Surface modifications may improve procedural safety of flow diverter (FD) treatment, but larger studies are rare. This multicenter study aims to evaluate the safety and efficacy of unruptured aneurysm treatment with surface-modified and coated FDs. Patients treated with the following FDs at 8 neurovascular centers were retrospectively reviewed: Pipeline Vantage Embolization Device, Pipeline Flex with Shield Technology, FRED X, p48/64 HPC, Derivo Embolization Device (DED), and DED 2heal. Aneurysm characteristics, procedural details, and angiographic results were evaluated in detail. A total of 511 patients with 545 aneurysms were included (mean aneurysm size: 8.2 ± 5.5 mm, 12

INTRODUCTION:The aim was to identify the clinical, laboratory, and radiological predictors of spontaneous secondary haemorrhagic transformation in acute ischaemic stroke and after systemic thrombolytic therapy with rt-PA. METHODS:A total of 909 acutely treated (rt-PA, n = 161) and non-treated (no-rt-PA, n = 748) patients with ischaemic stroke in MRI were investigated regarding the occurrence of haemorrhagic infarction (HI) and parenchymal haemorrhage (PH) within the first 5 days after stroke onset. Clinical, laboratory, and radiological data were analysed using a one-way ANOVA and univariate and multiple regression analyses. RESULTS:In the rt-PA group, the patients were clinically more severely affected, the infarct lesions were significantly larger, and HI and PH occurred more frequently than in the no-rt-PA group. In the no-rt-PA group, the clinical condition of patients with HI and PH was not different. Multiple regression analyses revealed atrial fibrillation, diabetes mellitus, and infarct volume as predictors of HI and of PH. CONCLUSIONS:The results support the association between greater infarct size and an increased risk of secondary haemorrhagic transformation both after systemic thrombolysis with rt-PA and in non-treated stroke patients. We hypothesize that risk factor reduction may be beneficial not only for the prevention of ischaemic stroke but also for the prevention of secondary haemorrhagic transformation. Pragmatically, the radiological assessment of infarct volume appears as a relevant prognostic factor.

Abstract Background and aims Mechanical thrombectomy (MT) for distal medium vessel occlusions (DMVO) in acute ischemic stroke (AIS) remains technically challenging, and evidence for dedicated devices is limited. The Tigertriever 17 is a manually expandable stent retriever designed for small-caliber, tortuous intracranial vessels. This study evaluated its safety and effectiveness when used as a first-line device for MT in DMVO. Methods This retrospective, multicenter observational study included patients with AIS due to DMVO treated between January 2024 and May 2025 using the Tigertriever 17 as a first-line thrombectomy device. Data were collected from three high-volume stroke centers in Germany. Inclusion required a neurological deficit and radiological evidence of DMVO. The primary endpoint was successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b). Secondary endpoints included symptomatic and non-symptomatic intracranial hemorrhage. Subgroup analyses were performed for co-aspiration use and M2/M3 occlusions. Results Fifty-five patients were included. Overall successful reperfusion was achieved in 46/55 patients (83.6%). In the co-aspiration subgroup (n=42), reperfusion was achieved in 37/42 patients (88.1%). Among patients with M2–M3 occlusions treated with co-aspiration (n=40), successful reperfusion occurred in 35/40 cases (87.5%). Rescue maneuvers were required in nine cases, achieving reperfusion in seven. No symptomatic intracranial hemorrhages occurred. Four non-symptomatic hemorrhages were observed, three unrelated to the device and one of unclear association. Conclusions This multicenter analysis suggests that the Tigertriever 17 is a safe and effective first-line device for MT in DMVO. Reperfusion rates, particularly with co-aspiration, exceeded historical benchmarks and support further prospective evaluation. Conflict of interest 1) P. Melessanakis: No conflicts of interest 2) L. Voss: No conflicts of interest 3) S. Fischer: SF received travel grants and speaker honoraria from Rapid Medical 4) P. Stracke: PS received travel grants and speaker honoraria from Rapid Medical 5) B. Turowski: No conflicts of interest 6) H. Nordmeyer: HN received travel grants and speaker honoraria from Rapid Medical

BACKGROUND:Although recently presented randomized trials have failed to prove an overall benefit of mechanical thrombectomy (MT) for patients with medium vessel occlusions (MeVOs), questions remain unanswered, particularly regarding the technology and the role of dedicated small devices. This prospective multicenter, core lab reviewed registry study investigates the efficacy and safety of the APERIO Hybrid used as a first-line device for the treatment of MeVO patients. METHODS:Data from all MeVO patients who underwent MT with the APERIO or APERIO Hybrid17 as a first-line technique were prospectively included. The primary endpoint was the successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b/3) after up to three passes with the APERIO without the use of a rescue technique and without any symptomatic intracranial hemorrhage (ICH). RESULTS:134 patients were enrolled from 10 stroke centers. The primary endpoint was reached in 97 patients (81.5%, 95% CI 74.5% to 88.5%). In patients who failed the primary endpoint, TICI 2b/3 was reached with 4 to 6 APERIO passes in 4 patients (3.3%) and with other techniques in 18 patients (15%). Overall recanalization success was 95.8%. TICI 2b/3 with APERIO Hybrid was achieved after the first pass in 76 patients (63.9%), in 23 (19.3%) after 2 passes, and in 1 patient (0.8%) after 3 passes. Modified Rankin Scale (mRS) 0-2 at 90 days was reached by 79.0% of the patients. Symptomatic ICH occurred in no patients, asymptomatic ICH in 16 (13.5%), and subarachnoid hemorrhage in 15 patients (12.6%). CONCLUSION:APERIO and APERIO Hybrid17 have been proven to be both safe and effective first-line devices for MT in MeVO stroke at different centers and with high rates of successful recanalization.

BACKGROUND AND PURPOSE:Flow diversion has become a key treatment option for complex intracranial aneurysms. Recent advancements include coated flow diverters (FDs), designed to potentially reduce the need for dual antiplatelet therapy, thereby removing the associated secondary risks while maintaining patency and low complication rates. Comparing coated and uncoated FDs may offer insights into long-term outcomes and treatment optimization. METHOD:In this retrospective single-center study, we investigated the data of 21 consecutive patients with cerebral aneurysms, treated between 2021 and 2023 with the coated Derivo 2heal Embolization Device and the uncoated Derivo Embolization Device (both Acandis). We described the procedure and analyzed clinical and radiological data, along with long-term outcomes after 18 months of follow-up. RESULTS:Nine patients (42.9%) had incidental, while 12 (57.1%) had symptomatic aneurysms, including 10 with World Federation of Neurosurgical Societies classification IV subarachnoid hemorrhages. Aneurysm locations included mostly the internal carotid (n = 9) and the vertebral artery (n = 7). All FDs were successfully deployed: 11 patients received the coated and 10 the uncoated device. After 18 months, 73.3% of patients had favorable outcomes (modified Rankin Score 0-2). One coated FD occluded asymptomatically after 6 months, and one uncoated FD occluded immediately but could be recanalized. CONCLUSIONS:We observed favorable occlusion rates for both coated and uncoated FDs. The role of dual antiplatelet therapy remains debated. Large multicenter studies are essential to evaluate the patency of coated compared to uncoated FDs and determine whether they can reduce thrombogenicity, potentially allowing for less or no antiplatelet therapy in emergencies.

BackgroundThis multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms.MethodsConsecutive patients treated with different cFDs for ruptured aneurysms under tirofiban at eight neurovascular centers between 2016 and 2023 were retrospectively analyzed. The majority of patients were loaded with dual antiplatelet therapy after the treatment. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading scale. Primary outcome measures were major procedural complications and aneurysmal rebleeding during hospitalization.ResultsThe study included 60 aneurysms (posterior circulation: 28 (47%)) with a mean size of 5.8±4.7 mm. Aneurysm morphology was saccular in 28 (47%), blister-like in 12 (20%), dissecting in 13 (22%), and fusiform in 7 (12%). Technical success was 100% with a mean of 1.1 cFDs implanted per aneurysm. Adjunctive coiling was performed in 11 (18%) aneurysms. Immediate contrast retention was observed in 45 (75%) aneurysms. There was 1 (2%) major procedural complication (a major stroke, eventually leading to death) and no aneurysmal rebleeding. A good outcome (modified Rankin Scale 0–2) was achieved in 40 (67%) patients. At a mean follow-up of 6 months, 27/34 (79%) aneurysms were completely occluded (OKM D), 3/34 (9%) had an entry remnant (OKM C), and 4/34 (12%) had residual filling (OKM A or B). There was 1 (3%) severe in-stent stenosis during follow-up that was treated with balloon angioplasty.ConclusionsTreatment of ruptured aneurysms with cFDs was reasonably safe and efficient and thus represents a valid treatment option, especially for complex cases.

The evidence-based acute treatment of stroke patients in Germany is carried out according to standardized algorithms in more than 300 certified stroke units, and its quality is repeatedly assured by the German Stroke Society (DSG) and others. However, nationally structured and uniform stroke aftercare programs are missing, despite evidence that they contribute to the success of rehabilitation and improvement of everyday life. We used a 27-item online questionnaire, which was mailed to 4,195 outpatient physicians in the catchment area of the neurovascular network Neurovascular Network North Rhine plus (NEVANO+) located in the western part of Germany to assess actual structures of stroke aftercare, identify barriers, and possible solutions. Based on 152 completed anonymous answers to the questionnaire, a descriptive evaluation revealed that general practitioners and neurologists are seen to be responsible for stroke aftercare. Important improvement aspects, among others, were identified in intersectoral cooperation, the use of a post-stroke checklist, and connections to local self-help organizations. Stroke units could play a key role in stroke aftercare by providing these checklists, connecting self-help organizations, and offering education and coaching for supportive coordinating staff. Furthermore, existing neurovascular networks can be expanded to include rehabilitation clinics, geriatric clinics, and outpatient physicians to improve intersectoral communication, collaboration, and post-stroke care. Further studies should investigate whether intersectoral cooperation, checklists, and cooperation with self-help organizations within an extended neurovascular network have a positive impact on stroke aftercare and patients’ quality of life.

Background/Objectives: Brain ischemia is a frequent complication in patients undergoing veno-arterial extracorporeal membrane oxygenation (va-ECMO) therapy due to hypoperfusion, low oxygenation, and thromboembolism. While concomitant intra-aortic balloon pump (IABP) therapy may improve the perfusion of the supra-aortic branches, it may also favor thromboembolism. This retrospective study aimed to evaluate the effects of combined va-ECMO and IABP therapy on procedural brain infarction compared to va-ECMO therapy alone, with a specific focus on analyzing the types of infarctions. Methods: Cranial computed tomography (CCT) scans of consecutive patients receiving va-ECMO therapy were analyzed retrospectively. Subgroups were formed for patients with combined therapy (ECMO and IABP) and va-ECMO therapy only. The types of infarctions and the potential impacts of va-ECMO vs. combined therapy with IABP on stroke were investigated. Results: Overall, 146 patients (36 female, 110 male, mean age 61 ± 13.3 years) were included, with 69 undergoing combined therapy and 77 patients receiving va-ECMO therapy alone. In total, 14 stroke events occurred in 11 patients in the ECMO-only group and there were 12 events in 12 patients in the ECMO + IABP-group, showing no significant difference (p = 0.61). The majority of infarctions were of thromboembolic (n = 23; 88%) origin, with 14 stroke-events in 12 patients in the ECMO + IABP-group and 9 stroke events in the ECMO-only group. The survival rate within 30 days of treatment was 29% in the ECMO-only group and 32% in the ECMO + IABP group. Conclusions: The results of this retrospective study show that concomitant IABP therapy appears to be neither protective nor more hazardous in relation to ECMO-related stroke. Thus, the indication for additional IABP therapy should be assessed independently from the procedural risk of brain ischemia. Thromboembolic infarctions seem to represent the most common type of infarction in ECMO, especially within the first 48 h of treatment.

BACKGROUND AND OBJECTIVES:The endovascular clip systems (eCLIPs) implant bridges the neck of wide neck bifurcation aneurysms. This study presents safety and efficacy of eCLIPs cases of the first generation, eCLIPs bifurcation remodeling system (eBRS), and the current generation, eCLIPs electrolytic bifurcation system (eB). METHODS:A prospective registry collected: patient age, sex, aneurysm details, safety end points, and occlusion scores. All patients were reported for safety events. A subset of 74% with eBRS implants and 99% with eB implants formed a group for efficacy. RESULTS:The mean age was 57 years, and 70% were female. The Registry describes 280 patients: 101 in eBRS group and 179 in eB, with aneurysms at bifurcation locations. Implantation success was 81% and 92% for eBRS and eB, respectively ( P = .007). The follow-up period averaged 38 months for eBRS and 12 months for eB cases. The all-cause death rate was 3.2% (7% for eBRS and 1.1% for eB, P = .007), and neurological death rate was 2.3% (5% for eBRS and 0.5% for eB, P = .014). The rate of stroke was 1.8%, 2.0% for eBRS and 1.7% for eB ( P = NS). Rate of repeat procedure was 4.6% (8.9% for eBRS and 2.2% for eB, P = .01). For 57 eBRS patients at average 38 months postprocedure, 77% had modified Raymond-Roy Occlusion Classification (mRROC) scores of 1, 19% had mRROC 2, and satisfactory result (1 + 2) of 96%. For 144 eB patients at average 12 months postprocedure, 81% had mRROC 1, 15% mRROC 2, and satisfactory result (1 + 2) of 96%. CONCLUSION:The eCLIPs implant provides durable aneurysm occlusion with a favorable safety profile. The current eB delivery system resulted in improved procedural and safety results over the archived eBRS. The eCLIPs platform offers an alternative treatment strategy for wide neck bifurcation aneurysms.

This study investigates the influence of carotid artery elongation on neurovascular intervention and outcome in acute stroke treatments proposing an easily assessable imaging marker for carotid elongation. 118 patients who underwent mechanical thrombectomy for middle cerebral artery occlusions were included. The carotid elongation ratio (CER), center-line artery length to scan’s Z-axis, was measured on the affected side in CT-angiographies. Full and partial correlations of CER with periprocedural times, complications and outcome were computed. Multivariate logistic regression, including comorbidities, for prediction of dichotomized mRS outcome after 3 months was performed. CER showed no significant correlation with recanalization success. Weak, outlier-driven correlation was found with recanalization time (p = 0.021, cor = 0.2). Weak correlations were found with improvement of NIHSS score at discharge and mRS score after 3 months (p = 0.023 and p = 0.031, each rho=-0.2). There was moderate correlation with NIHSS score at discharge (p = 0.001, rho = 0.3). Patients with favorable outcomes (mRS 0–2) exhibited lower CER (p = 0.012). Partial correlations of CER with favorable outcomes were observed after correcting for age, sex and cardiovascular risk factors (cor = 0.2, p = 0.048). Multivariate analysis (Nagelkerke’s R2 = 0.42) identified NIHSS score at admission, diabetes, hypertension and intervention time as significant factors for predicting outcome at 3 month, while CER showed the highest log Odd’s (2.97). Correlations between CER and clinical improvement suggest that carotid elongation might be a risk factor for poorer outcome without relevant effect on endovascular treatment and should not guide treatment decisions. Further studies should consider carotid elongation as an individual neurovascular risk factor, independent of hypertension. •The study investigates the influence of carotid elongation on endovascular stroke treatment and outcome. •There is correlation between carotid elongation and clinical improvement. However, no relevant effect on endovascular treatment was found. •Carotid elongation should not dictate acute stroke treatment. Rather it should be considered as an individual neurovascular risk factor.

Therapeutic options for the treatment of visceral artery aneurysms (VAA) and pseudoaneurysms (VAPA) include either a surgical or endovascular approach, depending on specific characteristics of both the aneurysm and the individual patient. The therapeutic use of flow diverters (FD) has already yielded excellent results. The purpose of this study is to evaluate initial experiences regarding the use of a novel abdominal FD. In this observational multicenter study, the data of nine consecutive patients with visceral or abdominal aneurysms from four interventional centers, treated with the Derivo peripher FD, between 2022 and 2024 were evaluated regarding the technical feasibility and procedural performance of the device, safety, and treatment outcome. The average size of the treated aneurysms was 18±11 mm, and the affected vessels were the splenic (55.6%), the hepatic (22.2%), the gastroduodenal (11.1%), and the renal artery (11.1%). Complete aneurysm occlusion was observed in every patient after three months, and mid-term follow-up after 12 months was available for eight patients. All FDs remained patent during the follow-up period. No major complications or adverse events arose. The overall mortality rate was 0%. Based on our initial multicenter experience, endovascular treatment of abdominal and visceral aneurysms with an FD was found to be effective and safe. The remarkable results in terms of aneurysm occlusion and low complication rates are promising.

Stentretrievers are key devices for endovascular treatment of acute ischemic stroke. Aim of this post market clinical follow-up study was to asses safety and outcomes of interventions using the APERIO® Hybrid/Hybrid17|21 thrombectomy device (AHD) in routine clinical use. We conducted a prospectively monitored, multicenter, national registry study with single-arm data collection including patients with acute intracranial vessel occlusion (anterior and posterior circulation, including medium vessel occlusions) who were treated with the AHD in Germany between November 2020 and June 2023. Patients (n = 173) with low pre-stroke morbidity (modified Rankin Scale [mRS] ≤ 2) were included. We assessed technical recanalization success (mTICI ≥ 2b), the occurrence of periprocedural symptomatic intracranial hemorrhages (sICH), good clinical outcome (mRS ≤ 2 at 90 days), and secondary outcomes. Recanalization mTICI ≥ 2b was achieved in 84.4

T1-weighted black blood FS sequences may provide a useful addition to imaging protocols in detection of subtle changes in venous vasculitides and, therefore, may have an impact on treatment options.

Abstract Background The reduction of processing times in the treatment of acute ischemic stroke is of outstanding importance. Our objective is to analyze the acute stroke care chain from onset to treatment in a city in Germany comprising three stroke units. Additionally, we discuss solutions for detected treatment delays. Methods We conducted an in-depth analysis of acute stroke care processing times across three local stroke centers in Düsseldorf among all emergency services transportations for suspected stroke. Isochrone mapping was performed to identify areas with prolonged transportation times. Results Among the 1,714 transportations, 943 patients had confirmed strokes. Prehospital care constituted 58% of total emergency care time until imaging. Patients with confirmed stroke had reduced in-hospital times while patients receiving treatment experienced faster in-hospital times. Isochrone mapping revealed disparities in transportation times within the city. Conclusions In conclusion, we identified confirmation of stroke symptoms as pre- and in-hospital and treatment eligibility as in-hospital process accelerators in stroke care. We propose the introduction of an in-ambulance video consulting model to accelerate contact to stroke-experts and accelerate processing times for patients eligible for treatment. Furthermore, we discuss the combination of in-ambulance video consulting with imaging and starting treatment outside traditional stroke centers, followed by transportation to a stroke center during thrombolysis, which might further accelerate treatment in specific cases.

Zielsetzung Volumetrische Methoden zur Detektion regionaler Hirnvolumenunterschiede sind aufgrund der aufwendigen Postprozessierung zeitintensiv und erfordern Expertise. Studienziel war die Detektion regionaler Hirnvolumenunterschiede mittels automatisierter Atrophiekarten bei Patienten mit Chorea Huntington durch die am Universitätsklinikum Düsseldorf entwickelte Open Source Software veganbagel.

General microvascular perfusion and its heterogeneity are pathophysiological features of delayed cerebral ischemia (DCI) that are gaining increasing attention. Recently, CT perfusion (CTP) imaging has made it possible to evaluate them radiologically using mean transit time (MTT) and its heterogeneity (measured by cvMTT). This study evaluates the effect of multimodal rescue therapy (intra-arterial nimodipine administration and elevation of blood pressure) on MTT and cvMTT during DCI in aneurysmal subarachnoid haemorrhage (aSAH) patients. A total of seventy-nine aSAH patients who underwent multimodal rescue therapy between May 2012 and December 2019 were retrospectively included in this study. CTP-based perfusion impairment (MTT and cvMTT) on the day of DCI diagnosis was compared with follow-up CTP after initiation of combined multimodal therapy. The mean MTT was significantly reduced in the follow-up CTP compared to the first CTP (3.7 ± 0.7 s vs. 3.3 ± 0.6 s; p < 0.0001). However, no significant reduction of cvMTT was observed (0.16 ± 0.06 vs. 0.15 ± 0.06; p = 0.44). Mean arterial pressure was significantly increased between follow-up and first CTP (98 ± 17 mmHg vs. 104 ± 15 mmHg; p < 0.0001). The combined multimodal rescue therapy was effective in addressing the general microvascular perfusion impairment but did not affect the mechanisms underlying microvascular perfusion heterogeneity. This highlights the need for research into new therapeutic approaches that also target these pathophysiological mechanisms of DCI.

The concept of early brain injury (EBI) is based on the assumption of a global reduction in brain perfusion following aneurysmal subarachnoid hemorrhage (aSAH). However, the heterogeneity of computed tomography perfusion (CTP) imaging in EBI has not yet been investigated. In contrast, increased mean transit time (MTT) heterogeneity, a possible marker of microvascular perfusion heterogeneity, in the delayed cerebral ischemia (DCI) phase has recently been associated with a poor neurological outcome after aSAH. Therefore, in this study, we investigated whether the heterogeneity of early CTP imaging in the EBI phase is an independent predictor of the neurological outcome after aSAH. We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation (cvMTT) in early CTP scans (within 24 h after ictus) of 124 aSAH patients. Both linear and logistic regression were used to model the mRS outcome, which were treated as numerical and dichotomized values, respectively. Linear regression was used to investigate the linear dependency between the variables. No significant difference in cvMTT between the patients with and those without EVD could be observed (p = 0.69). We found no correlation between cvMTT in early CTP imaging and initial modified Fisher (p = 0.07) and WFNS grades (p = 0.23). The cvMTT in early perfusion imaging did not correlate significantly with the 6-month mRS for the entire study population (p = 0.15) or for any of the subgroups (without EVD: p = 0.21; with EVD: p = 0.3). In conclusion, microvascular perfusion heterogeneity, assessed by the heterogeneity of MTT in early CTP imaging, does not appear to be an independent predictor of the neurological outcome 6 months after aSAH.

Abstract BACKGROUND Gliomas with CDKN2A mutations are known to have worse prognosis but imaging features of these gliomas are unknown. Our goal is to identify CDKN2A specific qualitative imaging biomarkers in glioblastomas using a new informatics workflow that enables rapid analysis of qualitative imaging features with Visually AcceSAble Rembrandtr Images (VASARI) for large datasets in PACS. Gliomas with CDKN2A mutations are known to have worse prognosis but imaging features of these gliomas are unknown. Our goal is to identify CDKN2A specific qualitative imaging biomarkers in glioblastomas using a new informatics workflow that enables rapid analysis of qualitative imaging features withVisually AcceSAble Rembrandtr Images (VASARI) for large datasets in PACS. MATERIAL AND METHODS Sixty nine patients undergoing GBM resection with CDKN2A status determined by whole-exome sequencing were included. GBMs on magnetic resonance images were automatically 3D segmented using deep learning algorithmsincorporated within PACS. VASARI features were assessed using FHIR forms integrated within PACS. RESULTS GBMs without CDKN2A alterations were significantly larger (64% vs. 30%, p=0.007) compared to tumors with homozygous deletion (HOMDEL) and heterozygous loss (HETLOSS). Lesions larger than 8 cm were four times more likely to have no CDKN2A alteration (OR: 4.3; 95% CI:1.5-12.1; p<0.001). The pial invasion was predictive of HOMDEL (OR: 8.1, 95% CI: 1.8-53.2; p<0.012) as tumors with pial invasion were eight times more likely to be HOMDEL, even after adjusting for deep white matter and subependymal invasion. CONCLUSION We developed a novel integrated PACS informatics platform for the assessment of GBM molecular subtypes and show that tumors with HOMDEL are more likely to have radiographic evidence of pial invasion and less likely to have deep white matter invasion or subependymal invasion. These imaging features may allow noninvasive identification of CDKN2A allele status.