inhibitors, and 90-day mRS or stent occlusion was found. Postprocedural SAPT was associated with worse functional outcomes (adjusted odds ratio (aOR) 2.4, 95% CI 1.1-5.0, p = 0.02), higher mortality (aOR 2.1, 95% CI 1.05-4.0, p = 0.03), and increased stent occlusion rates (aOR 4.8, 95% CI 2.3-9.7, p < 0.001) compared to postprocedural DAPT. Symptomatic intracranial hemorrhage occurred in 6.8% of patients, with no significant difference between antiplatelet regimens. Conclusion:Extensive heterogeneity exists in platelet inhibition strategies following RS. Stent occlusion is associated with worse clinical outcomes, and the first 24 h post-RS are critical for stent patency. Compared to SAPT, DAPT was associated with better functional outcome, lower mortality, and lower stent occlusion rates.

Background and Purpose Neuroimaging is essential before intravenous thrombolysis (IVT) and endovascular treatment (EVT) for acute ischemic stroke (AIS). In May 2018, our center transitioned from computed tomography (CT) to magnetic resonance imaging (MRI) as the first-line imaging for suspected AIS. We aimed to assess the consequences of an MRI-based paradigm on patients’ selection, rates of acute treatment, time metrics, safety of both IVT and EVT, and clinical outcomes. Methods Using data from the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we analyzed an equal number of patients from the CT-period (December 2012 to May 2018) and the subsequent MRI-period (May 2018 to August 2022). We performed univariable and multivariable analysis. Results We included 2,972 consecutive AIS patients, 1,131 undergoing IVT and 662 EVT. Compared to the CT-period, the MRI-period showed similar rates of early and late IVT and EVT. The potentially missed-IVT opportunities decreased (3.1% vs. 0.8%; Padj<0.01). Median door-to-needle time was longer in the MRI-period (43 min vs. 31 min, β-coefficientadj=15, 95% confidence interval [CI]=11–27, Padj<0.01), while door-to-puncture time was unchanged (β-coefficientadj=9.95, 95% CI=-2.24–22.14, Padj=0.11). Rates of symptomatic intracranial hemorrhage (SICH) were similar after IVT (5.6% vs. 3.2%, Padj= 0.99) and EVT (±IVT) (6.5% vs. 4.2%, Padj=0.52). Disability at 3 months was unaffected for both IVT and EVT patients (Padj=0.36 and Padj=0.52 respectively). Conclusion The transition from CT to MRI as the first-line imaging reduced the rates of potentially missed IVT opportunities. While door-to-needle time increased, door-to-puncture time remained stable. Safety as measured by SICH rates and 3-month disability were unaffected by the imaging paradigm shift.

This case series examines mechanical thrombectomy (MT) with thromboaspiration in two infants under 1 year, a rarely performed procedure due to ethical challenges and limited data. Both cases involved thromboembolic complications during intra-arterial chemotherapy for retinoblastoma. An 11-month-old with left posterior inferior cerebellar artery occlusion and a 5-month-old with basilar artery occlusion underwent MT, achieving full recanalization (eTICI = 3) without infarction or hemorrhage. Postoperative imaging confirmed no complications, and both patients had normal neurological outcomes (pedNIHSS = 0). These cases highlight the feasibility and safety of MT in infants, demonstrating its potential to achieve excellent outcomes in high-risk situations. Further research is needed to establish standardized guidelines and expand MT's use in pediatric stroke management.

BACKGROUND:Non-ischemic cerebral enhancing (NICE) lesions following aneurysm endovascular therapy are exceptionally rare, with unknown longitudinal evolution. OBJECTIVE:To evaluate the radiological behavior of individual NICE lesions over time. METHODS:Patients included in a retrospective national multicentric inception cohort were analyzed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm treatment, with no other confounding disease. Lesion burden and the longitudinal behavior of individual lesions were assessed. RESULTS:Twenty-two patients were included, with a median initial lesion burden of 36 (IQR 17-54) on the first MRI scan. Of the 22 patients with at least one follow-up MRI scan, 16 (73%) had new lesions occurring mainly within the first 200 weeks after the date of the procedure. The median number of new lesions per MRI was 6 (IQR 2-16). Among the same 22 patients, 7 (32%) had recurrent lesions. The median persistent enhancement of a NICE lesion was 13 weeks (IQR 6-30). No factor was predictive of early regression of enhancement activity with lesion regression kinetics mainly being patient-dependent. CONCLUSIONS:The behavior of individual NICE lesions was found to be highly variable with an overall patient-dependent regression velocity.

For thrombectomy, some stroke centres have started to use two stents simultaneously instead of only one to achieve better recanalisation rates, i.e. a double stentriever (DS) technique. The first observations regarding this new technique are promising. We aim to report our experience in DS at the acute phase of stroke, compare with the single stentriever technique. We included consecutive individuals undergoing mechanical thrombectomy in the setting of acute ischemic stroke associated to a large vessel occlusion (LVO) or medium vessel occlusion (MeVO) in the anterior circulation. Individuals were included between 01.2022 and 07.2023. We excluded individuals <18 years old, those who were treated beyond 24h from last proof of good health and those who were not treated with stentriever as a first-line recanalization strategy. We compared patients undergoing double-stentriever (DS) technique for first-pass strategy vs single-stentriever (SS) technique for first-pass strategy. For the primary outcome analysis, we assessed first-pass complete recanalization (eTICI 2c-3) applying ordinal regression analyses using other prognostic co-variates. Secondary safety outcomes included procedure-related complications, early neurologic deterioration of ischemic origin (ENDi) and symptomatic intracerebral bleeding (sICH). Secondary functional outcomes included 24h-NIHSS and 3 month modified Rankin Scale (mRS). Complications such as procedural perforation, dissection, bleedings, embolization, access complication and/or reocclusion were also assessed as a dichotomized variable. Ethical commission approval and individual consent were not required according to the Swiss Human Research Act because all local data were anonymized before analysis, and because this quality assessment project aimed at the evaluation of safety and effectiveness of revascularisation treatment in current clinical practice. Among 187 consecutive people (median age 76 (IQR= 65-83), 97/187 (52 % female, median admission NIHSS 14 (IQR=7-19)). Among them, 39 (26%) were treated with first pass DS and 148 patients (74%) with first pass SS. Within the SS group, 16 patients had rescue DS. First-pass complete recanalization (eTICI 2c-3) was achieved in 29/39 (74%) individuals treated with DS technique compared to 63/148 (43%) receiving SS technique. Procedural complications were seen in 5/39 (13%) in the DS group vs 39/148 (26%) with SS. ENDi was evidenced in 3/39 (8%) with DS compared to 18/148 (12%) with SS. sICH according to ECASSII definition was seen in 2/39 (5%) in DS compared to 8/148 (5%) in the SS group. We dramatically increase the rate of first pass eTICI 2c/3 with DS. We didn't observe more complication rate during DS technique. Prospective randomized controlled trials are needed to support our conclusions.

BACKGROUND AND PURPOSE:Intraarterial thrombolysis as an adjunct to mechanical thrombectomy is increasingly being considered to enhance reperfusion in acute ischemic stroke patients. Intraarterial thrombolysis may increase the risk of post-thrombectomy intracerebral hemorrhage (ICH) in certain patient subgroups. METHODS:We analyzed acute ischemic stroke patients treated with mechanical thrombectomy in a multicenter registry. The occurrence of any (asymptomatic and symptomatic) post-thrombectomy ICH was ascertained using standard definition requiring serial neurological examinations and computed tomographic scans acquired within 48 hours of the thrombectomy. We determined the risk of ICH in subgroups defined by clinical characteristics and the use of intravenous (IV) thrombolysis. RESULTS:A total of 146 (7.5%) patients received intraarterial thrombolysis among 1953 acute ischemic stroke patients who underwent mechanical thrombectomy. The proportion of patients who developed any ICH was 26 (17.8%) and 510 (28.2%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .006). The proportion of patients who developed symptomatic ICH was 4 (2.7%) and 30 (1.7%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .34). Among patients who received IV thrombolysis (n = 1042), the proportion of patients who developed any ICH was 9 (16.7%) and 294 (30.7%) among patients who were and were not treated with intraarterial thrombolysis, respectively (p = .028). The risk was not different in strata defined by age, gender, location of occlusion, preprocedure National Institutes of Health Stroke Scale score, time interval between symptom onset and thrombectomy, Alberta Stroke Program Early CT Score, systolic blood pressure, and serum glucose concentrations. CONCLUSIONS:In patients undergoing mechanical thrombectomy, the risk of any ICH and symptomatic ICH was not increased with intraarterial thrombolysis, including in those who had already received IV thrombolytics.

BACKGROUND: The relative value of computed tomography (CT) and magnetic resonance imaging (MRI) in acute ischemic stroke (AIS) is debated. In May 2018, our center transitioned from using CT to MRI as first-line imaging for AIS. This retrospective study aims to assess the effects of this paradigm change on diagnosis and disability outcomes. METHODS: We compared all consecutive patients with confirmed diagnosis of AIS admitted to our center during the MRI-period (May 2018–August 2022) and an identical number of patients from the preceding CT-period (December 2012–April 2018). Univariable and multivariable analyses were performed to evaluate outcomes, including the number and delay of imaging exams, the rate of missed strokes, stroke mimics treated with thrombolysis, undetermined stroke mechanisms, length of hospitalization, and 3-month disability. RESULTS: The median age of the 2972 included patients was 76 years (interquartile range, 65–84), and 46% were female. In the MRI-period, 80% underwent MRI as first acute imaging. The proportion of patients requiring a second acute imaging modality for diagnostic ± revascularization reasons increased from 2.1% to 5% ( P unadj <0.05), but it decreased in the subacute phase from 79.0% to 60.1% ( P adj <0.05). In thrombolysis candidates, there was a 2-minute increase in door-to-imaging delay ( P adj <0.05). The rates of initially missed AIS diagnosis was similar (3.8% versus 4.4%, P adj =0.32) and thrombolysis in stroke mimics decreased by half (8.6% versus 4.3%; P adj <0.05). Rates of unidentified stroke mechanism at hospital discharge were similar (22.8% versus 28.1%; P adj =0.99). The length of hospitalization decreased from 9 (interquartile range, 6–14) to 7 (interquartile range, 4–12) days ( P adj =0.62). Disability at 3 months was similar (common adjusted odds ratio for favorable Rankin shift, 0.98 [95% CI, 0.71–1.36]; P adj =0.91), as well as mortality and symptomatic intracranial hemorrhage. CONCLUSIONS: A paradigm shift from CT to MRI as first-line imaging for AIS seems feasible in a comprehensive stroke center, with a minimally increased delay to imaging in thrombolysis candidates. MRI was associated with reduced thrombolysis rates of stroke mimics and subacute neuroimaging needs.

BACKGROUND:In intra-arterial chemotherapy for retinoblastoma, a backflow from unreachable external carotid artery branches in the ophthalmic artery can be challenging.OBJECTIVE:To describe a new endovascular technique using Gelfoam pledgets to temporarily occlude distal branches of the external carotid artery to reverse the competitive backflow into the ophthalmic artery in order to perform intra-arterial chemotherapy via the ostium of the ophthalmic artery in selected cases.METHODS:We queried our prospectively collected database of 327 consecutive patients treated for retinoblastoma by intra-arterial chemotherapy and identified those employing Gelfoam pledgets. We describe this new technique with emphasis on feasibility and safety.RESULTS:We treated 11 eyes with 14 infusions of intra-arterial chemotherapy using Gelfoam pledgets to occlude the distal branches of the external carotid artery. We report no perioperative complications due to this occlusion technique. At the ophthalmologic follow-up 1 month after the injection of Gelfoam pledgets, all cases showed tumor regression or stable disease. Two injections into the same eye as the rescue intra-arterial chemotherapy infusion resulted in a transient exudative retinal detachment, and one injection in a heavily pretreated case was followed by iris neovascularization and retinal ischemia. None of the pledget injections led to irreversible vision-threatening intraocular complications.CONCLUSIONS:Intra-arterial chemotherapy in retinoblastoma using Gelfoam to transiently occlude the distal branches of the external carotid artery and reverse the backflow into the ophthalmic artery seems feasible and safe. Larges series will help to confirm the effectiveness of this new technique.

BackgroundThe periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. MethodsWe followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. Results34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, P-heterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. ConclusionsIn AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.

BACKGROUND AND PURPOSE: Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world.MATERIALS AND METHODS: We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24?hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6?hours) versus late window (6?24?hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome.RESULTS: Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively).CONCLUSIONS: The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.

Background Intracranial atherosclerotic disease (ICAD) is a common cause of posterior circulation acute ischemic stroke. We aimed to compare baseline characteristics, recanalization rates, and clinical outcomes in patients with acute basilar occlusion due to underlying ICAD to patients with other causes of occlusion. Methods The Trevo Registry (ClinicalTrials.gov Identifier: NCT02040259) was a prospective open‐label mechanical thrombectomy registry that included 2008 patients from 76 sites across 12 countries. For a secondary analysis, we selected patients with isolated acute basilar occlusion. We then classified patients into 2 groups: patients with acute basilar artery occlusion due to ICAD (ICAD group) and patients with acute basilar occlusion due to another cause (non‐ICAD group). Results We identified 90 subjects with acute basilar occlusion. According to stroke mechanism, there were 9 (10.0%) patients in the ICAD group and 81 (90.0%) in the non‐ICAD group. There was a significant difference ( P =0.001) in the lesion location between the 2 groups, with 60.5% of non‐ICAD occlusions located in the distal region and no ICAD occlusions there. The 2 groups showed a significant difference ( P =0.003) for rescue therapy with balloon angioplasty, with 33.3% in the ICAD group and 1.2% in the non‐ICAD group, respectively. In a multivariable model adjusted for age, baseline National Institutes of Health Stroke Scale, and intravenous tissue‐type plasminogen activator (tPA), the odds of 90‐day death (odds ratio=4.6; P =0.10) were higher for atherosclerotic subjects. Conclusion Acute basilar occlusions related to ICAD showed a similar good clinical outcome (modified Rankin scale (mRS) 0–2) and a tendency for a higher rate of 90‐day mortality compared with non‐ICAD occlusions.