Abstract Papilledema due to elevated intracranial pressure may indicate life-threatening conditions such as intracranial mass lesions or cerebral sino-venous thrombosis. This bicentric retrospective cohort study evaluated neuroimaging outcomes and clinical predictors in adults presenting with suspected papilledema to emergency departments between 2009 and 2022. Diagnostic outcomes were categorized as confirmed papilledema (due to idiopathic intracranial hypertension, space-occupying lesions, hydrocephalus or secondary intracranial causes) or papilledema ruled out. Clinical features, visual acuity, and frequency of focal neurological deficits were compared between groups. Diagnostic yield and number needed to scan (NNS) for CT and MRI were calculated, and univariable logistic regression was performed to identify predictors of secondary intracranial causes. Among 225 patients (mean age 43.0 ± 16.8 years; 57% female), papilledema was confirmed in 124 (55%), including 44 (35.5%) with secondary intracranial causes. Papilledema was excluded in 73 patients (32.4%). Primary CT and MRI identified secondary pathology in 13.3% (NNS 7.5) and 16.7% (NNS 6) of patients, respectively. Diplopia, nausea/vomiting, and focal neurological deficits were associated with secondary causes but were not consistently present. Secondary intracranial pathology is common in suspected papilledema. Given the limited discriminatory value of clinical features, timely neuroimaging should be performed in the diagnostic evaluation.

Background Acute stroke due to large vessel occlusion (LVO) is a serious complication of cardiac surgery or other cardiac interventions. Little is known about the epidemiological characteristics of affected patients, the temporal relationship between stroke detection and surgery/intervention, the efficacy of mechanical thrombectomy, or the associated clinical outcomes.Methods We retrospectively analyzed the demographic and thrombectomy characteristics and neurological outcomes of patients who underwent mechanical thrombectomy for acute ischemic stroke due to LVO after cardiac surgery/intervention in a large academic heart center.Results From January 2018 to January 2022, a total of 39 patients underwent thrombectomy for acute ischemic stroke with LVO following cardiac surgery/intervention. The median age was 66 years (IQR 57.5-76.0), and 13 patients (33.3%) were female. The highest frequency of thrombectomy for LVO-related stroke was observed after left ventricular assist device (LVAD) surgery (1.9%), followed by coronary artery bypass grafting (CABG) (0.20%), transcatheter aortic valve replacement (0.14%), and heart catheterization (0.04%). Stroke symptoms were detected in a wake-up constellation in 20 of the 39 patients (51.3%). Successful recanalization (TICI 2b/3) was achieved in 83.8% of patients. At three months, 21.2% of patients attained a good functional outcome (modified Rankin scale score 0-2).Conclusions Thrombectomy for LVO stroke was conducted in a small subset of patients after cardiac surgery/intervention. A large proportion of these strokes were detected in a wake-up constellation. Early detection, optimized acute neurological workup, and rapid thrombectomy may result in good functional outcomes. The establishment of a standardized diagnostic and treatment algorithm seems advisable for the optimization of acute stroke treatment in large heart centers.

Purpose Acute stroke from non-terminal internal carotid artery (non-T ICA) occlusions presents with variable symptoms. Although collaterals influence stroke severity, their role in non-T ICA occlusions remains unclear. This study evaluated the safety and efficacy of endovascular therapy (EVT) for isolated non-T ICA occlusions and examined the impact of collateral status. Material and methods Patients treated with EVT for acute isolated non-T ICA occlusion between August 2015 and February 2023 were retrospectively analyzed. Demographic, clinical, imaging, and interventional data were collected. Regression models assessed associations between collateral status and clinical outcomes, symptomatic intracranial hemorrhage (sICH), and in-hospital mortality. Results Fifty-eight patients were included. Median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) were 10 (interquartile range [IQR] 8-10) and 13 (IQR 7-18). Successful (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3) and complete (mTICI 3) reperfusion was achieved in 91% and 85%, respectively. sICH occurred in 5%, and in-hospital mortality was 21%. Excluding patients with pre-stroke disability, 42% achieved modified Rankin Scale (mRS) ≤ 2 at discharge. Good collaterals were associated with higher ASPECTS at discharge (9 vs. 7, p = 0.035) and numerically lower morta­lity (17% vs. 28%). Complete reperfusion (mTICI 3) was associated with favorable outcomes, with 100% reaching mRS ≤ 2 and ≤ 3 at discharge and 90 days, compared to poorer outcomes after incomplete reperfusion (mTICI 2b/c). Stroke etiology showed no association with collateral status. Conclusions EVT for isolated non-T ICA occlusions is technically effective and appears to be reasonably safe, although clinical outcomes remain modest. Collateral quality was associated with imaging outcomes, while complete reperfusion after distal embolization was associated with better clinical recovery. Collateral assessment and careful management of distal emboli may aid treatment decision-making. The clinical effectiveness of EVT in this setting requires confirmation in controlled trials.

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.

BACKGROUND AND OBJECTIVES:The optimal target blood pressure (BP) during and after mechanical thrombectomy (MT) for acute ischemic stroke remains uncertain. While BP drops during MT are associated with worse outcomes, evidence on postprocedural BP instability is limited. We aimed to assess the impact of BP drops within the first 24 hours after MT on functional outcome. METHODS:Retrospective observational study analyzing data from 2 tertiary stroke centers, gathered between October 2020 and September 2022 within the German Stroke Registry Endovascular Treatment, a national prospective registry of patients receiving MT for ischemic stroke. High-resolution BP data of patients who reached successful recanalization at the end of MT (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b) were obtained using stroke unit monitoring. BP drops were defined as systolic BP decreases of ≥40 mm Hg occurring within 1 hour during the first 24 hours after groin puncture. Primary outcome was level of disability at 3 months, assessed on the modified Rankin Scale (mRS shift analysis). Secondary outcomes included early neurologic deterioration (defined as an increase of 4 or more points on the National Institutes of Health Stroke Scale (NIHSS) between admission and 24-hour assessment) and death at 3 months. Associations between BP drops and functional outcomes were evaluated using multivariable ordinal and binary logistic regression. RESULTS:Among 300 patients analyzed (median age 77 years [interquartile range (IQR) 65-83], 46.0% female, median admission NIHSS 13 points [IQR 7-17]), 123 patients (41.0%) had at least 1 drop, including 77 patients (62.6%) with 1 drop and 46 patients (37.4%) with 2 or more drops. BP drops were independently associated with worse functional outcome, both in binary (drops vs no drops; adjusted common odds ratio [OR] 1.66 [95% CI 1.02-2.70]) and count-based analysis (adjusted common OR per +1 drop; 1.33 [95% CI 1.05-1.69]). Patients with drops more often had early neurologic deterioration (22.2% vs 13.4%; adjusted OR 2.22 [95% CI 1.03-4.78]). BP drops were not associated with death at 3 months (adjusted OR 1.25, 95% CI 0.66-2.40). DISCUSSION:BP drops within 24 hours after successful MT are associated with worse functional outcome. Targeted measures to prevent or mitigate BP drops should be explored in future studies.

Background: Digital twin technology holds promise for personalized stroke care, but current applications remain fragmented. This systematic review investigates how digital twins are currently utilized in the stroke care continuum. Methods: Following PRISMA guidelines, we conducted a systematic search of PubMed, Web of Science, and the Cochrane Library through April 2025. Studies applying digital twins to acute ischemic stroke care were included. Each study was categorized along the stroke care continuum (pre-stroke, in-hospital, post-stroke) and assessed using a digital twin maturity framework (L0 to L3). We extracted data on clinical intent, modeling approach, validation strategy, study design, population, sample size, and key outcomes to enable structured synthesis. Results: Eight studies met inclusion criteria. Half targeted pre-stroke risk prediction (e.g., modeling atherosclerosis or atrial fibrillation), 2 simulated mechanical thrombectomy, 1 supported prehospital diagnosis, and 1 predicted post-stroke disease progression. Most models remained at maturity levels L1 to L2, lacking real-time updating or workflow integration. Technologies included machine learning ( n = 3), computational fluid dynamics ( n = 3), and hybrid or rule-based approaches ( n = 2). Conclusions: Digital twins in stroke care are promising but remain preclinical. Current models predominantly address pre-stroke risk prediction or procedural simulation, with limited representation of acute decision support or post-stroke monitoring. Clinical integration is constrained by low technological maturity, limited real-world validation, and a lack of interoperability.

Here, we report the case of a 65-year-old man who presented to the emergency department with paresthesia, psychomotor retardation, and dysarthria. Contrast-enhanced brain MRI revealed a solitary, contrast-enhancing mass in the right head of the caudate nucleus with extensive perifocal edema, raising a primary differential diagnosis of glioblastoma versus metastasis, among other possibilities. Prior to surgical removal of the suspected glioblastoma, the patient underwent additional diffusion tensor imaging and research MRI, including multifrequency magnetic resonance elastography (MRE) to generate mechanical property maps of stiffness and tissue viscosity and to potentially differentiate between glioma, brain metastases, and benign masses based on tissue biomechanical properties. MRE revealed abnormally high values of stiffness and viscosity—a mechanical signature known to be associated with brain metastases or meningioma, but not glioblastoma, which typically exhibits soft tissue properties with reduced viscous dissipation. Histopathologic evaluation confirmed MRE by revealing a distant metastasis of squamous cell carcinoma, the primary tumor of which was detected by PET-CT within the right hilus of the lung. This case demonstrates the diagnostic value of the biomechanical properties of brain tumors and raises the prospect of applying MRE as an easy-to-use MRI contrast that can rule out glioma when the suspicious lesion exhibits stiff-viscous material properties.

Idiopathic intracranial hypertension (IIH) primarily affects obese women of reproductive age. However, IIH can also occur in individuals outside this typical demographic, where it is associated with a more severe clinical course and poorer visual outcome. Characteristic features of IIH have been identified on cerebral MRI but have not been systematically studied in atypical patient subgroups. This retrospective cohort study investigated the prevalence of MRI features of IIH across the following subgroups: males, individuals with normal BMI (< 26 kg/m2), and patients diagnosed above the age of 45. The presence of empty sella (ES), posterior globe flattening (PGF), optic nerve sheath distension (ONSD), optic nerve tortuosity (ONT), transverse sinus stenosis (TSS), DWI-hyperintensity of the optic nerve head (ONH) and ONH-contrast enhancement were evaluated on MRI. The relationship between MRI features and the visual prognosis was investigated. The study included 172 patients. ES was most frequent with 87

Abstract About 3–10% of patients with acute ischemic stroke (AIS) have active cancer. Malignancy-associated hypercoagulability (MAH) is an established cause of cancer-associated stroke. Nonbacterial thrombotic endocarditis (NBTE) is a severe manifestation of MAH. However, no prospective study has examined its prevalence and anticoagulation management in AIS. We conducted a prospective observational study at a tertiary center including patients with AIS or transient ischemic attack (TIA) and active malignancy. All patients underwent transthoracic echocardiography, followed by transesophageal echocardiography when indicated. Among 3,491 screened patients, 16 with active cancer and AIS/TIA were included. Eleven (68.8%) showed embolic patterns suggestive of MAH, and 6 (37.5%) had NBTE. NBTE patients numerically more frequently had multiterritory embolic infarctions (100% vs. 60.0%, p = 0.102) and prior ischemic stroke (66.7% vs. 10.0%, p = 0.028). 4/6 were on direct oral anticoagulants (DOACs), while none were on low-molecularweight heparin (LMWH). Under LMWH, vegetations resolved or regressed in 3/4, whereas under DOACs, progression or recurrent embolism occurred in several patients. Twelve-month mortality was high in both MAH (90.9%) and NBTE (83.3%) groups. NBTE was frequently identified in this prospective cohort of patients with cancer-associated stroke and consistently associated with multi-territory embolic infarction. Recognition may enable earlier diagnosis. Larger studies are needed to define optimal anticoagulation strategies.

INTRODUCTION:ICH is a common complication following endovascular therapy (EVT) for ischaemic stroke. While sICH is known to worsen outcomes, the impact of ICH without early neurological deterioration (END), commonly referred to as "asymptomatic" (aICH), remains controversial. This study aimed to assess imaging patterns of aICH and its effect on clinical outcomes. PATIENTS AND METHODS:This study used data from the prospective, multicentre German Stroke Registry-Endovascular Treatment. Bleedings were assessed on follow-up imaging at 24 hours applying the Heidelberg Bleeding Classification. European Cooperative Acute Stroke Study III (ECASS)-III criteria were used to stratify patients into (1) no ICH, (2) aICH and (3) sICH. The primary outcome was functional independence (mRS ≤ 2) at 3 months. Secondary outcomes included mRS shift and 3-month mortality. RESULTS:Among 4834 patients with EVT (median age 76, 51% female, median NIHSS 14), ICH occurred in 13.2% (aICH: 9.7%, sICH: 3.5%). Haemorrhage patterns differed, with sICH being more often parenchymal (48.2% vs 34.6%), multicompartmental (34.1% vs 20.2%) and involving the ventricular system (18.8% vs 7.6%), while aICH were predominantly haemorrhagic transformation (34.6% vs 21.8%). Functional independence at 90 days was reached by 40.0% (no ICH), 25.4% (aICH; adjusted odds ratio [aOR] 0.43 [0.32-0.58]) and 6.5% (sICH; aOR 0.06 [0.03-0.14]), respectively. aICH was associated with worse overall recovery (mRS shift adjusted common OR 0.51 [0.41-0.63]) and higher 90-day mortality (35.5% vs 24.9%; aOR 1.90 [1.44-2.51]), when compared to no ICH. CONCLUSION:ICH after EVT was associated with worse functional recovery and higher mortality, even in the absence of END. Given these results, the term "asymptomatic ICH" warrants reconsideration.

Abstract Reduced fluidity and viscosity have been demonstrated as biomechanical hallmarks of in vivo glioblastoma and are increasingly used as radiological imaging markers by magnetic resonance elastography (MRE). However, the biological origin and consequences of this unusual mechanical behavior remain unclear. Here, we show that two mechanisms which promote collective cell migration are present in patient gliomas and can be detected in vivo by MRE-based cerebral tomoelastography. Vimentin-driven extracellular matrix remodeling and cellular elongation, quantified by automated histological readings and nuclear aspect ratio (AR) measurements, correlate with decreased in-vivo tumor fluidity and viscosity. These observations in patients are supported by experiments in tissue-mimicking actin–vimentin gels, which mechanistically link the soft-solid viscoelastic signature of in vivo glioma to vimentin’s migration-promoting role and to AR-based observations of cellular elongation in unjammed cancer cell clusters. Taken together, our results suggest in-vivo bulk tumor viscosity as a noninvasive biomechanical marker of collective cell migration and invasiveness in brain tumors.

Objective Phenox flow diverters (p64 and its smaller vessel variant p48) represent an established treatment option for intracranial aneurysms. This study evaluates the safety and efficacy of the new generation of these devices with an additional antithrombotic surface coating (HPC).Methods Consecutive patients treated between 2020 and 2023 at three institutions were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes.Results Sixty-one patients (mean age 56 years) were treated for 61 aneurysms. The mean aneurysm size was 8.3 +/- 4.9 mm, 12 (19.7%) were ruptured, 16 (26.2%) were recurrent after previous treatment, 10 (16.4%) were located in the posterior circulation, and 7 (11.5%) had nonsaccular morphology. All procedures were technically successful, with a single device sufficient in 60/61 (98%) cases. Delivery problems included device twisting in one case and incomplete proximal opening in another. Additional angioplasty was performed in 3/61 (4.9%) procedures and additional coiling in 4 (6.6%). There were 3 (4.9%) major events (1 thromboembolic ischemic stroke, 1 fatal intracranial hemorrhage, and 1 delayed aneurysm rupture) and 6 (9.8%) minor strokes. Follow up at a mean of 6 months showed complete occlusion in 33/42 (79%) aneurysms, neck remnants in 5 (12%), and aneurysm remnants in 4 (10%).Conclusions The results demonstrate comparable acceptable complication rates and angiographic results of the Phenox HPC, which are similar to other flow diverters. Long-term and comparative studies are needed to evaluate the full potential of these devices.

This study evaluates seven open-source Large Language Models (LLMs) in summarizing radiology reports of acute ischemic stroke patients treated with mechanical thrombectomy and predicting angiography-based outcome measures relevant to post-thrombectomy reperfusion. 2000 mechanical thrombectomy reports (findings and summarizing impression section as gold standard) were split into training set (N = 1900) for model fine-tuning and test set (N = 100). A two-step evaluation was performed: (1) Quantitative analyses of seven LLMs with metrics ROUGE-1, -2, -L, METEOR, BERTScore (F1) and BLEU comparing LLM-generated summaries against gold-standard impressions. (2) Qualitative manual evaluation of the four best-performing models by two radiologists, assessing correctness and completeness across key parameters: outcome-relevant scores, vessel information, occlusion side, number of passes, relevant additional information, hallucinations, and grammar quality. Statistical significance was assessed via a two-tailed, four-sample χ² test, followed by post hoc pairwise χ² comparisons. BioMistral-7b scored highest across most quantitative metrics (ROUGE-1: 0.47, ROUGE-2: 0.30, ROUGE-L: 0.43, METEOR: 0.46, BERTScore (F1): 0.82). Manual evaluation revealed gemma-2-9b most frequently documented pass counts (56 out of 100 cases (56

This study investigates the automation of MRI protocoling, a routine task in radiology, using large language models (LLMs), comparing an open-source (LLama 3.1 405B) and a proprietary model (GPT-4o) with and without retrieval-augmented generation (RAG), a method for incorporating domain-specific knowledge. This retrospective study included MRI studies conducted between January and December 2023, along with institution-specific protocol assignment guidelines. Clinical questions were extracted, and a neuroradiologist established the gold standard protocol. LLMs were tasked with assigning MRI protocols and contrast medium administration with and without RAG. The results were compared to protocols selected by four radiologists. Token-based symmetric accuracy, the Wilcoxon signed-rank test, and the McNemar test were used for evaluation. Data from 100 neuroradiology reports (mean age = 54.2 years ± 18.41, women 50

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.