BACKGROUND: To evaluate global stroke pathways in pediatric acute ischemic stroke care, including availability of personnel, imaging practices, hyperacute therapies available, and institutional resources. METHODS: A 25-question survey designed by the Society of Neurointerventional Surgery Pediatric Special Interest Group was distributed internationally via pediatric and neurointerventional societies. The survey collected data on institutional settings, stroke team composition, imaging protocols, use of artificial intelligence, and access to thrombectomy and thrombolysis. Responses from 103 stroke care providers were analyzed using descriptive statistics. Participation was voluntary and anonymous, and >1 respondent from the same institution was permitted. RESULTS: Ninety-one of 103 respondents (88%) reported managing pediatric acute ischemic stroke. However, only 65% offered both intravenous thrombolysis and thrombectomy. Computed tomography and computed tomography angiography were the most commonly used first-line imaging modality (34%), whereas perfusion imaging and artificial intelligence tools were underutilized. Pediatric neurologists were the most common decision-makers for thrombolysis (38%). Posterior circulation thrombectomy was widely unavailable (offered at only 45% of centers). CONCLUSIONS: Survey results revealed considerable variability in pediatric acute ischemic stroke pathways globally and a lack of standardization in treatment. Disparities in access to imaging, hyperacute therapies, and trained personnel underscore the need for standardization, international collaboration, and the creation of systems utilizing available resources to improve pediatric stroke care.

INTRODUCTION:The ATLAS trial was a prospective, multicenter, single-arm, investigational device exemption (IDE) study to evaluate the safety and effectiveness of the Neuroform Atlas Stent System for the treatment of wide-necked bifurcation aneurysms. This analysis presents the 36-month follow-up data for the anterior and posterior cohorts. METHODS:Of the 182 patients in the IDE anterior cohort, 146 consented to participate in the post-approval study (PAS) and, of the 116 patients in the IDE posterior cohort, 101 consented to participate in the PAS. The primary effectiveness endpoint was core laboratory adjudicated (Raymond-Roy 1; RR1) without retreatment or parent artery stenosis (>50%) at 36 months post-procedure. The primary safety endpoint was Clinical Event Committee-adjudicated major ipsilateral stroke or neurological death through 36 months. RESULTS:There were 146 patients in the anterior cohort and 101 patients in the posterior cohort. At 24 months the composite effectiveness endpoint was 77.3% (34/44) in the anterior cohort and 65.5% (19/29) in the posterior cohort and at 36 months these rates were 92.3% (24/26) and 75.0% (18/24), respectively. RR1 rates at 24 months were 84.1% (37/44) in the anterior cohort and 70.0% (21/30) in the posterior cohort; at 36 months they were 96.3% (26/27) and 79.2% (19/24), respectively. By 36 months the primary safety endpoint occurred in 4.1% (6/146) of patients in the anterior cohort and 5.0% (5/101) in the posterior cohort. CONCLUSION:The results of the long-term assessment of the Neuroform Atlas Stent System demonstrate favorable safety and effectiveness in the treatment of wide-necked bifurcation aneurysms without a single treated target aneurysm rupture beyond 12 months post-procedure.

PURPOSE:Large bore catheters are increasingly used in mechanical thrombectomy (MT) for large vessel occlusions (LVOs). OBJECTIVE:To evaluate the efficacy and safety of the super-large bore Cereglide 0.092" (C-92) catheter, featuring the largest inner diameter available. METHODS:A multicenter observational study was conducted across 12 comprehensive stroke centers in the United States. Efficacy outcomes included the first pass effect (FPE) and successful reperfusion. FPE was defined as a first MT pass achieving a modified Treatment in Cerebral Infarction (mTICI) score of ≥2c. Successful reperfusion was defined as final mTICI score ≥2c. Safety outcomes involved device-related complications, symptomatic intracranial hemorrhage (sICH), and inpatient mortality. Functional outcomes included modified Rankin Scale (mRS) score at discharge and delta National Institutes of Health Stroke Scale (NIHSS) score. RESULTS:Fifty patients were included. The most common LVO was the first segment of the middle cerebral artery in 31/50 cases (62%). The C-92 reached the thrombus in 41 patients (82%). Median puncture-to-thrombus and puncture-to-reperfusion times were 15 min (IQR 10-25) and 26 min (IQR 15-49), respectively. FPE was achieved in 25/50 (50%) cases, and in 25/41 (61%) cases when the C-92 reached the thrombus. Successful reperfusion occurred in 36/41 patients (88%). There were no vessel perforations, or sICH. Distal embolization occurred in 4/50 (8%) cases, and 4/50 (8%) died. The mRS score at discharge was 3 (IQR 2-6), and the delta NIHSS score was 8 (IQR 5-12). CONCLUSION:The C-92 catheter demonstrated a safe profile achieving an overall FPE rate of 50%, and favorable functional outcomes in 88% of cases.

Introduction Delivering large-bore aspiration catheters through tortuous anatomy remains challenging during mechanical thrombectomy (MT). The Carrier delivery-assist catheter (DAC) was designed to facilitate aspiration catheter navigation, but multicenter data remain limited. We evaluated the efficiency and safety of the Carrier DAC. Methods We performed a multicenter retrospective study of prospectively collected data from patients undergoing MT at 15 U.S. Comprehensive Stroke Centers (September 2024?September 2025). Co-primary endpoints were puncture-to-clot engagement time and first-pass effect (FPE; eTICI 2c?3). A pre-specified single-center analysis compared upfront contact aspiration using the Carrier DAC versus standard 0.021? microcatheter techniques with identical aspiration catheter sizes. Results The multicenter cohort included 211 Carrier-assisted MTs. Median aspiration catheter inner diameter was 0.071?, with super-bore catheters used in 5.7%. Median puncture-to-clot time was 12 minutes, and FPE was achieved in 50.7%. Median puncture-to-reperfusion time was 20 minutes, and mFPE occurred in 74.4%. Parenchymal hematoma and subarachnoid hemorrhage occurred in 11.8% and 6.6%, respectively. Cavernous tortuosity did not affect primary endpoints. The single-center analysis included 242 patients. Carrier use was associated with shorter puncture-to-clot times and numerically higher FPE rates without increased hemorrhagic complications. Conclusions The Carrier DAC enables efficient navigation of large-bore aspiration catheters and may reduce procedural time while maintaining procedural safety. Prospective studies are warranted. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding for manuscript submission was supported by Balt, USA. ### 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: The study was approved by the Emory University Institutional Review Board (IRB #0006851) and followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. Study protocol IRB0006851 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 The data that support the findings of this study are available from the corresponding author upon reasonable request.

OBJECTIVE:Venous sinus stenting (VSS) has emerged as a promising and less invasive treatment alternative to CSF diversion for patients with idiopathic intracranial hypertension (IIH). Fulminant IIH (fIIH) is a rare manifestation of IIH, affecting 2%-3% of IIH patients and characterized by rapid, progressive, and severe visual loss. Outcomes following different treatment modalities for fIIH remain unclear. METHODS:A dual-center retrospective cohort study was done comparing patients who underwent VSS or ventriculoperitoneal shunting (VPS) for fIIH over a 5-year time frame, defined as rapid visual loss secondary to IIH refractory to medical management. Patient demographic characteristics, baseline symptom characteristics focusing on headache and visual decline, operative parameters, postoperative complications, and outcomes were collected. The decision to proceed with VSS or VPS was based on surgeon discretion and institutional preference. Data were analyzed using the bivariate t-test or chi-square test as appropriate, and multivariate logistic regression was used to identify significant predictors. RESULTS:A total of 39 patients who underwent treatment for fIIH were identified, of whom 46% (n = 18) underwent VPS and 54% (n = 21) underwent VSS. The VSS cohort included more females (100% vs 76%, p = 0.03), otherwise no differences were seen in age, BMI, rate of preoperatively diagnosed headache disorder or psychiatric disorder, acetazolamide usage, preoperative papilledema grade, preoperative average visual acuity, or preoperative opening pressure. On univariate regression, VSS was associated with improved headache reduction (58% vs 25%, p < 0.001) as well as decreased headache recurrence (27% vs 65%, p = 0.03). Both cohorts showed a high rate of improvement in papilledema postoperatively (93.3% for VSS vs 92.8% for VPS, p > 0.99), and there was no significant difference in the rates of postoperative visual acuity improvement (83% for VSS vs 50% for VPS, p = 0.17). VPS patients were more likely to have reductions in acetazolamide usage postoperatively (85% vs 22%, p = 0.001). No postoperative hemorrhages, access site complications, or stent thromboses were observed. On multivariate regression, no significant predictors of improvement in headache severity, papilledema, or visual acuity were observed. CONCLUSIONS:Among patients presenting with fIIH, VSS is comparable to VPS with respect to visual outcomes defined as improvement in papilledema. Larger randomized studies are required to determine differences in outcomes between VSS and VPS in this subpopulation of IIH patients.

Intracranial cerebrovascular injury (iCVI) is a rare but potentially devastating complication of gunshot wounds to the head (GSWH). Despite firearm injuries being the leading cause of death of children in the United States, the incidence, prognosis, and treatment of iCVI in pediatric patients has not been clearly described. All pediatric GSWH from 01/2010 to 09/2023 at a large Level 1 trauma center in the southeastern US were retrospectively reviewed. Cases of injury to intracranial vasculature were identified. Demographics, injury patterns, treatments, and outcomes were collected. Statistical analyses were calculated using Fisher’s exact test and Friedman’s nonparametric Chi Square test where appropriate. A p-value of = 0.05 was considered significant. During the study period, there were 238 GSW to the head and face, with calvarial violation in 100 (42%) patients. Total incidence of iCVI was 18 (18%), and of these patients, 33.3% (6/18) suffered arterial injury, 44.4% (8/18) suffered venous injury (including sinus injury), and 22.2% (4/18) suffered both. iCVI was significantly associated with severe TBI (Glasgow Coma Score =8, p = 0.05). Ten (55.6%) patients with iCVI underwent repeat CT angiography, and 3 (16.7%) underwent catheter angiography. Four (22.2%) patients suffered radiographic vasospasm however none had radiographic stroke. Traumatic pseudoaneurysms requiring treatment were found in 2 patients (11.1%) at 12 days (received n-BCA embolization) and 4 years (received open trapping and excision) after injury respectively. Both patients with (55.6%) and without (62.2%) iCVI suffered a high mortality rate. iCVI is an important complication of GSWH, occurring in a non-insignificant portion of the pediatric population. While monitoring and treatment is limited by high up-front mortality, close attention to secondary vascular insult such as vasospasm and pseudoaneurysm formation is required.

INTRODUCTION:The impact of insurance status on mortality and functional outcomes has yet to be examined in Mechanical Thrombectomy (MT) patients, despite research on socioeconomic status. OBJECTIVE:Herein we describe the effects of insurance status on MT outcomes while controlling for other components of socioeconomic status like race, gender, and area deprivation index (ADI). METHODS:We performed a retrospective cohort study of 395 patients undergoing MT at a single comprehensive stroke center between 2018 and 2022. Patients were grouped based on presence of insurance on admission. Univariate and multivariate analysis were conducted examining the following outcome variables: length of stay (LoS), readmission within 90 days, good functional outcomes measured as a modified Rankin score at 90 days<3, and death. RESULTS:A total of 44/395 (11.1 %) patients were uninsured. Uninsured patients were significantly younger on average (59.5 ± 18.2 years compared to 67.1 ± 14.7 years (p = 0.010)) On multivariate analysis, insured status was associated with improved mortality rates (OR: 0.33; 95 % CI: 0.11-0.93; p = 0.035). On univariate analysis, insured status did not have a significant effect on favorable functional outcome (OR:1.15; 95 % CI:0.56-2.34; p = 0.70), LoS (OR:1.23; 95 % CI:0.66-2.32; p = 0.511) or readmission rate (OR:1.66; 95 % CI:0.38-7.31; p = 0.50). Discharge disposition neared significance, with 50 % of insured patients being discharged to a rehabilitation facility, while only 29.3 % of uninsured patients were discharged similarly (p = 0.06). CONCLUSION:Lack of insurance is associated with increased mortality following MT after controlling for other socioeconomic variables and may be an important marker of outcomes in AIS patients.

Large vessel occlusion causing acute ischemic stroke is ideally treated with endovascular clot retrieval, which is increasingly being performed via direct aspiration thrombectomy. Successful aspiration thrombectomy depends on multiple tenets of fluid and solid mechanics, including the application of hydrostatic and hydrodynamic forces to lodged clots. These fundamental concepts predict factors that may increase efficacy in clot removal, and help to explain the differences in performance seen among varying aspiration techniques (remote vs direct), catheters (suction force increases with diameter), and vacuum sources (pump type, whether electrical or manual, should not have an impact on negative pressure). Cyclic aspiration is also predicted to show more substantial clot removal and ingestion than static aspiration due to the dynamic forces it imposes on elastic clots.In this paper we will review the basic scientific principles underlying the fluid mechanics of aspiration thrombectomy and explain the application of these principles in practice, to provide a more thorough understanding for the neurointerventional clinician.

The impact of stent retriever (SR)-clot integration for mechanical thrombectomy has been highlighted by several studies. However, it has also been shown that SRs can stretch or collapse during thrombectomies in tortuous anatomies. Therefore, this study focused on the behavior of commercial SRs (Solitaire and EmboTrap) during deployment and retrieval. Benchtop experiments were performed to measure the degree of SR collapse in an arterial model of varying tortuosity, and a custom testing structure was developed to measure SR outward forces at deployment and changes in radial force density (RFD). The degree of collapse was significantly influenced by the model's tortuosity index (TI) and the number of curves the SR pushwire interacted with (p < 0.05); a slight collapse was present at deployment, while more pronounced collapse occurred during retrieval. Solitaire SRs experienced more significant collapse than EmboTrap SRs, which was most pronounced in the highest tortuosity segment (TI = 1.74) where the Solitaire and EmboTrap degrees of collapse were 67.8 % and 32.5 %, respectively. While longer SRs were shown to have greater collapse overall, their distal segments remained expanded. We hypothesize this behavior supports prior clinical studies highlighting the benefits of longer SRs; during retrieval the distal SR region applies force to the clot to assist in dislodgment. SR behavior was also reflected in RFD trends. SRs with the least collapse generated the greatest RFDs and decreased with higher tortuosity. Overall, an evaluation of SR behaviors indicated that both SR design and length will influence the degree of collapse and RFD in tortuous segments.

IntroductionMechanical thrombectomy becomes more complex when the occlusion occurs in a tortuous cerebral anatomy, increasing the puncture to reperfusion time and the number of attempts for clot removal. Therefore, an understanding of stent retriever performance in these locations is necessary to increase the efficiency and safety of the procedure. An in vitro investigation into the effects of occlusion site tortuosity, blood clot hematocrit, and device geometry was conducted to identify their individual influence on stent retriever removal forces.MethodsEmbolus analogs were used to create occlusions in a mock circulatory flow loop, and in vitro mechanical thrombectomies were performed in arterial models of increasing tortuosity. The stent retriever removal forces of Solitaire Platinum and EmboTrap II devices were recorded through each geometry with and without embolus analogs present. Similar experiments were also conducted with Solitaire stent retrievers of varying lengths and diameters and 0, 25, and 50% hematocrit embolus analogs.ResultsThe removal force increased as model tortuosity increased for both the Solitaire Platinum and EmboTrap II stent retriever devices. The average removal forces in the simplest geometry with the Solitaire Platinum and EmboTrap II were 0.24 ± 0.01 N and 0.37 ± 0.02 N, respectively, and increased to 1.2 ± 0.08 N and 1.6 ± 0.17 N, respectively, in the most complex geometry. Slight increases in removal force were found with 0% hematocrit embolus analogs, however, no statistical significance between removal force and EA hematocrit was observed. A comparison between stent retriever removal forces between devices of different diameters also proved to be significant (p < 0.01), while forces between devices of varying lengths were not (p > 0.05).ConclusionBenchtop mechanical thrombectomies performed with commercial stent retrievers of varying geometry showed that device removal forces increase with increasing model tortuosity, clot hematocrit does not play a significant role in device removal force, and that a stent retriever’s diameter has a greater impact on removal forces compared to its length. These results provide an improved understanding of the overall forces involved in mechanical thrombectomy and can be used to develop safer and more effective stent retrievers for the most difficult cases.

BACKGROUND:Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms. METHODS:A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA. RESULTS:Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care. CONCLUSIONS:Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field.

Background Mechanical thrombectomy via direct aspiration is a rapid treatment for acute ischemic stroke. This method often results in the partial ingestion of the clot or “corking” of the catheter tip. Cyclic aspiration may take advantage of the mechanical properties of the clot, resulting in greater clot ingestion and overall procedure success. Methods An in vitro analysis was performed comparing static and cyclic (plunger technique) aspiration. Embolus analogs were used to create occlusions in a mock circulatory flow loop, and one aspiration attempt (first pass effect) using either a static or plunger technique was performed. The percent ingestion of each embolus analog was recorded for each trial. Results Static aspiration for 0% and 50% hematocrit embolus analogs resulted in ingestions of 12.8 ± 4.6% and 15.1 ± 10.0%, respectively, while plunger technique (cyclic) aspiration resulted in 15.8 ± 7.3% and 34.4 ± 19.5% ingestion. Complete ingestion was observed only with 50% hematocrit analogs, occurring in 30% of plunger and 10% of static cases. Statistical differences were determined between the two aspiration techniques for the 50% hematocrit samples, with the plunger technique yielding significantly more ingestion. In addition, the plunger technique was shown to maintain a negative vacuum pressure throughout the duration of cyclic plunging. Conclusions The plunger technique for manual cyclic aspiration resulted in higher rates of complete ingestion and greater average % ingestions when compared to static aspiration. Increased clot ingestion can result in a higher rate of complete reperfusion during the first aspiration attempt, maximizing the number of patients with good clinical outcomes.