BACKGROUND:The RESCUE-ICAS study (Registry of Emergent Large-Vessel Occlusion due to Intracranial Stenosis) demonstrated that patients undergoing acute stenting of intracranial atherosclerosis with large-vessel occlusion after mechanical thrombectomy had better outcomes than those undergoing mechanical thrombectomy alone. We present 2 secondary analyses of RESCUE-ICAS to evaluate intracranial stenting among patients who achieved successful reperfusion. METHODS:From a prospective observational cohort of 25 stroke centers (2022-2023), patients with acute intracranial occlusion, National Institutes of Health Stroke Scale score ≥6, and 50% to 99% residual stenosis or occlusion after endovascular thrombectomy were included. In the first analysis, we compared patients with stenting versus those without stenting from among those patients with a final modified Thrombolysis in Cerebral Infarction score of 2B-3. In the second analysis, we compared patients who underwent stenting with those who did not from among the patients with a Thrombolysis in Cerebral Infarction (TICI) score of 2B-3 before stenting. The odds of a favorable 90-day mRS (0-2) and 24-hour MRI infarct volume <30 mL were assessed using multivariable logistic regression. We also examined the rates of symptomatic ICH and death at 90 days in these cohorts. RESULTS:Overall, 351 (84.2%) patients had successful reperfusion, with 181 (51.7%) undergoing stenting. More patients who underwent acute stenting achieved an mRS score of 0 to 2 at 90 days (adjusted odds ratio, 1.88; P=0.024). Patients who underwent stent placement were more likely to have 24-hour MRI infarct volume <30 mL (70.1% versus 54.8%, P=0.022). Our second analysis demonstrated that 89 patients who underwent acute intracranial stenting after successful perfusion (postmechanical thrombectomy) experienced higher odds of mRS scores of 0 to 2 at 90 days (adjusted odds ratio, 2.19 [95% CI, 1.01-4.74]) and 24-hour MRI infarct volume <30 mL (adjusted odds ratio, 3.27 [95% CI, 1.05-10.19]) than the 170 without stenting after successful reperfusion. There was no significant difference in rates of symptomatic ICH (7.2% versus 5.3%; P=0.466) or death at 90 days (22.7% versus 25.9%; P=0.480). CONCLUSIONS:Among both the cohort with final successful reperfusion and the cohort with initial successful reperfusion after mechanical thrombectomy alone, intracranial stenting was associated with better long-term clinical and radiographic outcomes, without higher morbidity and mortality. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05403593.

CSF-venous fistulas (CVF) are an important cause of spontaneous intracranial hypotension (SIH) and are increasingly treated with transvenous embolization (TVE). Based on the current published literature, approximately 8% of patients experience symptomatic recurrence due to local CVF persistence at the same site and level of prior TVE. The mechanisms responsible for persistent local CVF after TVE are unknown. Among 10 patients with local CVF persistence/recurrence after TVE, we found two mechanisms: 1) CVFs that occur at the margin of the Onyx cast, typically within the external venous plexus or the basivertebral vein; and 2) CVFs that occur due to inadequate occlusion of the internal epidural venous plexus, though not necessarily at the distal end of the Onyx cast. These findings may facilitate technical optimization of TVE for CVF and may also enable localization of persistent CVF in patients with symptomatic recurrence after TVE.

BACKGROUND:The Millipede AspiRation for Revascularization in Stroke (MARRS) pivotal study was a prospective, multicenter, single arm trial evaluating the safety and efficacy of the corrugated Millipede catheter system in patients with acute ischemic stroke due to large vessel occlusion. METHODS:Patients aged 18-85 years with internal carotid artery, M1, M2, or basilar artery occlusions treatable within 8 hours were eligible. Catheter selection was based on target vessel diameter (Millipede88 >2.7 mm; Millipede70 >2.2 mm). The primary efficacy endpoint was modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b within ≤3 passes without rescue therapy. Imaging and clinical outcomes were independently adjudicated. Secondary endpoints included first pass effect (mTICI ≥2c). RESULTS:180 patients were treated (57% US, 43% EU). Median age was 69 years, mean baseline National Institutes of Health Stroke Scale score was 17, and median Alberta Stroke Program Early CT Score was 9. M1 occlusion was the most common target lesion (62%). The primary endpoint was achieved in 160/180 patients (88.9%; 95% CI lower bound 84.3%) in the intention-to-treat cohort. Direct first pass aspiration was performed with Millipede88 and Millipede70 in 64% and 36% of patients, respectively. Navigation success was 96% with Millipede88 and 99% with Millipede70. Among Millipede88 patients, first pass mTICI ≥2c was achieved in 60%, increasing to 75% in the M1 subgroup. Final mTICI ≥2c was achieved in 85% of primary Millipede88 cases. Symptomatic intracranial hemorrhage occurred in 2.3%, intracranial dissection in 1.1%, no perforations occurred, and 90 day all cause mortality was 13.9%. CONCLUSIONS:The Millipede aspiration system demonstrated excellent deliverability and high rates of first pass and final mTICI ≥2c, particularly in M1 occlusions, with low rates of adverse events. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov NCT05714501.

BACKGROUND:Neutrophil extracellular traps (NETs) are important in host defense but implicated in pathologic thrombosis in acute ischemic stroke. NET quantification is typically done with immunostaining for NET-specific markers, but molecular techniques like mass spectrometry can provide another angle into thrombophysiology. OBJECTIVES:This study leverages both histological analysis of NETs and molecular insights from proteomics to validate using proteomics for evaluating stroke thrombus NET burden. METHODS:Sections of 30 acute ischemic stroke thrombi were stained for myeloperoxidase, citrullinated histone H3, and DNA. ImageJ measured average staining area. Mass spectrometry of sample thrombi fragments detected 5784 proteins. Spearman correlations and Mann-Whitney U-tests compared NET burden from staining to proteomic composition. Dimensional reduction of citrullinated histone H3 and myeloperoxidase staining created a single NET marker variable (principal component 1), used to compare thrombus composition between thrombi with NET marker greater (NET-rich) or lesser (NET-poor) than median. RESULTS:Percentage coverage for the 3 stains was interrelated (Spearman ρ > 0.6; P < 5 × 10-4 for all); 531 neutrophil degranulation proteins were positively associated with all stains. Principal component 1 explained approximately 92% of the variance. Ubiquitin-proteasome degradation pathways were negatively correlated with the NET markers (q < 0.05 for all relevant pathways). Older patient age (median, 79 years [IQR, 73-85 years] vs 61 years [IQR, 57-73 years]; Mann-Whitney U-test, P = .03) and atrial fibrillation-associated stroke (Fisher exact test, P = .03) thrombi were associated with NET-rich composition. CONCLUSION:This study combines immunostaining and proteomics for quantifying NET burden, pointing to molecular phenotypes within NET-rich and NET-poor thrombi that may underpin NET formation and maintenance in stroke thrombi.

Collateral circulation influences outcomes in large-vessel occlusion (LVO) stroke, yet its modifying effect on endovascular therapy for intracranial atherosclerosis-related LVO (ICAS-LVO) remains uncertain. This study evaluated whether collateral status alters the association between stent-assisted thrombectomy and outcomes in anterior-circulation ICAS-LVO. An analysis was performed on 271 anterior-circulation ICAS-LVO patients from the RESCUE-ICAS registry. Collateral status was graded using the Tan collateral score (0–1 = poor, 2–3 = good). Patients were treated with mechanical thrombectomy (MT) alone or MT with adjunctive stenting. The primary outcome was functional independence (modified Rankin Scale [mRS] = 0–2) at 90 days. Secondary outcomes included successful reperfusion (mTICI≥2b), symptomatic intracranial hemorrhage (sICH), and mortality. Among 271 patients, 172 (63.5

BACKGROUND:Point-of-care imaging of the brain is a major unmet need. Attenuation of ultrasound by the skull hinders sonographic evaluation of the brain in adults. PURPOSE:Ultrasound tomography holds potential in sonographic imaging of the brain through the skull. This work assesses the ability of a commercial ultrasound tomography machine to image the human brain. MATERIALS AND METHODS:A cadaveric specimen was prospectively imaged in the SoftVue commercial ultrasound tomography machine from August to September 2025. A neurosurgeon placed a 40-cc water-filled inclusion in the left cerebral hemisphere intended to mimic hemorrhage. Ultrasound tomography was obtained before and after the inclusion placement without and with an intervening cadaver skull. Fellowship trained neuroradiologists assessed the images for quality and visualization of key anatomic structures and inclusions. Sound speed values, signal-to-noise ratios, and contrast-to-noise ratios were also calculated on the acquired images. RESULTS:Ultrasound tomography allowed visualization of basic brain anatomy without a skull. The spatial resolution of the images without the skull was approximately 0.75 mm. Additionally, the implanted water-filled inclusion mimicking hemorrhage was visualized through the skull per neuroradiologist assessment. The implanted inclusion could also be quantitatively identified as different from the surrounding normal anatomy. CONCLUSION:Ultrasound tomography allowed visualization of major brain anatomy and a water-filled inclusion mimicking hemorrhage in the brain parenchyma demonstrating potential utility in neuroimaging. Ultrasound tomographic images through the skull visualizing the water-filled inclusion mimicking hemorrhage were also obtained showing the potential value of ultrasound tomography in intact samples.

OBJECTIVE:Normal pressure hydrocephalus (NPH) is a neurological condition characterized by impaired gait, cognitive decline, and urinary incontinence. Endovascular shunting using the eShunt Implant diverts cerebrospinal fluid (CSF) from basal cisterns to the internal jugular vein via a transvenous, transfemoral procedure. We report initial eShunt safety data for treatment of NPH through 90 days in a prospective, multicenter, single-arm trial. METHODS:NPH participants indicated for endovascular shunt placement were included after exhibiting positive gait response to lumbar CSF withdrawal and candidate anatomy. NPH symptoms at baseline and following eShunt Implant placement were assessed using the Timed Up & Go (TUG) test for gait, Montreal Cognitive Assessment (MoCA) for cognition, and Neurogenic Bladder Symptom Score-Short Form (NBSS-SF) for urinary symptoms. The primary endpoint was the rate of device and/or procedure-related serious adverse events (SAE) at 90-day follow-up. RESULTS:Sixty-six participants were treated with the eShunt Implant without immediate or delayed cerebral hemorrhage, over-drainage, infection or device-related SAEs. Two procedure-related SAEs (3.0%) occurred, one sigmoid sinus thrombosis and one femoral artery pseudoaneurysm, both resolved without surgical intervention. Matched-pair analysis showed statistically significant improvements in TUG time (37.2%; P<0.0001), MoCA score (+2.3; P<0.0001), and NBSS-SF score (-2.1; P<0.002). CONCLUSIONS:Endovascular shunting for NPH was feasible with a low rate of SAEs typically associated with conventional shunt surgery. An acceptable clinical response through 90 days was observed. These findings suggest further investigation of this minimally invasive, endovascular approach to NPH in a randomized controlled trial comparing to standard of care. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov Identifiers: NCT05250505 and NCT05232838.

OBJECTIVE Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without an identifiable cause, commonly affecting young obese women. While transverse sinus stenosis (TSS) and empty sella are frequent radiological findings in IIH, the relationship between the severity of empty sella and the extent of TSS remains poorly understood. METHODS In this retrospective study, authors analyzed patients with IIH diagnosed by established criteria in 2013-2023 and healthy controls matched for age, sex, and BMI. All patients underwent 3T brain MRI with contrast-enhanced T1-weighted sequences and MR venography within 3 months of IIH diagnosis. Volumetric analysis was performed using FreeSurfer software. Pituitary and sella turcica areas were manually segmented on midsagittal T1-weighted images, and the pituitary/sella turcica (PS) ratio was calculated. TSS severity was assessed using the Farb scoring system (0-8, with lower scores indicating greater stenosis). Statistical analysis included linear regression and receiver operating characteristic (ROC) curve analysis. RESULTS Patients with IIH (n = 69) demonstrated a significantly lower pituitary volume (48.9 vs 63.3 mm(2), p = 0.0023), larger sella turcica area (116 vs 73.1 mm(2), p < 0.0001), and reduced PS ratio (0.44 vs 0.86, p < 0.0001) compared to those in healthy controls (n = 15). A significant association was found between a declining PS ratio and increasing TSS severity (R = 0.26, p = 0.03) and normalized total brain volume (R = 0.24, p = 0.044). ROC analysis revealed that the PS ratio had 92.8% sensitivity and 100% specificity in differentiating patients with IIH from healthy controls (area under the curve = 0.981). CONCLUSIONS The PS ratio correlates significantly with TSS severity and brain volume in patients with IIH, suggesting that both findings reflect CSF and interstitial fluid dyshomeostasis. The PS ratio is highly sensitive and specific for IIH and may serve as a noninvasive imaging biomarker for assessing the severity of venous sinus stenosis and intracranial pressure elevation in IIH, particularly useful in settings where MR venography is unavailable. Further research is needed to explore the causative relationship between venous stenosis and empty sella formation.

BACKGROUND:Final infarct volume (FIV) on 24-hour magnetic resonance imaging is a well-established imaging biomarker linked to functional recovery after ischemic stroke, yet its prognostic value in intracranial atherosclerosis-related large vessel occlusion remains poorly explored. The impact of adjunct intracranial stenting on both infarct size and progression also remains unclear in this population. This study aimed to examine the association between FIV and clinical outcome, evaluate the effect of adjunct stenting on FIV and infarct progression, and assess the relationship between infarct progression and functional independence. METHODS:We conducted a post hoc secondary analysis of the RESCUE-ICAS registry (Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis); only patients with anterior circulation large vessel occlusion with magnetic resonance imaging after thrombectomy were included. FIV was measured on diffusion-weighted magnetic resonance imaging performed 24 to 36 hours postthrombectomy. Infarct progression was defined as the difference between baseline computed tomography perfusion infarct volume (cerebral blood flow <30%) on presentation and 24- to 36-hour FIV. The primary outcome was 90-day functional independence (modified Rankin Scale score 0-2). Additional analyses evaluated the association between adjunct intracranial stenting and FIV, and the association between infarct progression and 90-day functional outcome. Associations were analyzed using multivariable logistic regression and inverse probability of treatment weighting. RESULTS:Of the 417 patients included in RESCUE-ICAS, 203 had anterior circulation intracranial atherosclerosis-related large vessel occlusion and underwent magnetic resonance imaging 24 to 36 hours postthrombectomy. Among these, 80 patients (39%) received adjunct stenting. FIV was independently associated with 90-day functional independence (adjusted odds ratio per 10 mL increase, 0.8 [95% CI, 0.68-0.94]; P=0.007). Adjunct stenting was associated with a significant relative reduction in FIV, with inverse probability of treatment weighting-adjusted analyses demonstrating a 37.8% lower FIV compared with no stenting (β=-0.47 [95% CI, -0.93 to -0.02]; P=0.043). Among 108 patients with baseline computed tomography perfusion data, infarct progression was strongly associated with outcome, with each additional 10 mL associated with ≈25% lower odds of achieving modified Rankin Scale score 0 to 2 at 90 days (adjusted odds ratio, 0.74 [95% CI, 0.60-0.90]; P=0.004), although infarct progression did not differ significantly between stented and nonstented groups (Δ -9.53 mL [95% CI -37.9 to 18.8]; P=0.506). In inverse probability of treatment weighting-weighted models adjusted for successful recanalization, stenting was not independently associated with reduced FIV (β=-0.41; P=0.066), but remained independently associated with higher odds of 90-day functional independence (odds ratio, 2.29 [95% CI, 1.24-4.27]; P=0.008). CONCLUSIONS:Among intracranial atherosclerosis-related large vessel occlusion patients, 24- to 36-hour FIV is a strong predictor of functional outcome. Adjunct stenting is associated with smaller FIV. Lower infarct progression was also associated with favorable outcome. These findings highlight FIV as a reliable imaging biomarker and potential surrogate end point in future trials.

BACKGROUND:Acute ischemic stroke due to large-vessel or medium-vessel occlusion is often treated with aspiration thrombectomy. Delivery-assist catheters (DAsCs) are a new class of tapered support catheters designed to facilitate navigation of large-bore aspiration catheters through tortuous anatomy. OBJECTIVE:To perform a meta-analysis to evaluate the procedural efficacy and safety of DAsC-assisted aspiration thrombectomy. METHODS:A PRISMA-guided systematic review identified studies using DAsCs during aspiration thrombectomy for large- or medium-vessel occlusions. We extracted data on successful reperfusion; first pass effect (FPE), defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b (FPE≥2b) and mTICI≥2c (FPE≥2); use of adjunctive devices; and symptomatic intracranial hemorrhage (sICH). Pooled event rates with 95% CIs were calculated using a random-effects meta-analysis of proportions. RESULTS:14 studies were identified with 720 patients. Pooled successful reperfusion was 95% (95% CI 91 to 97%) for final mTICI ≥2b and 71% (95% CI 59% to 81%) for final mTICI ≥2c. FPE ≥2c was achieved in 51% (95% CI 43% to 59%) of cases, while FPE ≥2b was 65% (95% CI 54% to 75%). Adjunctive rescue devices were used in 23% (95% CI 17% to 30%) of procedures. Puncture-to-recanalization time was 26.1 min on average. The rate of sICH was 1% (95% CI 0% to 3%), and 44% (95% CI 39% to 50%) of patients had a 90-day modified Rankin Scale score of 0-2. CONCLUSIONS:In pooled analysis, DAsC-assisted aspiration thrombectomy demonstrated high first pass efficacy and low hemorrhagic rates across single-arm studies. This meta-analysis supports DAsCs as a safe adjunct to aspiration thrombectomy. Prospective comparative studies are warranted to evaluate technical performance and safety relative to standard aspiration techniques.

OBJECTIVE:Intrathecal nicardipine (ITN) is one treatment for vasospasm in subarachnoid hemorrhage (SAH), however, its efficacy is unclear. We sought to evaluate outcomes when ITN is utilized. METHODS:We performed retrospective chart review of all patients with aSAH requiring placement of an extra-ventricular drain at our institution from 2013 to 2023. We identified patients who received ITN (cases). Patients who received EVDs but no intrathecal nicardipine served as controls. We collected admission Hunt-Hess (HH) and Modified Fisher (mF), and trans-cranial doppler Lindegaard ratios. Delayed cerebral ischemia (DCI) was defined as the onset of infarcts on imaging or acute focal neurologic deficits (≥1 h) consistent with vasospasm. The circumstances in which ITN was initiated was defined as reactionary if it followed the onset of DCI and anticipatory otherwise. The incidence of DCI infarcts on imaging was our primary outcome. RESULTS:We identified 44 cases and 87 controls. Controls had higher mF (median=4) than cases (median=3, p = 0.038), but there was no significant difference in HH (p = 0.16). Overall, there was no difference in the incidence of DCI infarct between cases and controls (56.2% versus 55.2%, p = 0.86), yet cases were less likely to attain functional independence than controls (31.8% versus 54%, p = 0.016). Of the 44 cases, 16 received anticipatory ITN. Controls and anticipatory cases had no difference in mF and a trend toward increased HH among anticipatory cases. Anticipatory cases were significantly less likely to develop DCI infarct than controls (31.3% versus 55.2%, p = 0.042). Controls and anticipatory cases had similar incidences of 90-day mRS≤ 2 (54% and 38%, p = 0.13). CONCLUSION:Anticipatory ITN was associated with reduced rates of parenchymal infarcts and recalcitrant vasospasm. Among patients already experiencing DCI, reactionary ITN was not associated with reduced rates of additional infarcts or recalcitrant vasospasm. This offers rationale for further study of earlier initiation of ITN among SAH patients at high risk of DCI.

BACKGROUND AND OBJECTIVES:After surgical drainage of a chronic subdural hematoma (cSDH), middle meningeal artery (MMA) embolization aids in preventing the revascularization of the cSDH membranes at the capillary level and, in turn, reaccumulation. With the MMA circulation ipsilateral to the surgical side often being disrupted, there is recruitment of collaterals from the contralateral MMA tree to the ipsilateral cSDH membranes. The aim of this study was to demonstrate the ability of additive contralateral liquid embolic (LE) injection after ipsilateral surgery to augment MMA embolization. We hypothesized that contralateral LE injection may provide additional MMA embolization to the affected ipsilateral side and increase response to treatment. METHODS:Consecutive cases of unilateral cSDH surgery with ipsilateral MMA embolization and additive contralateral LE injection were retrospectively identified from a prospectively maintained database of the senior authors. RESULTS:Over the study period, 26 consecutive cases of recurrent cSDH after unilateral surgery were identified. There was an average age of 73 ± 2.7 years (range 27-90 years), and 14 patients (54%) were female. All 26 patients (100%) had previous burr holes or a craniotomy. The average cSDH thickness after surgery and before embolization was 10 ± 0.3 mm, and the average midline shift was 3.5 ± 0.7 mm. Of the 26 patients who underwent bilateral MMA embolization, 96% had over-the-top contralateral-to-ipsilateral LE injection and penetration, providing additional embolization to membranes of the index ipsilateral cSDH. The average cSDH thickness on follow-up was 4 ± 5 mm and midline shift of 0.2 ± 0.7 mm. Complete cSDH resolution was achieved in 7 patients (39%). Two patients had cSDH recurrence, one of which required reoperation. There were no LE or catheter-related complications. CONCLUSION:Contralateral MMA embolization in patients who have undergone ipsilateral cSDH evacuation and traditional ipsilateral MMA embolization allows for over-the-top LE penetration of cSDH membranes, thereby further augmenting the desired ipsilateral MMA embolization.