PurposeThis study aimed to provide a representative overview of the current research conditions in neuroradiology at German hospitals.MethodsIn 2024, the German Society of Neuroradiology (DGNR) conducted an anonymous online survey targeting neuroradiology researchers working at German hospitals. Participants were recruited via targeted e-mail-outreach and professional social media channels. Data were collected using the Easyfeedback platform. A total of 60 individuals participated, of whom 33 completed the full 33-item questionnaire. Data were analyzed descriptively.ResultsAmong respondents who completed the survey, 50% reported being satisfied or very satisfied with their current research conditions. Respondents from non-independent departments expressed more dissatisfaction than those of independent institutes. Major challenges for researchers included insufficient research time, lack of funding, and limited infrastructure. Scientific work was most frequently conducted alongside clinical duties or during personal time, while only a minority of respondents reported receiving continuousely protected research time. Intramural university funding represented the most common funding source. Any type of structured research program was available at approximately half of the institutions. Mentoring opportunities within these programs were reported by a majority of respondents, with generally positive evaluations and corresponding higher satisfaction with research conditions.ConclusionStructural independence, expanding protected research time, improving funding opportunities, and promoting structured research and mentoring programs appear essential to ensure sustainable academic development and innovation in the field.

BACKGROUND/OBJECTIVE:Perimesencephalic subarachnoid haemorrhage (pmSAH) has traditionally been considered benign and of venous origin. However, advanced imaging increasingly identifies basilar artery perforator aneurysms (BAPAs) as a subset of cases historically labelled as non-aneurysmal, atraumatic (NAA) pmSAH. The objective was to compare clinical characteristics and outcomes of patients with NAA, BAPA and ruptured posterior circulation aneurysms (r-pc-AN), assessing the impact of pmSAH aetiology on patient outcomes. METHODS:This retrospective, multicentre, observational cohort study included BAPA cases from the international PERForator Aneurysm registry (2013-2025, 60 centres, 19 countries). Comparison cohorts were from a single high-volume tertiary care centre (2004-2025). The study included 444 patients (n=167 NAA, n=157 BAPA, n=120 r-pc-AN). Excellent outcome was defined as a modified Rankin Scale score of 0-1 at 3-6 months. RESULTS:Excellent outcomes were achieved in 137/167 (82%) of NAA, 96/140 (69%) of BAPA and 56/102 (55%) of r-pc-AN cohorts (p<0.001). Mortality rates were 1% (NAA), 11% (BAPA) and 18% (r-pc-AN). cCompared with BAPA, NAA patients had significantly higher odds of excellent outcome (adjusted OR, aOR 2.0, 95% CI 1.2 to 3.4, p=0.01), while r-pc-AN were associated with significantly lower odds of excellent outcome (aOR 0.5, 95% CI 0.3 to 0.9, p=0.01). Hydrocephalus and external ventricular drain rates were highest in r-pc-AN (83% and 87%), followed by BAPA (48% and 44%) and NAA (28% and 16%) (p<0.001). CONCLUSIONS:While pmSAH has been considered benign, our findings challenge this assumption. Patients with BAPA-related pmSAH demonstrated significantly worse outcomes than NAA but better outcomes than r-pc-AN. Further research is needed to distinguish BAPA-pmSAH from NAA-related pmSAH and to establish diagnostic and therapeutic guidelines. TRIAL REGISTRATION NUMBER:NCT06189014.

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.

ABSTRACT Objective Intravenous thrombolysis (IVT) before thrombectomy for ischemic stroke may alter clot structure and procedural performance. We investigated how IVT relates to thrombectomy metrics across stroke etiologies. Methods We performed a time‐to‐event analysis of consecutive patients with anterior circulation large vessel occlusion (acLVO) stroke from a prospective thrombectomy registry at a German tertiary stroke center (January 2017–January 2023). The associations between IVT and groin‐to‐recanalization time and number of aspiration attempts were assessed using multivariable stratified Cox regression adjusted for demographic, cardiovascular, and stroke‐related variables. Results Of 1702 patients screened, 798 (413 female [51.8%], median age 77 years [66, 84; IQR]) underwent thrombectomy. IVT was administered to 395 (49.5%) patients, and successful reperfusion (mTICI ≥ 2b) was achieved in 680 (85.2%) patients. In non‐cardioembolic stroke, IVT facilitated clot removal, yielding a 40% higher likelihood of successful reperfusion at any time point compared with direct thrombectomy (aHR 1.40; 95% CI [1.08, 1.81]; p = 0.01) and a 36% reduction of aspiration attempts (IRR = 0.64, 95% CI [0.50–0.84], p = 0.001). In cardioembolic stroke, IVT did not alter the incidence of successful reperfusion during thrombectomy (aHR 1.13; 95% CI [0.92, 1.39]; p = 0.26) or the number of aspiration attempts (combined IRR ≈ 1.00, 95% CI [0.82–1.22]) but was associated with a 43% lower likelihood of successful reperfusion throughout the intervention if distal thrombus migration occurred (aHR 0.57; 95% CI [0.33, 0.96]; p = 0.03). Interpretation IVT was associated with faster reperfusion during thrombectomy in non‐cardioembolic acLVO, whereas in cardioembolic stroke with distal clot migration it was associated with delayed reperfusion.

BACKGROUND:Long-term evidence for endovascular treatment in medium or distal vessel occlusion stroke is scarce. Three out of four randomised trials reported no benefit of endovascular treatment over best medical treatment at 90 days. We aimed to assess efficacy of endovascular treatment plus best medical treatment versus best medical treatment alone at 12 months in patients enrolled in the DISTAL trial, as well as overall survival. METHODS:DISTAL was an open-label, randomised trial with blinded endpoint assessment conducted at 55 hospitals in Europe and the Middle East. Adults (≥18 years) with acute ischaemic stroke due to medium or distal vessel occlusion (occlusion of co-dominant or non-dominant M2 or M3-M4 middle cerebral artery, A1-A3 anterior cerebral artery, or P1-P3 posterior cerebral artery) presenting from home within 6 h of last known well, or between 6 h and 24 h if neuroimaging demonstrated potentially salvageable tissue, were randomly assigned (1:1) through a centralised web-based system to endovascular treatment plus best medical treatment or best medical treatment alone. The prespecified primary outcome at 12 months was disability measured by use of the ordinal modified Rankin Scale (mRS; scores 5 and 6 combined) in the intention-to-treat population. The only safety outcome was overall survival. The trial is registered on ClinicalTrials.gov (NCT05029414) and is completed. FINDINGS:Between Dec 16, 2021, and July 10, 2024, we enrolled 553 patients. Ten patients declined post-hoc consent, leaving 543 participants in the analysis (239 [44%] females and 304 [56%] males; median age 77 years, IQR 68-84). 271 (50%) were assigned to endovascular treatment plus best medical treatment and 272 (50%) to best medical treatment alone. The median NIHSS score at admission was 6 (IQR 5-9); 355 (65%) participants received intravenous thrombolysis. Predominant occlusion locations were the M2 (239 [44%]), M3 (146 [27%]), P2 (73 [13%]), and P1 (30 [6%]) segments. 12-month data were available for 524 (97%) participants. The median mRS score was 2 (IQR 1-4) in the endovascular treatment plus best medical treatment group and 2 (1-4) in the best medical treatment alone group. There was no difference in 12-month mRS distribution between endovascular treatment plus best medical treatment and best medical treatment alone (adjusted common odds ratio for better functional outcome 0·81, 95% CI 0·59-1·12; p=0·20). Overall survival was similar between the two groups (hazard ratio 1·46, 95% CI 0·93-2·30; p=0·10). INTERPRETATION:In patients with a medium or distal vessel occlusion stroke, endovascular treatment plus best medical treatment was not associated with a reduction of disability or death at 12 months compared with best medical treatment. These results are consistent with the 90-day results. Routine endovascular treatment is therefore not supported for patients with mild-to-moderate medium or distal vessel occlusion stroke. FUNDING:Swiss National Science Foundation, Gottfried und Julia Bangerter-Rhyner-Foundation, Medtronic, Stryker Neurovascular, Phenox, Rapid Medical, and Penumbra.

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.

INTRODUCTION:The optimal thrombectomy technique for medium/distal vessel occlusions (MDVOs) remains uncertain. OBJECTIVE:To compare the safety and efficacy of aspiration thrombectomy (ADAPT) versus stent retriever thrombectomy (SR only) versus a primary combined approach (PCA). PATIENTS AND METHODS:In this post hoc analysis of the DISTAL Trial, patients treated with first-line ADAPT, SR only, or PCA were included. The primary outcome was successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3). Secondary outcomes included functional outcome (modified Rankin Scale score at 90 days) and intracranial hemorrhage. Statistical analysis was performed using mixed-effects logistic regression models. RESULTS:Of 222 patients treated with thrombectomy, 36 underwent ADAPT, 37 SR only, and 149 a PCA as first-line strategy. The median number of thrombectomy passes was 1 (IQR 1-2). Final successful reperfusion was achieved in 76.5% with first-line ADAPT, in 61.1% with first-line SR only, and in 82.4% with first-line PCA. First pass successful reperfusion was achieved in 44.4% with ADAPT, 59.5% with SR only, and 66.4% with PCA. PCA was associated with higher first pass reperfusion rates compared with ADAPT (aOR=2.37, 95% CI 1.13 to 5.05, P=0.024). There were no significant differences in functional outcomes or safety endpoints among the techniques. ADAPT resulted in numerically more favorable functional outcome. PCA resulted in numerically higher numbers of symptomatic intracranial hemorrhage. DISCUSSION AND CONCLUSION:Final successful reperfusion rate after PCA was higher than after SR only. Functional and safety outcomes were not significantly different. Further research is warranted, including individual patient data meta-analyses and data on novel aspiration devices not used in this trial.

BACKGROUND:In acute ischemic stroke, a longer time from onset to endovascular treatment (EVT) is associated with worse clinical outcome. We investigated the association of clinical outcome with time from last known well to arrival at the EVT hospital and time from hospital arrival to arterial access for anterior circulation large vessel occlusion patients treated > 6 hours from last known well. METHODS:Retrospective analysis of the prospective, multicenter cohort study ESCAPE-LATE. Patients presenting > 6 hours after last known well with anterior circulation large vessel occlusion undergoing EVT were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes were good (mRS 0-2) and poor clinical outcomes (mRS 5-6) at 90 days, as well as the National Institutes of Health Stroke Scale at 24 hours. Associations of time intervals with outcomes were assessed with univariable and multivariable logistic regression. RESULTS:Two hundred patients were included in the analysis, of whom 85 (43%) were female. 90-day mRS was available for 141 patients. Of the 150 patients, 135 (90%) had moderate-to-good collaterals, and the median Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7-10). No association between ordinal mRS and time from last known well to arrival at the EVT hospital (odds ratio [OR] = 1.01, 95% CI = 1.00-1.02) or time from hospital arrival to arterial access (OR = -0.01, 95% CI = -0.02-0.00) was seen in adjusted regression models. CONCLUSION:No relationship was observed between pre-hospital or in-hospital workflow times and clinical outcomes. Baseline ASPECTS and collateral status were favorable in the majority of patients, suggesting that physicians may have chosen to predominantly treat slow progressors in the late time window, in whom prolonged workflow times have less impact on outcomes.

Animal studies suggest that high-density lipoprotein cholesterol (HDL-C) attenuates reperfusion injury. We aimed to assess whether higher serum HDL-C levels modulate the risk of intracranial haemorrhage (ICH) after thrombectomy in human stroke survivors. We included consecutive patients from our prospective anterior circulation large vessel occlusion (acLVO) registry who underwent thrombectomy between 01/2017 and 01/2023 at the tertiary stroke centre of the University Hospital Carl Gustav Carus in Dresden, Germany in a propensity score-matched analysis. We assessed the association between serum HDL-C levels and post-interventional ICH as well as 90-day functional outcome quantified by the modified Rankin Scale (mRS). For sensitivity analysis, we used multivariable lasso logistic regression. Analyses were adjusted for demographics, cardiovascular risk profiles, stroke characteristics, and procedural times. Of 1702 patients screened, 807 (420 women, median age 77 years [66–84, IQR]) were included. Post-interventional ICH reduced the probability of a favourable functional outcome (90-day mRS 0–2) by 14.8

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:It remains unclear whether outcomes of patients treated with endovascular thrombectomy with large-vessel occlusion and unwitnessed onset of stroke differ from those with witnessed onset in the extended time window. METHODS:We enrolled patients with anterior circulation large-vessel occlusion (internal carotid artery, M1, or M2 segment of the middle cerebral artery) undergoing endovascular thrombectomy within 6 to 24 hours from the time last seen well, from 2014 to 2022, at 66 sites in Europe, North America, and Asia. Patients with a prestroke modified Rankin Scale score of >3 or age <18 were excluded. We categorized patients by onset mode as witnessed or unwitnessed. The primary outcome was the modified Rankin Scale shift at 90 days. Secondary outcomes were functional independence, a composite of functional independence or return of Rankin to prestroke level, symptomatic intracranial hemorrhage, mortality, and a composite of severe disability or mortality at 90 days. We applied inverse probability of treatment weighting to compare outcomes between the groups. RESULTS:Of 5098 patients assessed for eligibility, we included 2073, of whom 1760 (84.9%) had unwitnessed onset, and 313 (15.1%) were witnessed. In the univariate comparison (before inverse probability of treatment weighting), 38.8% of the unwitnessed and 45.7% of the witnessed patients achieved functional independence (P=0.022). Mortality was 21.6% among unwitnessed and 22.0% among witnessed (P=0.847), and symptomatic intracranial hemorrhage rates were 6.6% and 5.8%, respectively (P=0.623). The primary outcome (modified Rankin Scale shift) showed no difference comparing unwitnessed to witnessed patients (odds ratio, 1.35 [95% CI, 0.82-2.20]; P=0.235) in the inverse probability of treatment weighting. Unwitnessed patients were more likely to achieve functional independence or return of Rankin (1.53 [1.01-2.33]; P=0.045). Other secondary outcomes did not differ between the witnessed and unwitnessed patients. CONCLUSIONS:In the extended time window, unwitnessed patients with large-vessel occlusion undergoing endovascular thrombectomy have at least the same likelihood of favorable outcomes as witnessed patients. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

BACKGROUND:There is uncertainty about whether patients with M2 occlusion benefit from endovascular therapy (EVT) in the late (6-24-hour) time window. We evaluated the clinical outcomes of patients with M2 occlusion selected for EVT compared with those who received medical management (MM) in the late window. METHODS:This multinational cohort study was conducted at 66 sites across 10 countries (January 2014 to May 2022). We included consecutive patients with late-window stroke due to M2 occlusion, baseline National Institutes of Health Stroke Scale score of ≥5, and premorbid modified Rankin Scale score of ≤2 who received EVT or MM alone. The primary end point was 90-day ordinal shift in the modified Rankin Scale score. Safety end points were symptomatic intracranial hemorrhage and 90-day mortality. Differences in outcomes were determined using inverse probability of treatment weighting-adjusted logistic regression models. RESULTS:Among 5098 patients, 496 met inclusion criteria (median [interquartile range] age, 74 years [62-81 years]; baseline National Institutes of Health Stroke Scale score, 12 [8-17]), of whom 394 (79.4%) received EVT and 102 (20.6%) MM. In inverse probability of treatment weighting adjusted analyses, there was no favorable 90-day ordinal modified Rankin Scale shift (odds ratio, 1.39 [95% CI, 0.92-2.12]) and no difference of functional independence rates (modified Rankin Scale score of 0-2; odds ratio, 1.72 [95% CI, 0.93-3.15]) with EVT compared with MM. Moreover, symptomatic intracranial hemorrhage risk (odds ratio, 3.46 [95% CI, 0.50-23.92]) and 90-day mortality (odds ratio, 1.11 [95% CI, 0.66-1.87]) were not statistically different between treatment groups. CONCLUSIONS:In patients with M2 occlusion in the 6- to 24-hour time window, there was no difference in disability outcomes or symptomatic intracranial hemorrhage risk between patients treated with EVT compared with MM. Results of ongoing randomized trials will provide further insight. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.

Background Endovascular treatment (EVT) of stroke with large-vessel occlusion is known to be safe and effective. The effect of EVT for occlusion of medium or distal vessels is unclear. Methods We randomly assigned participants with an isolated occlusion of medium or distal vessels (occlusion of the nondominant or codominant M2 segment of the middle cerebral artery [MCA]; the M3 or M4 segment of the MCA; the A1, A2, or A3 segment of the anterior cerebral artery; or the P1, P2, or P3 segment of the posterior cerebral artery) to receive EVT plus best medical treatment or best medical treatment alone within 24 hours after the participant was last seen to be well. The primary outcome was the level of disability at 90 days, as assessed with the modified Rankin scale score. Results A total of 543 participants (women, 44%; median age, 77 years) were included in the analysis: 271 were assigned to receive EVT plus best medical treatment and 272 to receive best medical treatment alone. The median score on the National Institutes of Health Stroke Scale (range, 0 to 42, with higher scores indicating more severe symptoms) at admission was 6 (interquartile range, 5 to 9). Intravenous thrombolysis was given to 65.4% of the participants. The predominant occlusion locations were the M2 segment (in 44.0% of the participants), M3 segment (in 26.9%), P2 segment (in 13.4%), and P1 segment (in 5.5%). In the comparison between EVT plus best medical treatment and best medical treatment alone, no significant difference in the distribution of modified Rankin scale scores was observed at 90 days (common odds ratio for improvement in the score, 0.90; 95% confidence interval, 0.67 to 1.22; P=0.50). All-cause mortality was similar in the two groups (15.5% with EVT plus best medical treatment and 14.0% with best medical treatment alone), as was the incidence of symptomatic intracranial hemorrhage (5.9% and 2.6%, respectively). Conclusions In persons with stroke with occlusion of medium or distal vessels, EVT did not result in a lower level of disability or a lower incidence of death than best medical treatment alone.

The advent of endovascular thrombectomy has significantly improved outcomes for stroke patients with intracranial large vessel occlusion, yet individual benefits can vary widely. As demand for thrombectomy rises and geographical disparities in stroke care access persist, there is a growing need for predictive models that quantify individual benefits. However, current imaging methods for estimating outcomes may not fully capture the dynamic nature of cerebral ischaemia and lack a patient-specific assessment of thrombectomy benefits.Our study introduces a deep learning approach to predict individual responses to thrombectomy in acute ischaemic stroke patients. The proposed models provide predictions for both tissue and clinical outcomes under two scenarios: one assuming successful reperfusion and another assuming unsuccessful reperfusion. The resulting simulations of penumbral salvage and difference in National Institutes of Health Stroke Scale (NIHSS) at discharge quantify the potential individual benefits of the intervention. Our models were developed on an extensive dataset from routine stroke care, which included 405 ischaemic stroke patients who underwent thrombectomy. We used acute data for training (n = 304), including multimodal CT imaging and clinical characteristics, along with post hoc markers such as thrombectomy success, final infarct localization and NIHSS at discharge.We benchmarked our tissue outcome predictions under the observed reperfusion scenario against a thresholding-based clinical method and a generalized linear model. Our deep learning model showed significant superiority, with a mean Dice score of 0.48 on internal test data (n = 50) and 0.52 on external test data (n = 51), versus 0.26/0.36 and 0.34/0.35 for the baselines, respectively. The NIHSS sum score prediction achieved median absolute errors of 1.5 NIHSS points on the internal test dataset and 3.0 NIHSS points on the external test dataset, outperforming other machine learning models.By predicting the patient-specific response to thrombectomy for both tissue and clinical outcomes, our approach offers an innovative biomarker that captures the dynamics of cerebral ischaemia. We believe this method holds significant potential to enhance personalized therapeutic strategies and to facilitate efficient resource allocation in acute stroke care. Von Braun et al. have developed an AI method to predict patient-specific responses to thrombectomy following acute ischaemic stroke. The model analyses brain scans and patient data to forecast tissue and clinical outcomes, and could help physicians identify those patients most likely to benefit from the procedure.

BackgroundThe optimal anesthetic strategy for endovascular therapy (EVT) in acute ischemic stroke is still under debate. The aim of this study was to compare the clinical outcomes of patients with isolated posterior cerebral artery (PCA) occlusion stroke undergoing EVT by anesthesia modality with conscious sedation (non-GA) versus general anesthesia (GA).MethodsPatients from the Posterior CerebraL Artery Occlusion (PLATO) study were analyzed with regard to anesthetic strategy. GA was compared with non-GA using multivariable logistic regression and inverse probability of weighting treatment (IPTW) methods. The primary endpoint was the 90-day distribution of the modified Rankin Scale (mRS) score. Secondary outcomes included functional independence or return to Rankin at day 90, and successful reperfusion, defined as expanded Thrombolysis in Cerebral Infarction (eTICI) 2b to 3. Safety endpoints were symptomatic intracranial hemorrhage and mortality.ResultsAmong 376 patients with isolated PCA occlusion stroke treated with EVT, 183 (49%) had GA. The treatment groups were comparable, although the GA group contained more patients with severe stroke and lower posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS). On IPTW analysis, there was no difference between groups with regard to ordinal mRS shift analysis (common OR 0.89, 95% CI 0.53 to 1.51, P=0.67) or functional independence (OR 0.84, 95% CI 0.50 to 1.39, P=0.49). There were greater odds for successful reperfusion with GA (OR 1.70, 95% CI 1.17 to 2.47, P=0.01). Safety outcomes were comparable between groups.ConclusionIn patients with isolated PCA occlusion undergoing EVT, patients treated with GA had higher reperfusion rates compared with non-GA. Both GA and non-GA strategies were safe and functional outcomes were similar.

Background: Animal studies suggest that high-density lipoprotein cholesterol (HDL-C) protects against reperfusion injury. We hypothesised that higher serum HDL-C levels would have a protective effect against cerebral reperfusion injury in human stroke survivors treated with thrombectomy. Methods: We included consecutive patients from our prospective anterior circulation large-vessel occlusion (acLVO) registry who underwent thrombectomy between January 2017 and January 2023 at a tertiary stroke centre in Germany in a propensity score-matched analysis. We assessed the association between serum HDL-C levels and imaging indices of post-interventional reperfusion injury according to the Heidelberg Bleeding Classification as well as 90-day functional outcome quantified by the modified Rankin Scale (mRS). We performed sensitivity analyses using multivariable lasso logistic and linear regression adjusted for demographic, clinical and imaging characteristics. Results: Out of 1702 patients assessed for eligibility, 807 acLVO patients treated with thrombectomy (420 females, median age 77 years [66-84, IQR]) were included. Reperfusion injury reduced the probability of a favourable functional outcome (90-day mRS 0-2) by 14.8% (β=0.15; 95% CI [0.06;0.24]; p=0.001. A serum HDL-C level above the median (1.15 mmol/L) decreased the probability of reperfusion injury by 13.6% (β=-0.14; 95CI% [-0.22; -0.05]; p=0.002) and increased the probability of favourable functional outcome by 13.2% (β=-0.13; 95CI% [-0.22; -0.05]; p=0.003). In sensitivity analyses, higher HDL-C levels were associated with lower odds of reperfusion injury (adjusted OR 0.62; 95% CI [0.43;0.88]; p=0.008) and emerged as a predictor of a favourable functional outcome (adjusted OR 0.60; 95% CI [0.40; 0.90]; p=0.015). Conclusions: In patients undergoing thrombectomy for acLVO, higher serum levels of HDL-C were associated with a reduced probability of reperfusion injury and favourable functional outcome at 90 days. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial N/A ### Funding Statement This study received no external 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 The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Our study was approved by the local institutional review board (Ethikkommission an der TU Dresden, IRB reference number: EK 272072017). Written informed consent for participation was waived in accordance with the national legislation and the institutional requirements. 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 Data available on reasonable request.

Background Emerging evidence suggests that endovascular thrombectomy is beneficial for treatment of childhood stroke, but the safety and effectiveness of endovascular thrombectomy has not been compared with best medical treatment. We aimed to prospectively analyse functional outcomes of endovascular thrombectomy versus best medical treatment in children with intracranial arterial occlusion stroke. Methods In this prospective registry study, 45 centres in 12 countries across Asia and Australia, Europe, North America, and South America reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischaemic stroke caused by a large-vessel or medium-vessel occlusion who received either endovascular thrombectomy plus best medical practice or best medical treatment alone. Intravenous thrombolysis was considered part of best medical treatment and therefore permitted in both groups. The primary outcome was the difference in median modified Rankin Scale (mRS) score between baseline (pre-stroke) and 90 days (+/- 10 days) post-stroke, assessed by the Wilcoxon rank test (alpha=005). Efficacy outcomes in the endovascular thrombectomy and best medical treatment groups were compared in sensitivity analyses using propensity score matching. The Save ChildS Pro study is registered at the German Clinical Trials Registry, DRKS00018960. Findings Between Jan 1, 2020, and Aug 31, 2023, of the 241 patients in the Save ChildS Pro registry, 208 were included in the analysis (115 [55%] boys and 93 [45%] girls). 117 patients underwent endovascular thrombectomy (median age 11 years [IQR 6-14]), and 91 patients received best medical treatment (6 years [3-12]; p<00001). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score on admission was 14 (IQR 10-19) in the endovascular thrombectomy group and 9 (5-13) in the best medical treatment group (p<00001). Both treatment groups had a median pre-stroke mRS score of 0 (IQR 0-0) at baseline. The change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0020). One (1%) patient developed a symptomatic intracranial haemorrhage (this patient was in the endovascular thrombectomy group). Six (5%) patients in the endovascular thrombectomy group and four (5%) patients in the best medical treatment group had died by day 90 (p=089). After propensity score matching for age, sex, and PedNIHSS score at hospital admission (n=79 from each group), the change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0029). Regarding the primary outcome for patients with suspected focal cerebral arteriopathy, endovascular thrombectomy (n=18) and best medical treatment (n=33) showed no difference in 90-day median mRS scores (2 [IQR 1-3] vs 2 [1-4]; p=0074). Interpretation Clinical centres tended to select children with more severe strokes (higher PedNIHSS score) for endovascular thrombectomy. Nevertheless, endovascular thrombectomy was associated with improved functional outcomes in paediatric patients with large-vessel or medium-vessel occlusions compared with best medical treatment. Future studies need to investigate whether the positive effect of endovascular thrombectomy is confined to older and more severely affected children. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Background and purpose: To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a "real-world" setting. Methods: Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a "real-world" setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY. Results: Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%-99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%-61.6%), but not the "real-world" setting (acceptability:32.9%-42.6%). Conclusion: EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and "real-world" setting, although this was largely related to baseline patient differences favoring the "real-world" EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.