Background: Intracranial aneurysms are abnormal dilatations of arteries in the brain, often necessitating intricate endovascular interventions. Preoperative planning using 3D-printed models can enhance the understanding of complex aneurysm anatomy and improve treatment strategies. This study aims to evaluate the impact of patient-specific 3D-printed aneurysm models on procedural planning, treatment efficacy, and clinical outcomes. Methods: We conducted a retrospective analysis of patients treated for non-ruptured intracranial aneurysms at our institution between 2021 and 2023. Nine patients underwent preoperative simulation using 3D-printed models, while 32 patients received standard care without simulation. The vascular models were created using 3D Slicer for segmentation and Meshmixer for model refinement. The simulations were performed on a biplane Allura system. Data on demographics, aneurysm characteristics, hospitalization duration, procedure times, treatment changes, and unused materials were collected and analyzed using SPSS software. Statistical significance was assessed with independent one-tail t-tests, with a p-value < 0.05 considered significant. Results: The experimental group (nine patients) showed a trend towards reduced procedure times compared to the control group (126 ± 48 mins vs. 142 ± 68 mins, p = 0.253). There was no significant difference in mean hospitalization days between the groups (4 ± 0.9 days vs. 4 ± 1.7 days, p = 0.502). Interestingly, the treatment strategy was altered in four cases based on 3D simulation insights. The 3D simulation group also experienced fewer procedural complications (22.2 % vs. 31.2 %). Conclusions: simulation using 3D-printed models shows potential in enhancing procedural planning and reducing complication rates in the treatment of intracranial aneurysms. While the study did not demonstrate statistically significant differences in procedure time and hospitalization days, the observed trends and changes in treatment strategies suggest that 3D printing technology can provide valuable insights for neurointerventionists. Further research with larger sample sizes and prospective designs is warranted to validate these findings and establish standardized protocols for integrating 3D printing into clinical practice.

Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is often complicated by delayed cerebral vasospasm (DCV), a major cause of morbidity and mortality. Balloon angioplasty is standard for refractory cases but carries a high risk in distal vessels. This study reports preliminary single-center experience with the Comaneci device for DCV, emphasizing distal segments beyond the circle of Willis, where evidence remains limited.Methods We retrospectively analyzed patients with aSAH and symptomatic DCV refractory to medical therapy treated with Comaneci-assisted angioplasty (CAA). Demographic, procedural, clinical, and angiographic data were collected from electronic records. Angiographic response was graded using a vasospasm severity scale.Results CAA was performed in 94 vessels across 14 patients (median age 63 years; 85.7% female). Severe-to-critical vasospasm was present in 88.6%. Most interventions involved the anterior circulation (79.1%), with distal segments (M2 and A2-A4) comprising 54.1%. The M2 segment was most frequently treated (36.4%). Patients underwent a median of three interventions (range 2-6). Angioplasty resulted in significant resolution of vasospasm in 92.7% of vessels, with retreatment required in 8.3%. At 6 months, a favorable outcome (mRS 0-2) was observed in 51.5% of patients, while 90-day mortality was 21.4%. No vessel perforations or long-term complications occurred; one transient occlusion was successfully managed with aspiration.Conclusions CAA appears feasible and safe for DCV, particularly in the distal vasculature where balloon angioplasty is rarely used. These findings suggest the device may provide a valuable alternative to conventional therapy. Larger prospective studies are required to confirm safety, efficacy, and long-term clinical impact.

Background and purposeTo assess the safety and efficacy of Tigertriever 13 (T13) (one center experience) for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) in patients with primary or secondary distal, medium-size vessel occlusions (DMVOs).MethodsWe performed a retrospective analysis of all consecutive AIS patients who underwent thrombectomy with T13 for DMVO (from 2018 until the present). Patient's characteristics were analyzed as well as procedural complications, angiographic (modified thrombolysis in cerebral infarction [mTICI]) score, and clinical outcomes (modified Rankin Scale [mRS]).ResultsOur cohort included 43 patients. Male predominance was noticed (60.5%), the median age was 71 years (interquartile range [IQR], 65-83), and 37.2% of patients received IV lytics prior to MT. Our cohort was divided into three sub-groups: (1) primary DMVO (17 patients, 39.5%), (2) secondary DMVO following large vessel occlusion (19 patients, 44.18%), and (3) DMVO related to the non-stroke endovascular procedure, such as aneurysm repair and carotid artery stenting (seven patients, 16.2%). Successful recanalization (mTICI 2b-3) was achieved in most of the patients (37/43, 86.04%). None of the patients have experienced symptomatic intracranial hemorrhage (ICH), and seven patients (16.3%) had asymptomatic ICH. Median mRS score was 3 at day 90 (IQR, 2-5), with 17 patients (39.5%) gained favorable outcome (mRS ≤ 2). Mortality was documented among 11.8% in primary DMVO and 10.52% in secondary DMVO.ConclusionsT13 for MT seems to be safe and effective for DMVO. Clinical outcomes and complications were in line with those described among patients with proximal occlusions. Although considered a remote target, it seems to be technically achievable with a reasonable outcome.

Introduction: Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia. Method: A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching. Results: Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes. Discussion: Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.

Background and Objectives Incidental diffuse-weighted imaging (DWI)-positive subcortical and cortical lesions, or acute incidental cerebral microinfarcts (CMIs), are a common type of brain ischemia, which can be detected on magnetic resonance DWI for approximately 2 weeks after occurrence. Acute incidental CMI was found to be more common in patients with cancer. Whether acute incidental CMI predicts future ischemic stroke is still unknown. We aimed to examine the association between acute incidental CMI in patients with cancer and subsequent ischemic stroke or transient ischemic attack (TIA). Methods This is a retrospective cohort study. We used Clalit Health Services records, representing over half of the Israeli population, to identify adults with lung, breast, pancreatic, or colon cancer who underwent brain MRI between January 2014 and April 2020. We included patients who underwent scan between 1 year before cancer diagnosis and 1 year after diagnosis. Primary outcome was ischemic stroke or TIA using International Classification of Diseases, Ninth Revision codes. Secondary outcomes were intracranial hemorrhage (ICH) and mortality. Records were followed from first MRI until primary outcome, death, or end of follow-up (January 2023). Cox proportional hazards models were used to calculate hazard ratio (HR) for patients with and without acute incidental CMI, as a time-dependent covariate. Results The study cohort included 1,618 patients with cancer, among whom, 59 (3.6%) had acute incidental CMI on at least 1 brain MRI. The median (interquartile range) time from acute incidental CMI to stroke or TIA was 26 days (14-84). On multivariable analysis, patients with acute incidental CMI had a higher stroke or TIA risk (HR 2.97, 95% CI 1.08-8.18, p = 0.035) compared with their non-CMI counterparts. Acute incidental CMIs were also associated with mortality after multivariable analysis (HR 2.76, 95% CI 2.06-3.71, p < 0.001); no association with ICH was found. Discussion Acute incidental CMI on brain MRI in patients with active cancer is associated with an increased risk of near-future ischemic stroke or TIA and mortality. This finding might suggest that randomly detected acute incidental CMI in patients with cancer may guide primary cerebrovascular risk prevention and etiologic workup.

The Tigertriever is a novel, radially adjustable stentriever that addresses limitations in traditional mechanical thrombectomy devices by providing enhanced user control over clot integration. This provides the ability to adapt to patient-specific factors such as varying vessel sizes and clot compositions and may be particularly crucial for ensuring efficacy and safety in distal locations. This consensus paper synthesizes the clinical techniques from a consortium of experienced international operators. It outlines the current data on the Tigertriever, discusses the new operator-controlled capabilities, and provides a recommended approach for both proximal and distal mechanical thrombectomy, emphasizing the "FLEX" approach (Fast Controlled Expansion with Relaxation) for optimal integration and reduced clot disruption.

Background Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear. Method This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed. Results Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups. Conclusion Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Background and Objectives: Cerebral microinfarcts (CMIs) are the most common type of brain ischemia; however, they are extremely rare in the general population. CMIs can be detected by magnetic resonance diffusion-weighted imaging (MRI-DWI) only for a very short period of approximately 2 weeks after their formation and are associated with an increased stroke risk and cognitive impairment. We aimed to examine CMI detection rate in patients with lung cancer (LC), which is strongly associated with ischemic stroke risk relative to other cancer types.Methods: We used the Clalit Health Services record (representing more than 5 million patients) to identify adults with LC and breast, pancreatic, or colon cancer (non-lung cancer, NLC) who underwent brain magnetic resonance diffusion (MRI) scan within 5 years following cancer diagnosis. All brain MRI scans were reviewed, and CMIs were documented, as well as cardiovascular risk factors.Results: Our cohort contained a total of 2056 MRI scans of LC patients and 1598 of NLC patients. A total of 143 CMI were found in 73/2056 (3.5%) MRI scans of LC group compared to a total of 29 CMI in 22/1598 (1.4%) MRI scans of NLC (p < 0.01). Cancer type (e.g. LC vs NLC) was the only associated factor with CMI incidence on multivariate analysis. After calculating accumulated risk, we found an incidence of 2.5 CMI per year in LC patients and 0.5 in NLC.Discussion: CMIs are common findings in cancer patients, especially in LC patients and therefore might serve as a marker for occult brain ischemia, cognitive decline, and cancer-related stroke (CRS) risk.

BACKGROUND Intracranial atherosclerotic disease (ICAD) is a common cause for stroke and can be defined as symptomatic (stroke) or asymptomatic. Current guidelines recommend against intracranial stenting (ICS) for patients with ICAD; treatment of patients who failed the best medical therapy is still debatable. METHODS We introduce a preliminary retrospective analysis of our tertiary stroke center during 2018-2022 of patients that were treated with ICS either in acute phase or elective (eICS). Study endpoints were stroke, functional outcome (modified Rankin Score [mRS] at 3 months), and serious adverse events. RESULTS Thirty-three stents were implanted, 21 in acute group and 12 in the eICS group. Most patients (75%) were treated with a new generation self-expandible stent. One patient had peri-procedural stroke and four patients had transient ischemic event or stroke during follow-up. There were eight cases of death (all acute group patients, seven of which occurred in the posterior circulation). Fifteen patients (62%) had favorable clinical outcomes (mRS 0-2 for pre-stroke), of which 10/10 (100%) in the eICS, the other two eICS patients had pre-morbid mRS 3 with no clinical change. CONCLUSIONS The evolution of new devices for ICS and the accumulating interventional experience might open a new era. As no other effective alternative treatment options exist for preventing recurrent stroke, stenting is still common practice in many tertiary centers either urgently or as elective procedure for refractory cases.

BackgroundEndovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome.MethodsWe present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT.ResultsAmong a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients).ConclusionOur results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.

HHV6 is a ubiquitous beta-herpesvirus with >95% of the population found to be seropositive in early adulthood. This virus infects a variety of host cells with a lifelong latency. HHV6 with a unique mechanism of latency, integrates its genome into the telomeres of latently infected cells as well as into the germline chromosomes, thus resulting in individuals carrying a copy of the HHV6 genome in every nucleated cell. Inherited chromosomally integrated HHV6 (iciHHV6) has been observed in 1% of the human population. Herein, we describe a confirmed case of iciHHV6 in a 27-year-old female who presented with a tonic clonic generalized seizure.

BACKGROUND AND OBJECTIVES Cerebral microinfarcts (CMI) are the most common type of brain ischemia, however they are extremely rare in the general population. CMI can be detected by Magnetic resonance diffusion-weighted imaging (MRI-DWI) only for a very short period of approximately 2 weeks after their formation, and are associated with an increased stroke risk and cognitive impairment. We aimed to examine CMI detection rate in patients with lung cancer (LC), which is strongly associated with ischemic stroke risk relative to other cancer types. METHODS We used Clalit health services record (representing more than 5 million patients) to identify adults with LC, breast, pancreatic or colon cancer (non-lung-cancer, NLC) who underwent brain MRI scan within 5 years following cancer diagnosis. All brain MRI scans were reviewed and CMI were documented, as well as cardiovascular risk factors. METHODS Our cohort contained a total of 2056 MRI scans of LC patients and 1598 of NLC patients. A total of 143 CMI were found in 73/2056 (3.5%) MRI scans of LC group, compared to a total of 29 CMI in 22/1598 (1.4%) MRI scans of NLC,(p<0.01). Cancer type (e.g., LC vs. NLC) was the only associated factor with CMI incidence on multivariate analysis. After calculating accumulated risk, we found an incidence of 2.5 CMI per year in LC patients, and 0.5 in NLC. DISCUSSION CMI are common findings in cancer patients, especially in LC patients, therefore might serve as a marker for occult brain ischemia, cognitive decline and CRS risk.

Background Endovascular treatment (EVT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO) is the standard of care treatment today. Although elderly patients comprise the majority of stroke patients, octogenarians and non-agenarians are often poorly represented or even excluded in clinical trials. We looked at the safety and efficacy of EVT for AIS with LVO in patients over 90 (Non-agenarians), in comparison to patients aged 80–89 (Octogenarians) and to patients younger than 80 years (<80yrs). Methods A retrospective analysis of patients who underwent EVT in a single stroke center during 2015–2019. Patients were divided into three subgroups based on their age: Non-agenarians, Octogenarians, and patients <80 yrs. The groups were compared based on baseline characteristics and stroke variables. In addition, we compared clinical and radiological outcomes including functional outcomes measured by the modified ranking scale (mRS) at day 90, symptomatic intracranial hemorrhage (sICH), and mortality. Results Three hundred and forty seven patients were included, 20 (5.7%) of them were non-agenarians, 96 (27.7%) were octogenarians and 231 (66.6%) were <80 yrs. No statistically significant differences were found between groups regarding baseline characteristics, cardiovascular risk factors, stroke variables, or successful revascularization rates. Puncture to recanalization time intervals showed an age-related non-significant increase between the groups with a median time of 67.8, 51.6, and 40.2 min of the non-agenarian, octogenarian, and <80 yrs groups, respectively (p-value = 0.3). Favorable outcome (mRS 0–2) was 15% in non-agenarians vs. 13.54% in octogenarians (p-value = 1) and 40.2% in <80 yrs. sICH occurred among 5% of non-agenarians, compared to 4% among octogenarians (p-value = 1) and 2.6% in <80 yrs. The mortality rate at 3 months was significantly higher (55%) in non-agenarians compared to octogenarians (28%) (p-value = 0.03) and to <80 yrs (19.48%). Conclusion EVT in nonagenarians demonstrated a high rate of successful revascularization, whilst also showing an increased rate of sICH when compared to octogenarians. Mortality rates showed an age-related correlation. Although further studies are needed to clarify the patient selection algorithm and identify sub-groups of elderly patients that could benefit from EVT, we showed that some patients do benefit from EVT therefore exclusion should not be based on age alone.

BACKGROUND:Despite advances in transcatheter aortic valve replacement (TAVR), periprocedural acute ischemic stroke remains a concern.OBJECTIVES:The aims of this study were to investigate acute ischemic stroke complicating TAVR (AISCT) and to describe the indications and outcomes of interventions to treat AISCT.METHODS:An international multicenter registry was established focusing on AISCT within 30 days of TAVR. Stroke severity was assessed using the National Institutes of Health Stroke Scale. Primary outcomes were 1-year all-cause death and neurologic disability status at 90 days according to modified Rankin scale score.RESULTS:Of 16,615 TAVR procedures, 387 patients with AISCT were included (2.3%). Rates of 1-year death were 28.9%, 35.9%, and 77.5% in patients with mild, moderate, and severe stroke, respectively (P < 0.001). Although 348 patients were managed conservatively, 39 patients (10.1%) underwent neurointervention (NI) with either mechanical thrombectomy (n = 26) or thrombolytic therapy (n = 13). In a subanalysis excluding patients with mild stroke, there was no clear 1-year survival benefit for NI compared with conservative management (47.6% vs 41.1%, respectively; P = 0.78). In a logistic regression model controlling for stroke severity, NI was associated with 2.9-fold odds (95% CI: 1.2-7.0; P = 0.016) of independent survival at 90 days.CONCLUSIONS:AISCT carries significant morbidity and mortality, which is correlated with stroke severity. The present findings suggest that neurologic disability for patients with moderate or worse stroke could potentially be improved by timely intervention and highlight the importance of collaboration between cardiologists and neurologists to optimize AISCT outcomes.

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

Background: According to the latest reported data from the National Acute Stroke Israeli Survey (NASIS), around 18,000 strokes occur annually in Israel. Data regarding disparities in stroke care between the Jewish and the Arab populations in Israel are lacking. Aims: We wished to compare demographics, comorbidities, stroke characteristics and outcomes between Jewish and Arab stroke patients in Israel that were acutely treated with intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), in order to test if there are disparities or any ethnic-specific parameters. Methods: The National Acute Stroke Israeli registry of patients undergoing revascularization (NASIS-REVASC) prospectively enrolled patients in six comprehensive stroke centers between 1/2014 and 3/2016. In this observational research, we compared demographics, comorbidities, time metrics, stroke characteristics and outcomes between Jewish and Arab patients enrolled. Results: NASIS-REVASC included 1432 patients out of which 143 (10%) were of Arab ethnicity and 1289 (90%) of Jewish ethnicity. Arab patients were significantly younger (66 ? 14 vs. 73 ? 29, p = 0.004), exhibited higher rates of smoking and diabetes (31% vs. 18% and 57% vs. 34%, p < 0.001 for both), and were less often treated with systemic thrombolysis (48% vs. 59%, p = 0.012). However, the rates of any interventional treatment with either intravenous thrombolysis or endovascular thrombectomy as well as the rates of favorable outcomes and mortality were comparable between groups. Conclusions: Despite several baseline differences between Arab and Jewish Israeli stroke patients, treatment allocations, survival and functional outcomes were similar indicating lack of disparity in stroke care among patients treated acutely with IVT and/or EVT in Israel. Data access statement: Full data is available following a formal request to the NASIS-REVASC registry at the Israeli Health Ministry.

BACKGROUND AND PURPOSE:Independent randomized controlled clinical trials (RCTs) have provided robust evidence for endovascular treatment (EVT) as the standard of care treatment for acute large vessel occlusions in the anterior circulation. We examined available studies specific to posterior cerebral circulation ischemic strokes to see if any conclusions can be drawn regarding EVT options.METHODS:We performed a systematic literature search to identify studies evaluating the safety and efficacy of EVT versus standard medical treatment for patients with acute basilar artery occlusion (BAO). We extracted data for outcomes of interest and presented associations between the two groups with the use of risk ratios (RRs) or odds ratios (ORs), with corresponding 95% confidence intervals (CIs). We used a random-effects model to pool the effect estimates.RESULTS:We identified five studies (two RCTs, three observational cohorts) including a total of 1098 patients. Patients receiving EVT had a higher risk of symptomatic intracranial hemorrhage (sICH) compared to those receiving non-interventional medical management (RR 5.42, 95% CI 2.74-10.71). Nonsignificant trends towards modified Rankin Scale (mRS) scores 0-2 (RR 1.02, 95% CI 0.74-1.41), mRS scores 0-3 (RR = 0.97, 95% CI 0.64-1.47), overall functional improvement (OR 0.93, 95% CI 0.57-1.51), and all-cause mortality (RR 1.03, 95% CI 0.78-1.35) at 3 months were seen.CONCLUSION:Although EVT increases the probability of sICH, the available data do not exclude the possibility of improved functional outcomes over standard therapy. As larger studies are challenged by the perceived lack of equipoise in this vulnerable patient population, results of ongoing RCTs are expected to provide substantial input for future meta-analyses.

Background Endovascular therapy (EVT) is currently the most effective treatment for emergent large vessel occlusion (ELVO) stroke. Earlier treatment is associated with a better clinical outcome. Our aim was to examine the association between onset-to-EVT (OTE) time and clinical outcomes using real-world nationwide data from the National Acute Stroke ISraeli (NASIS)-REVASC registry. Methods Stroke patients undergoing EVT within the Endovascular Capable Centres (ECCs) in Israel between January 2014 and March 2016 were prospectively included. Several clinical and radiological outcomes were evaluated. The association between OTE time and outcomes was analyzed with logistic regression models using time as a continuous variable and then by OTE groups of <2, 2–4, 4–6, and >6 hours. Results 299 patients with acute stroke were included in the analysis. OTE time was significantly associated with favorable outcomes. ORs for each hour of delay in EVT were 0.84 (95% CI 0.71 to 0.99) for significant early recovery, 0.80 (95% CI 0.68 to 0.94) for discharge to home, 0.80 (95% CI 0.66 to 0.95) for freedom from disability at discharge, and 0.78 (95% CI 0.67 to 0.91) for excellent reperfusion (Thrombolysis in Cerebral Ischemia 3). The <2 OTE group was significantly associated with better outcomes than the ≥2 OTE group including significant early recovery (OR 3.3, 95% CI 1.2 to 9.1), discharge to home (OR 3.32, 95% CI 1.3 to 8.5), and excellent reperfusion (OR 4.6, 95% CI 1.3 to 29.5). The same trend was observed for freedom from disability at discharge and 3 months (OR 2.08, 95% CI 0.7 to 5.7 and OR 2.57, 95% CI 0.8 to 8.3, respectively). Only 1% of transferred patients achieved an OTE time of <2 hours. Conclusions Nationwide real-life registry data indicate that benefit from EVT is strongly associated with OTE time and is most prominent within the ‘two golden hours’ from stroke onset. This time goal may not be applicable in inter-hospital transfer patients.

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