BACKGROUND AND OBJECTIVES:Venous sinus stenting (VSS) has emerged as an alternative treatment for selected idiopathic intracranial hypertension (IIH) cases, but its comparative effectiveness and safety vs ventricular shunting (VS) remain uncertain. Given the heterogeneity of IIH, we hypothesized that outcomes differ by patient phenotype defined by obesity and visual disturbance at diagnosis. METHODS:Adults with IIH who underwent VSS or VS shunting were identified using TriNetX. Patients were stratified into 4 prespecified phenotypes: nonobese-visual-disturbance (NO-V), nonobese-no-visual-disturbance (NO-NV), obese-visual-disturbance (OV), and obese-no-visual-disturbance (ONV). Within each phenotype, 1:1 propensity score matching balanced baseline demographics, comorbidities, and laboratory parameters. Primary outcomes were persistent headache, papilledema, and visual disturbance within 24 months. Secondary outcomes included retreatment, head computed tomography use, and emergency department visits. RESULTS:After matching (NO-V = 69, NO-NV = 186, OV = 305, ONV = 440 per arm), cohorts were well balanced. In NO-NV, VS was associated with higher rates of headache (risk difference [RD]: 0.11, P = .049), visual disturbances (RD: 0.11, P = .010), and emergency department visits (RD: 0.15, P = .006). NO-V showed no primary outcome differences, although vestibular disorders were more common with shunts (RD: 0.15, P = .008). In OV, VS shunting was linked to higher rates of visual deficits (RD: 0.11, P = .045). Conversely, in ONV, shunting was associated with lower rates of papilledema (RD: -0.6, P = .024) and pulsatile tinnitus (RD: -0.5, P = .004) but increased headaches (RD: 0.12, P < .001). Across phenotypes, shunted patients had greater head computed tomography use and retreatment rates, while VSS patients more often required ongoing medical therapy. CONCLUSION:The comparative effectiveness of VSS and VS in IIH varies by phenotype. VSS appears preferable in nonobese patients without visual symptoms, whereas VS may better control papilledema in obese patients without visual disturbance. Both treatments show similar efficacy in patients with baseline visual impairment. These findings underscore the need for phenotype-guided, prospective trials.

PURPOSE:This systematic review and meta-analysis aimed to synthesize evidence on baseline and procedural neuroimaging markers associated with futile recanalization in posterior circulation stroke. DATA SOURCES:A systematic search was conducted across PubMed, Scopus, Web of Science, and Embase from inception through April 2025. STUDY SELECTION:Studies evaluating neuroimaging predictors of futile recanalization in patients with posterior circulation stroke who achieved successful recanalization (mTICI ≥2b) after endovascular treatment were included. DATA ANALYSIS:Risk of bias was assessed using PROBAST. Random-effects meta-analysis was performed for imaging parameters reported in two or more studies. Heterogeneity was assessed using I2 statistics, and leave-one-out sensitivity analyses were conducted. DATA SYNTHESIS:Twelve studies comprising 3,521 patients met the inclusion criteria. Meta-analysis of five studies demonstrated that higher PC-ASPECTS scores were significantly associated with reduced odds of futile recanalization (pooled OR = 0.72, 95% CI: 0.60-0.86; I2 = 74.8%). The BATMAN collateral score showed a non-significant general direction toward lower futile recanalization with higher scores (OR = 0.81; 95% CI: 0.57-1.14; I2 = 51.8%). Additional imaging predictors identified across studies included PMT score, PC-CS, PComA patency, CBF <35% volume, and cerebral circulation time. Perfusion metrics such as hypoperfusion intensity ratio and core volume did not independently predict futile recanalization. LIMITATIONS:The current study has several limitations. A small number of included studies (mostly retrospective with limited sample sizes), high heterogeneity (I2 = 74.8% for PC-ASPECTS), varying definitions of functional outcome, differing covariates in multivariable models with possible residual confounding, and wide variation in study size/design. Furthermore, we were unable to perform reliable formal subgroup analyses, and publication-bias assessments due to only five eligible studies for PC-ASPECTS and two for BATMAN, necessitating reliance on qualitative assessment and leave-one-out sensitivity analyses while leaving publication bias and small-study effects unexcluded. CONCLUSION:PC-ASPECTS is a robust imaging predictor of futile recanalization in posterior circulation stroke. Location-based and collateral-based imaging parameters demonstrate greater prognostic value than volumetric thresholds in this territory. Integration of multiple imaging parameters into composite scores may enhance predictive accuracy and guide patient selection.

Idiopathic intracranial hypertension (IIH) is a complex and increasingly prevalent disorder that results in significant morbidity despite a broad array of available treatments. While lifestyle modifications, pharmacologic agents, and surgical interventions can produce meaningful short-term symptomatic improvements, long-term outcomes are poor, characterized by high rates of symptom recurrence. Weight loss remains the only disease-modifying therapy, though sustained reductions in weight are rarely achieved outside of bariatric surgery. In addition, a subset of patients is not overweight, limiting applicability. Pharmacologic therapies such as acetazolamide, topiramate, and glucagon-like peptide-1 (GLP-1) receptor agonists offer benefits but are limited by the side effect profile and poor efficacy. Surgical approaches often address only a portion of IIH's multifactorial pathophysiology, and recurrent symptoms may arise from persistent venous hypertension or new venous stenoses. This review evaluates the current evidence on medical and surgical treatment failures in IIH, emphasizing unresolved questions in disease pathogenesis and the need for personalized therapeutic approaches that advance the development of more durable treatment options.

BACKGROUND:Dynamic internal jugular vein (IJV) stenosis is increasingly recognized in patients with cerebral venous outflow disorders (CVD). Although the hemodynamic effects of dynamic jugular stenosis have been characterized, its role in disease remains undefined. This study evaluated the safety and early outcomes of IJV stenting for symptomatic rotational stenosis. METHODS:This retrospective, single-institution study included adult patients that underwent IJV stenting for dynamic, symptomatic IJV stenosis between 2023 and 2025. Inclusion required dynamic venography demonstrating >75% rotational IJV stenosis and ≥6 mmHg trans-stenotic pressure gradient. Demographic, procedural, and clinical data were analyzed. Symptom severity was assessed using the Cerebral Venous Disorder Symptom Severity (CVDSS) scale and the Headache Impact Test (HIT-6). RESULTS:Sixteen patients (mean age 37.1 years, 75% female) were included. All underwent successful IJV stent placement without periprocedural complications. The median trans-stenotic pressure gradient improved from 7 mmHg (range 6-18) to 1 mmHg (range 0-9) after stenting. CVDSS scores improved from 13.5 (11.0-16.0) to 8.5 (4.75-12.0) at peak improvement (p<0.001), with sustained improvement (10.5 (8.0-12.3), p<0.001) at a median follow-up of 10.1 months. Median HIT-6 scores decreased from 65.5 (64.0-67.3) to 61.0 (57.0-64.0) (p<0.001). Thirteen patients reported meaningful symptom improvement at last follow-up, and 88% were satisfied with their decision to pursue stenting. CONCLUSION:Jugular vein stenting in refractory CVD patients with severe, symptomatic rotational IJV stenosis is technically feasible and associated with meaningful clinical improvement in patients though partial symptom recurrence is common. Optimal patient selection and procedural expertise are essential to maximize patient safety and efficacy.

Prolonged venous transit (PVT) on perfusion imaging is an emerging venous outflow (VO) biomarker exhibiting microvascular integrity and downstream venous drainage. Conventional arterial parameters such as time to maximum (Tmax), CBF, and CBV often fail to capture postrecanalization microcirculatory dysfunction that contributes to infarct progression and poor outcomes in anterior circulation ischemic stroke. A comprehensive literature review was conducted to evaluate the clinical, radiologic, and functional implications of PVT, factors influencing its status, and predictive models integrating PVT with other perfusion metrics in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) undergoing mechanical thrombectomy. Across studies, PVT-positive status (delayed dural sinus opacification, Tmax ≥10 seconds) correlated with higher admission and discharge NIHSS, longer hospital stay, larger Tmax >6 seconds and mismatch volumes, and worse 90-day outcomes (mRS 3-6). PVT-positive status independently predicted mortality and poor functional recovery, with advanced age and higher NIHSS as associated factors. Compared with other imaging markers, PVT demonstrated superior predictive performance for functional outcomes (AUC up to 0.821), further enhanced when combined with CBV index (AUC 0.831). PVT offers a reproducible, easily interpretable imaging marker of delayed venous outflow due to microvascular dysfunction, providing superior prognostic value beyond arterial parameters and supporting its inclusion in AIS-LVO imaging assessment.

BACKGROUND:The eccentric stenosis morphology in patients with intracranial atherosclerotic stenosis (ICAS) has a critical impact on the efficacy of endovascular treatment. This study aimed to establish a rabbit model of eccentric carotid atherosclerotic stenosis that mimics the pathophysiological and morphological characteristics of eccentric plaques in humans. METHODS:Rabbits received localized cryoinjury of the right carotid artery after 2 weeks of a high fat, high cholesterol diet, followed by an additional 8 weeks on the same diet. On the experimental endpoint, comprehensive analyses of the model's pathological changes were conducted using serum lipid analysis, DSA, optical coherence tomography (OCT), histopathological analysis, and immunohistochemistry. RESULTS:The high fat, high cholesterol diet significantly elevated serum lipid levels in rabbits. Hematoxylin and eosin staining results at 24 hours postoperatively revealed focal intimal damage induced by 5 s of cryoinjury. After localized cryoinjury and high fat, high cholesterol diet feeding, DSA results demonstrated significant carotid stenosis, with a stenosis degree of 47±5% and a length of approximately 9 mm. OCT images revealed eccentric fibrous plaque formation at the stenotic site. Morphological analysis of the plaque samples demonstrated a plaque eccentricity index of 0.66±0.05 and a plaque burden of 60.68±7.41%. Histopathological analysis showed that atherosclerotic lesions developed in all rabbits of the model group. Among them, three rabbits had intermediate lesions, one rabbit had atheroma, and eight rabbits had fibroatheroma. CONCLUSIONS:This study successfully established a rabbit model of eccentric carotid atherosclerotic stenosis, providing a novel experimental platform for transformation research of neurointerventional devices.

BackgroundThe Oahu large vessel occlusion (LVO) bypass protocol is a real-world island-wide EMS initiative designed to identify patients with suspected LVOs in the field and triage them directly to a Comprehensive Stroke Center (CSC) for endovascular therapy (EVT).MethodsA retrospective preimplementation-postimplementation study was conducted to investigate the impact of the bypass protocol on endovascular treatment times and patient outcomes between January 1, 2017 to January 1, 2023.ResultsA total of 351 patients met inclusion criteria (102 patients pre-bypass vs. 249 patients post-bypass). In an interrupted time series analysis, there was a sustained 66-min reduction in onset-to-CSC door time (p = 0.0046), and a 41-min reduction in onset-to-reperfusion time (p = 0.08) in the post-bypass period with no changes in temporal trends. Interfacility transfers for EVT declined 5-fold (55.9% to 11.6%; p < 0.001) with no delay in onset-to-thrombolytic time (p = 0.13). In multivariate logistic regression modeling, longer onset-to-reperfusion times were independently associated with worse clinical outcomes, where every 30-min delay increased the odds of a higher 90-day mRS score by 6% (OR 1.062, 95% CI 1.001–1.125, p = 0.033). The post-bypass era, itself, however, was not associated with improved 90-day good outcomes (mRS 0–2: 40.2% vs. 44.6%; adjusted OR 0.98 [95% CI, 0.57–1.69]; p = 0.93) or a shift in 90-day mRS disability (adjusted OR 0.93 [0.60–1.41]; p = 0.72), though a nonsignificant trend toward improved 90-day excellent outcomes was observed (mRS 0–1: 23.5% vs. 34.5%; unadjusted OR 1.75 [1.01–2.90], p = 0.045; adjusted OR 1.51 [0.84–2.72], p = 0.17).ConclusionsImplementation of a system-wide EMS LVO bypass protocol successfully reduced onset-to-door and onset-to-reperfusion times within a uniquely closed catchment geography. The impact on clinical outcomes, however, remains to be seen.

BackgroundProlonged venous transit (PVT) on computed tomography perfusion (CTP) indicates impaired macroscopic venous outflow. The Brush Sign on susceptibility-weighted imaging (SWI) reflects microvascular venous congestion and the “no-reflow” phenomenon. We investigated whether pre-treatment PVT independently predicts the post-treatment Brush Sign in patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) following successful mechanical thrombectomy (MT).MethodsWe retrospectively analyzed patients with anterior-circulation acute ischemic stroke due to large-vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b–3) and underwent post-treatment magnetic resonance imaging (MRI). Pre-treatment PVT positivity (Tmax ≥10 s in the superior sagittal sinus and/or torcula) was evaluated on baseline CTP. The primary outcome was the presence of the Brush Sign on follow-up SWI. A multivariable logistic regression model evaluated the independent association between PVT and the Brush Sign, adjusting for age, admission National Institutes of Health Stroke Scale (NIHSS), intravenous thrombolysis, final infarct volume, mTICI score, and baseline Alberta Stroke Program Early CT Score (ASPECTS).ResultsOf 187 included patients, 29 (15.5%) demonstrated the Brush Sign. Pre-treatment PVT + was significantly more prevalent in patients who developed the Brush Sign (48.3% vs. 27.2%, p = 0.02). In the adjusted multivariable model (N = 130), PVT + remained a strong, independent predictor of the Brush Sign (OR 3.82, 95% CI 1.32–11.77, p = 0.02). The association remained robust across sensitivity analyses accounting for MRI timing, complete reperfusion, occlusion segment, and suspected stroke etiology.ConclusionPre-treatment PVT independently predicts the post-treatment Brush Sign in AIS-LVO patients despite successful macrovascular reperfusion. This finding links macroscopic venous congestion to downstream microvascular failure, highlighting PVT as an easily accessible imaging biomarker for anticipating the no-reflow phenotype.

Distal medium-vessel occlusions (DMVOs) account for roughly 25%-40% of acute ischemic strokes and often evade early detection, delaying treatment, and worsening outcomes. Conventional imaging (non-contrast CT, CT angiography [CTA], MR angiography [MRA]) can miss smaller distal thrombi, and even experienced readers have limited sensitivity, which can be as low as 35%. Recent studies highlight that advanced neuroimaging (CT perfusion, multiphase CTA, magnetic resonance imaging [MRI]) and automated analysis improve DMVO identification. In particular, machine learning (ML) and deep learning algorithms have shown promise in detecting subtle occlusions on multimodal stroke imaging. This review summarizes current imaging approaches for DMVOs, surveys ML-based detection methods, and examines validation studies and clinical evidence. We discuss barriers to clinical integration, including the need for large, annotated datasets and regulatory validation. Finally, we outline future directions: improved algorithms (explainable AI, multimodal networks), prospective trials, and workflow integration in the neurovascular service. In sum, ML-driven DMVO detection holds potential to augment rapid stroke care, but further research and collaboration are needed to translate these tools into routine practice.

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.

Post-stroke cognitive impairment is common after acute ischemic stroke, yet early cognitive deficits are often underrecognized in routine care. Prolonged venous transit (PVT) on perfusion imaging reflects impaired venous drainage and has been linked to worse functional outcomes in large-vessel occlusion (LVO) stroke, but its relationship with early cognitive impairment remains unclear. In this retrospective study, we evaluated consecutive patients with anterior-circulation LVO who underwent baseline perfusion imaging and had a documented discharge Cog-4 score (derived from four NIHSS items: orientation, command following, language, and attention/neglect). PVT was defined as a Tmax delay ≥10 s within the posterior superior sagittal sinus or torcula. The primary outcome was discharge Cog-4 score. Among 253 patients, 85 (34%) had PVT. Patients with PVT had higher Cog-4 scores than those without PVT (median, 2 vs 0; P < 0.001). In multivariable linear regression adjusting for age, admission NIHSS score, occlusion laterality, and follow-up infarct volume, PVT remained independently associated with higher Cog-4 scores (β, 0.63; 95% CI, 0.07–1.2; P = 0.029). A multivariable model demonstrated good discrimination for identifying normal or minimal impairment (Cog-4 score 0–1) with an area under the curve of 0.86 (95% CI, 0.81–0.90). These findings suggest that venous outflow impairment on baseline perfusion imaging is independently associated with early cognitive dysfunction at hospital discharge and may serve as a practical imaging marker for early cognitive risk stratification in anterior-circulation LVO stroke.

BACKGROUND:The Flow Re-Direction Endoluminal Device X (FRED X) offers several benefits over other flow-diverter devices including an antithrombotic coating, optimized in-vessel stability, and increased flexibility for easier device placement. We present a to-date experience of the safety and utility of the FRED X device in the repair of posterior and anterior circulation aneurysms. METHODS:A retrospective review was conducted on all endovascular procedures that utilized the FRED X device at our center from May 2022 to November 2023. RESULTS:77 patients (72.7% women, mean age 58.9), underwent a total of 85 procedures using the FRED X device. Indications included treatment of incidentally discovered aneurysms, acute dissections, aneurysm rupture, repair of residual filling following prior intervention, and use of FRED X for recanalization of non-aneurysmal extracranial stroke. 31.3% of the aneurysms were in the posterior circulation, 68.7% were in the anterior circulation. 9.4% of patients presented with SAH due to acute aneurysm rupture. Patients treated with FRED X were separated into OFF-Label (40.0%) or ON-label (60.0%) indications. Occlusion rate at 6-month follow-up were 72.2% in the OFF-label group, 66.7% in the ON-label group, and 68.4% overall. Rate of major periprocedural complications was 1.2% and the cumulative rate of postprocedural complication at follow-up was 5.3%. CONCLUSION:This study shows that FRED X treatment of intracranial aneurysms is safe in both OFF-label and ON-label indications. Continued follow-up of our patient population will further establish the safety, efficacy, and long-term stability of this device.

Flow diversion for intracranial aneurysms is indicated for wide-necked aneurysms in non-perforator-rich segments. However, devices are challenging to deploy in distal/tortuous vasculature. LVIS TM EVO TM is a braided intermediate-density stent offering greater flexibility and navigability than flow diverters with higher metal-to-surface ratios. We investigated its off-label use as an independent flow diverter for small, complex intracranial aneurysms. We retrospectively reviewed patients at a single center who underwent independent stenting with LVIS TM EVO TM from December 2023 to September 2024. Demographics, procedural details, and angiographic outcomes were analyzed. Follow-up computed tomography angiography was performed from May 2024 to October 2025. Descriptive statistics were used; non-parametric tests compared aneurysm and parent vessel diameters. Nine patients (median age 59; 89% female) with off-label intracranial aneurysms (median diameter 5 mm) were treated using LVIS TM EVO TM (median diameter 3 mm, length 18 mm). Deployment was technically successful in 100% of cases with no peri-procedural complications. One patient experienced delayed hemorrhage with full neurological recovery. At follow-up (available for 6 patients), 83.3% showed complete aneurysm occlusion (Raymond-Roy Occlusion Classification [RROC] class I). All patients demonstrated 100% stent patency and no new neurological deficits. LVIS TM EVO TM demonstrated technical feasibility and acceptable initial safety as an off-label flow-diverting device for small (as low as 2.5 mm), distal aneurysms in this limited single-center experience. Its favorable deliverability, safety profile, and occlusion rates suggest it as a possible alternative to currently marketed flow diverters in anatomically challenging patients. These findings warrant validation in larger, multicenter studies with extended follow-up.

Background Nickel hypersensitivity is the most common metal related allergy. Nickel containing alloys are frequently used in endovascular devices. The use of intracranial stents in patients with nickel hypersensitivity appears to be safe, but these small series only evaluated arterial stent placement. This case series aimed to assess the safety of intracranial venous stent placement in patients with documented nickel allergy.Methods In this retrospective multicenter case series, patients with idiopathic intracranial hypertension and documented nickel allergy underwent treatment with a permanently implanted nickel containing stent in the dural venous sinuses.Results Nine patients with nickel allergy were included. All patients reported clinical improvement in their idiopathic intracranial hypertension symptoms. Of the five patients who had follow-up intracranial venous imaging, all stents remained patent. No patients experienced intraoperative, postoperative, or long term procedure related complications, with follow-up ranging from 1.8 weeks to 49.1 months.Conclusion In this limited case series, the use of nickel containing stents in intracranial venous sinuses in patients with nickel allergy did not result in any allergic reaction or adverse outcome.

Background: There are limited therapy options in case of failed reperfusion after stent-retriever and/or aspiration based endovascular treatment (EVT) for acute ischemic stroke. Despite the absence of data supporting its use, rescue angioplasty (RA; with or without stent implantation) is often utilized in such cases. Studies are limited to large vessel occlusions, while the outcomes and complications after RA in medium/distal vessel occlusions (MDVOs) have not been reported. This study aims to report the outcomes of RA in MDVO stroke patients. Methods: We performed a retrospective sub-analysis of the “Blood pressure and Antiplatelet medication management after reScue angioplasty after failed Endovascular treatment in Large and distal vessel occlusions with probable IntraCranial Atherosclerotic Disease” (BASEL ICAD) registry. All MDVO stroke patients were included in the analysis. Results: Out of 718 patients, 92 (12.8%) presented with an MDVO. Sixty-one patients (65.9%) presented with an occlusion of the M2 segment of the middle cerebral artery. Rescue stenting (RS) was performed in 83 patients (90.2%) and balloon angioplasty alone was performed in 9 patients (9.8%). Successful reperfusion (modified thrombolysis in cerebral infarction (mTICI) score ≥ 2b) before RA was achieved in 34 patients (36.9%) and after RA in 76 (82.6%) patients. Symptomatic intracranial hemorrhage (sICH) occurred in 8 patients (9.1%) and post-treatment stent occlusion in 14 patients (16.7%). 90 days mortality was 24.1%. Twenty-nine patients (34.9%) achieved functional independence at 90 days (modified Rankin Scale 0 – 2). Conclusion: Rescue Angioplasty might be a viable treatment option in case of failed reperfusion after conventional EVT in selected MDVO patients. However, safety concerns remain.

BACKGROUND:Post-recanalization target vessel re-occlusion (TVR) following endovascular thrombectomy (EVT) is a known complication of the procedure, and it is associated with worse long-term functional outcomes. The incidence and factors that contribute to TVR are not well understood, particularly within the immediate timeframe following EVT. METHODS:A prospective, multicenter study was performed across four comprehensive stroke centers on adult patients undergoing EVT for acute large vessel occlusion. Modified Thrombolysis in Cerebral Infarction (TICI) score was recorded at the end of the standard procedure, and another TICI score was recorded 10 min later to evaluate for TVR. RESULTS:167 patients underwent EVT for a large vessel occlusion, 93.4% of which were in the anterior circulation. Twenty-seven patients (16.2%) had a change in their TICI score 10 min after EVT, with 19 of these patients (70%) having a worsening in their score. Of the total sample, 13% had their post-procedure care altered by any intervention, and 8% underwent further endovascular interventions due to the change in reperfusion over the 10 min time period. Functional independence (modified Rankin Scale score 0-2) at 90 days was observed in 31% of the entire cohort and in 21% of patients with a worse TICI score at 10 min. CONCLUSIONS:This is the first study to prospectively assess for TVR in the immediate timeframe following EVT. One in six patients had a change in their TICI score, and one in 11 patients had additional intervention. Accordingly, neurointerventionalists should consider integrating angiographic evaluation at 10 min following EVT.

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.