This systematic review and meta-analysis compares the safety and efficacy of atherectomy as a vessel preparation tool prior to balloon angioplasty (ATH + BA) versus balloon angioplasty alone (BA) for the treatment of peripheral arterial disease (PAD). Medline, Embase, CENTRAL, and Clinicaltrials.gov databases were searched for randomized controlled trials (RCTs) comparing ATH + BA versus BA alone in treating PAD. The outcomes analysed included primary patency, technical success, bailout stenting, flow-limiting dissection, clinically driven target lesion revascularization (CD-TLR), distal embolization, arterial perforation, major amputation, and all-cause mortality. A subgroup analysis was done to compare femoropopliteal versus infrapopliteal and plain balloon angioplasty versus drug-coated balloon. Seven RCTs met the inclusion criteria (489 patients). Atherectomy as vessel preparation was associated with reduced rates of bailout stenting (OR: 0.14, 95

Background and Purpose Spontaneous intracranial hypotension (SIH) is a debilitating condition most often caused by spontaneous cerebrospinal fluid (CSF) leaks, with CSF-venous fistulas (CVF) representing an increasing number of cases. Pathophysiological understandings of CVFs, particularly those concerning pressure dynamics between the CSF and venous systems, remain elusive. This study aimed to mathematically model CVFs using first principles physics and to explore pressure dynamics and their implications for treatment and complications. Materials and Methods CSF-venous pressure dynamics were modelled using physics first-principles. Adjustable parameters included initial CSF pressure, CSF production rate, fistula radius, and dural elastance. Dynamic equilibrium pressures and volumes were calculated iteratively, with results plotted against fistula radius, CSF production rate, and dural elastance. Results The model demonstrated that an increase in CSF daily production increased the dynamic equilibrium pressure. Greater dural elastance lowered CSF volume at equilibrium without changing equilibrium pressure. CSF pressure rapidly equilibrated to that of venous pressure for larger fistulas and physiological CSF pressure for smaller fistulas. Conclusions Fistula radius, altered states of CSF production, and dural stiffening complicate the clinical presentation of CVFs. Current hypotheses do not adequately account for raised opening pressures and rebound intracranial hypertension. Instead, global CSF dysregulation, including increased production and impaired secondary outflow, may co-exist in patients with CVFs. Future management should evaluate CSF volume-pressure dynamics, rather than exclusively focusing on the fistula, to improve both diagnosis and anticipate complications. Key Messages CSF-venous fistulas are an increasingly recognised cause of spontaneous intracranial hypotension. Current understandings of CSF-venous pressure dynamics remain elusive. This study modelled the behaviour of CSF pressures to inform a discussion on potential secondary pathophysiological factors. In doing so, it seeks to ensure clinicians consider patient-specific compensatory mechanisms when providing treatment, to anticipate complications and ensure efficacy.

INTRODUCTION:This narrative review examines endovascular treatments for acute pulmonary embolism (PE), focusing on percutaneous mechanical thrombectomy (MT). METHODS:PubMed (Medline) and Google Scholar were searched from January 1990 up to November 2024 (updated Feb 2026). Studies were included if they discussed PE and the use of thrombectomy devices. Full-text randomised controlled trial studies, observational studies, case series, and case reports were included. Opinion articles, letters to the editor, animal studies, and non-English studies were excluded. RESULTS:A total of 116 articles were reviewed. Current guidelines recommend systemic thrombolysis as first-line reperfusion for high-risk PE, whereas intermediate-high-risk PE is managed with anticoagulation and monitoring, with reperfusion reserved for deterioration. MT is currently an alternative, mainly when thrombolysis is contraindicated or has failed. However, the last two decades have seen a surge in thrombectomy devices including the FlowTriever, Indigo, and AngioVac. Numerous studies, most notably the PEERLESS trial, have reported rapid haemodynamic improvement with MT, including reduced pulmonary artery pressure, low major bleeding rates, and fewer intensive care admissions [1]. CONCLUSION:MT has shown early promise in the management of PE. Much of the current evidence derives from single-arm trials, registries, and industry-sponsored observational studies, with randomised comparative data still limited. Nonetheless, randomised evidence suggests MT may reduce clinical deterioration, intensive care use, and hospital length of stay compared with catheter-directed thrombolysis, though without a demonstrated difference in mortality, intracranial haemorrhage, or major bleeding. Further trial evidence is required before MT is recommended as first-line in PE.

Surgical repair is the recommended management for intraperitoneal bladder perforation. In certain cases, repair may be unsuccessful or non-feasible, resulting in refractory urine leak. Ileal conduit formation remains an alternative, howeve it may not be suitable for all patients. In this case, an intraperitoneal bladder perforation occurred during TURBT. Laparoscopic repair was unsuccessful, as were bilateral nephrostomies in controlling the urine extravasation. The patient was not a candidate for surgical urinary diversion. We occluded both ureters using stents, microvascular plugs and embolisation coil and glue. Post intervention the urine leak resolved and the patient was discharged with nephrostomies in-situ.

OBJECTIVE:To synthesize the evidence from recent large randomized controlled trials (RCTs) on middle meningeal artery embolization (MMAE) for non-acute subdural haematoma (SDH) and to propose a unified, evidence-based treatment algorithm to guide clinical practice. METHODS:We conducted a systematic review and meta-analysis of large (n ≥ 100), multicentre RCTs comparing MMAE with surgical evacuation or conservative management for non-acute SDH. A comprehensive search of PubMed/MEDLINE, Embase, and CENTRAL was performed to August 2025. The primary outcome was treatment failure, a composite of radiological recurrence, symptomatic progression, or need for repeat surgery/surgical rescue at 90-180 days. Key secondary outcomes included functional status (modified Rankin Scale, mRS) and safety. Random-effects models were used for pooled analyses. RESULTS:Four RCTs involving 1,774 patients were included. For patients managed non-surgically, standalone MMAE was associated with a 64% relative risk reduction in treatment failure compared to conservative management (Risk Ratio [RR] 0.36, 95% CI [0.22, 0.60]). The number needed to treat was 4. As a surgical adjunct, MMAE offered a more modest but significant benefit in reducing recurrence or progression (RR 0.65, 95% CI [0.48, 0.89]). MMAE did not significantly improve functional outcomes or all-cause mortality but demonstrated a favourable safety profile with low rates of serious complications. CONCLUSIONS:MMAE significantly reduces treatment failure in non-acute SDH, with the most profound benefit seen in non-surgical patients by lowering the need for surgical rescue. Its role as a routine surgical adjunct is less clear, suggesting a stratified approach for patients at high risk of recurrence.

Background Intrasaccular flow diversion using the woven endobridge device (WEB; MicroVention, Aliso Viejo, CA, USA) for the treatment of intracranial aneurysms has demonstrated large scale safety and efficacy. However, limitations arise from its structural configuration, restricting its application to specific aneurysm sizes and shapes. Technique Overview We introduce the CUPCAKE technique, a combination of conventional coiling followed by WEB intrasaccular flow disruption in select cases of atypical aneurysms with technically challenging morphology not typically treatable by WEB alone. Materials and Methods A retrospective analysis of a prospectively-maintained dataset from three Australian neurovascular tertiary referral centers, identifying patients treated with the CUPCAKE technique between April 2018 and September 2023. Evaluation of patient and aneurysm characteristics, procedure parameters, complications, radiological and clinical outcomes at follow-up was performed. Results The CUPCAKE technique was used for the treatment of 22 intracranial aneurysms of total 169 treated with WEB. Overall successful immediate flow stagnation was observed in 95.5% ( n = 21) of aneurysms with no cases of perforation or intraoperative hemorrhage. Imaging confirmed thromboembolic complications occurred in two patients, one patient had persistent flow requiring re-treatment during initial admission. Follow-up imaging demonstrated 88.2% complete aneurysm conclusion with no delayed aneurysm expansion or rupture. Conclusion Synergistic use of conventional coiling with WEB intrasaccular flow disruption presents a viable solution for technically difficult aneurysm treatment. In our series, 13% of all patients treated with WEB received CUPCAKE treatment, resulting in high technical success and no increase in thromboembolic complications with the union of two methods.

Neuroendovascular therapies have redefined the management of multiple intracranial pathologies and are now recognised as first-line treatments for cerebral aneurysms and shunting lesions. New advances and innovative technologies require development of equally advanced techniques to optimise their feasibility, safety and efficacy. We describe a novel catheter arrangement technique, termed "Sidecar," intended to maximise value for the operator and minimise complications with the Benchmark BMX096 guide catheter (Penumbra Inc, Alameda, CA, USA). The 0.096″ internal diameter of this large bore access device enables operators to safely and efficiently treat a broad range of neurovascular pathologies while minimising risk and allowing intra-procedural digital subtraction angiograms to be acquired without losing the position of established microcatheters.

OBJECTIVES:Aneurysm number (An) is a novel prediction tool utilizing parameters of pulsatility index (PI) and aneurysm geometry. An has been shown to have the potential to differentiate intracranial aneurysm (IA) rupture status. The objective of this study is to investigate the feasibility and accuracy of An for IA rupture status prediction using Australian based clinical data. METHODS:A retrospective study was conducted across three tertiary referral hospitals between November 2017 and November 2020 and all saccular IAs with known rupture status were included. Two sets of An values were calculated based on two sets of PI values previously reported in the literature. RESULTS:Five hundred and four IA cases were included in this study. The results demonstrated no significant difference between ruptured and unruptured status when using An ≥1 as the discriminator. Further analysis showed no strong correlation between An and IA subtypes. The area under the curve (AUC) indicated poor performance in predicting rupture status (AUC1 = 0.55 and AUC2 = 0.56). CONCLUSIONS:This study does not support An ≥1 as a reliable parameter to predict the rupture status of IAs based on a retrospective cohort. Although the concept of An is supported by hemodynamic aneurysm theory, further research is needed before it can be applied in the clinical setting. ADVANCES IN KNOWLEDGE:This study demonstrates that the novel prediction tool, An, proposed in 2020 is not reliable and that further research of this hemodynamic model is needed before it can be incorporated into the prediction of IA rupture status.

Enhancing patient comprehension of their health is crucial in improving health outcomes. The integration of artificial intelligence (AI) in distilling medical information into a conversational, legible format can potentially enhance health literacy. This review aims to examine the accuracy, reliability, comprehensiveness and readability of medical patient education materials (PEMs) simplified by AI models. A systematic review was conducted searching for articles assessing outcomes of use of AI in simplifying PEMs. Inclusion criteria are as follows: publication between January 2019 and June 2023, various modalities of AI, English language, AI use in PEMs and including physicians and/or patients. An inductive thematic approach was utilised to code for unifying topics which were qualitatively analysed. Twenty studies were included, and seven themes were identified (reproducibility, accessibility and ease of use, emotional support and user satisfaction, readability, data security, accuracy and reliability and comprehensiveness). AI effectively simplified PEMs, with reproducibility rates up to 90.7% in specific domains. User satisfaction exceeded 85% in AI-generated materials. AI models showed promising readability improvements, with ChatGPT achieving 100% post-simplification readability scores. AI's performance in accuracy and reliability was mixed, with occasional lack of comprehensiveness and inaccuracies, particularly when addressing complex medical topics. AI models accurately simplified basic tasks but lacked soft skills and personalisation. These limitations can be addressed with higher-calibre models combined with prompt engineering. In conclusion, the literature reveals a scope for AI to enhance patient health literacy through medical PEMs. Further refinement is needed to improve AI's accuracy and reliability, especially when simplifying complex medical information.

Endovascular management of intracranial aneurysms has become the mainstay of treatment in recent years; however, retreatment rates remain as high as 1 in 5. High-frequency optical coherence tomography (HF-OCT) is an emerging imaging modality for the assessment, treatment and follow-up of cerebral aneurysms. EMBASE and SCOPUS databases were searched for studies relating to the management of intracranial aneurysm with OCT. A combination of keywords were used including 'cerebral aneurysm', 'intracranial aneurysm', 'high-frequency optical coherence tomography', 'optical coherence tomography', and 'optical frequency domain imaging'. There were 23 papers included in this review. For the assessment of intracranial aneurysm, OCT was able to accurately assess aneurysm morphology as well as detailed analysis of arterial wall layers. During IA treatment, OCT was used to assess and troubleshoot stent placement to optimise successful isolation from the circulation. In the follow-up period, endothelial growth patterns were visualised by OCT imaging. OCT shows promise for the treatment of IAs at all stages of management. Due to the novel development of HF-OCT, there is limited longitudinal data in human studies. Further research in this area is required with a focus specifically on long-term treatment outcomes in humans.

A four-dimensional phase-contrast magnetic resonance imaging sequence with respiratory-controlled adaptive k-space reordering (ReCAR-4DPC) offers potential benefits of improved scan efficiency and motion robustness. The purpose of this study was to evaluate the reproducibility of flow measurement using this technique and to compare hemodynamic metrics obtained to two-dimensional phase contrast MRI (2DPC)-derived metrics of the thoracic aorta. ReCAR-4DPC was performed with identical scan parameters in 15 healthy volunteers (6M,9F, mean [range] 37 [23–47] years) and 11 patients with thoracic aortic dissection (6M,5F, 56 [31–81] years) and acquisition time was recorded. Peak systolic velocity (PSV), average flow (AF) and net forward volume (NFV) were quantified by two readers for ReCAR-4DPC at ascending, descending and diaphragmatic aorta levels. Reference standard 2DPC measurements at the same levels were performed by a separate experienced cardiovascular radiologist. ReCAR-4DPC intra-reader agreement, inter-reader agreement, inter-scan repeatability and concordance with 2DPC-derived metrics (all segments combined) were evaluated with Lin’s concordance correlation coefficient (LCCC) and reduced major axis regression. The overall average ± SD MRI acquisition time of all subjects was 11:59 ± 3:57 min, with shorter average times (9:37 ± 1:57 min) in healthy volunteers compared to patients (15:13 ± 3:44 min). There was near-perfect intra-reader, inter-reader and inter-scan concordance (LCCC for all metrics > 0.97, > 0.98 and > 0.92 respectively) for ReCAR-4DPC. Concordance with 2DPC was also high (LCCC all > 0.89), with overall minimally lower PSV, AF and NFV values derived from ReCAR-4DPC compared to reference 2DPC derived metrics. ReCAR-4DPC is a reproducible and relatively fast approach for comprehensive measurement of thoracic aortic flow metrics, with robust correlation to conventional 2DPC.

Background Time to reperfusion is an important predictor of outcome in ischaemic stroke from large vessel occlusion (LVO). For patients requiring endovascular thrombectomy (EVT), the transfer times from peripheral hospitals in metropolitan and regional Victoria, Australia to comprehensive stroke centres (CSCs) have not been studied. Aims To determine transfer and journey times for patients with LVO stroke being transferred for consideration of EVT. Methods All patients transferred for consideration of EVT to three Victorian CSCs from January 2017 to December 2018 were included. Travel times were obtained from records matched to Ambulance Victoria and the referring centre via Victorian Stroke Telemedicine or hospital medical records. Metrics of interest included door-in-door-out time (DIDO), inbound journey time and outbound journey time. Results Data for 455 transferred patients were obtained, of which 395 (86.8%) underwent EVT. The median DIDO was 107 min (IQR 84–145) for metropolitan sites and 132 min (IQR 108–167) for regional sites. At metropolitan referring hospitals, faster DIDO was associated with use of the same ambulance crew to transport between hospitals (75 (63–90) vs 124 (99–156) min, p<0.001) and the administration of thrombolysis prior to transfer (101 (79–133) vs 115 (91–155) min, p<0.001). At regional centres, DIDO was consistently longer when patients were transported by air (160 (127–195) vs 116 (100–144) min, p<0.001). The overall door-to-door time by air was shorter than by road for sites located more than 250 km away from the CSC. Conclusion Transfer times differ significantly for regional and metropolitan patients. A state-wide database to prospectively collect data on all interhospital transfers for EVT would be helpful for future study of optimal transport mode at regional sites and benchmarking of DIDO across the state.

BACKGROUND:Following reperfusion treatment in ischemic stroke, computed tomography (CT) imaging at 24 h is widely used to assess radiological outcomes. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield unit-based imaging metrics, such as net water uptake (NWU). AIMS:We aimed to assess the presence and factors associated with retained contrast post-thrombectomy on 24-h imaging using dual-energy CT (DECT), and its impact on the accuracy of NWU as a measure of cerebral edema. METHODS:Consecutive patients with anterior circulation large vessel occlusion who had post-thrombectomy DECT performed 24-h post-treatment from two thrombectomy stroke centers were retrospectively studied. NWU was calculated by interside comparison of HUs of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention and bilateral infarcts were excluded. Cerebral edema was measured by relative hemispheric volume (rHV) and midline shift (MLS). RESULTS:Of 125 patients analyzed (median age 71 (IQR = 61-80), baseline National Institutes of Health Stroke Scale (NIHSS) 16 (IQR = 9.75-21)), reperfusion (defined as extended-Thrombolysis-In-Cerebral-Infarction 2b-3) was achieved in 113 patients (90.4%). Iodine-subtracted NWU was significantly higher than unadjusted NWU (17.1% vs 10.8%, p < 0.001). In multivariable median regression analysis, increased age (p = 0.024), number of passes (p = 0.006), final infarct volume (p = 0.023), and study site (p = 0.021) were independently associated with amount of retained contrast. Iodine-subtracted NWU correlated with rHV (rho = 0.154, p = 0.043) and MLS (rho = 0.165, p = 0.033) but unadjusted NWU did not (rHV rho = -0.035, p = 0.35; MLS rho = 0.035, p = 0.347). CONCLUSIONS:Angiographic iodine contrast is retained in brain parenchyma 24-h post-thrombectomy, even without visually obvious hyperdensities on CT, and significantly affects NWU measurements. Adjustment for retained iodine using DECT is required for accurate NWU measurements post-thrombectomy. Future quantitative studies analyzing CT after thrombectomy should consider occult contrast retention.

Introduction: CT performed 24h post-treatment is widely used to assess radiological outcomes in stroke studies. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield Unit-based imaging metrics such as Net Water Uptake (NWU), a measure of cerebral edema based on tissue hypoattenuation. We aimed to assess (1) the presence of retained contrast post-thrombectomy on 24h CT by comparing NWU measurements with and without adjustment for iodine using dual energy CT (DECT), (2) factors associated with amount of retention, and (3) its impact on the accuracy of NWU. Methods: In a prospective study of patients with anterior circulation large vessel occlusion who had post-thrombectomy follow-up DECT performed 24h post-treatment from two Comprehensive Stroke Centres (November 2021 to May 2022), NWU was calculated by interside comparison of Hounsfield Units of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. We tested correlation between NWU and tissue swelling using relative hemispheric volume (rHV) and midline shift (MLS). Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention, and bilateral infarcts were excluded. Results: Of 125 patients analysed (median age 71 [IQR 61-80], baseline NIHSS 16 [IQR 9.75-21]), reperfusion (eTICI 2b-3) was achieved in 120 patients (96.8%). NWU measured with iodine adjustment was significantly higher than NWU measured without adjustment (17.1% vs 10.8%, p<0.001). In multivariable median regression analysis, age (p=0.031), number of passes (p<0.001) and having CT perfusion at baseline (p=0.008) were independently associated with amount of retained contrast. NWU measured with iodine adjustment correlated with rHV (p=0.043) and MLS (p=0.033), but NWU without adjustment did not (rHV p=0.350; MLS p=0.347). Conclusion: Occult angiographic iodine contrast significantly affects NWU on CT at 24h. Our data suggest adjustment for retained iodine using DECT is required for accurate NWU measures post-thrombectomy. Future studies analysing CT post-thrombectomy should consider the significance of occult contrast retention.

Aim: To assess the safety and utility of tranexamic acid (TXA) as an adjunct sal-vage therapy in iatrogenic vessel perforation complicating endovascular clot retrieval. Iatrogenic vessel perforation and extravasation are known and poten-tially fatal complications of endovascular clot retrieval (ECR). Various methods of establishing haemostasis post perforation have been reported. TXA is widely utilised intraoperatively to reduce bleeding in various surgical specialities. The use of TXA in endovascular procedures has not been previously described in the literature. Methods: Retrospective case control study of all cases that under-went ECR. Cases where arterial rupture occurred were identified. Details of man-agement and functional status at 3 months were recorded. Modified Rankin score (mRS) 0-2 was considered a good functional outcome. Comparison of proportions analysis was performed. Results: Of 1378 cases of ECR, rupture complicated 36 (2.6%). TXA was administered in addition to standard care in 11 cases (31%). At 3 months, 4 of 11 cases (36%) where TXA was administered had a good functional outcome compared to 3 of 22 (12%) in the standard care group (P=0.09). Mortality at 3 months occurred in 4 of 11 cases (41.7%) where TXA was administered com-pared to 16 of 25 (64%) where it was not (P=0.13). Conclusion: Tranexamic acid administration in iatrogenic vessel rupture was associated with a lower mortality rate and a larger proportion of patients achieving a good functional outcome at 3 months. This effect trended towards but was not statistically significant. TXA administration was not associated with adverse effects.Crown Copyright (c) 2023 Published by Elsevier Inc. All rights reserved.

Background Deep learning (DL) algorithms are playing an increasing role in automatic medical image analysis. Purpose To evaluate the performance of a DL model for the automatic detection of intracranial haemorrhage and its subtypes on non-contrast CT (NCCT) head studies and to compare the effects of various preprocessing and model design implementations. Methods The DL algorithm was trained and externally validated on open-source, multi-centre retrospective data containing radiologist-annotated NCCT head studies. The training dataset was sourced from four research institutions across Canada, the USA and Brazil. The test dataset was sourced from a research centre in India. A convolutional neural network (CNN) was used, with its performance compared against similar models with additional implementations: (1) a recurrent neural network (RNN) attached to the CNN, (2) preprocessed CT image-windowed inputs and (3) preprocessed CT image-concatenated inputs. The area under the receiver operating characteristic curve (AUC-ROC) and microaveraged precision (mAP) score were used to evaluate and compare model performances. Results The training and test datasets contained 21,744 and 491 NCCT head studies, respectively, with 8,882 (40.8%) and 205 (41.8%) positive for intracranial haemorrhage. Implementation of preprocessing techniques and the CNN-RNN framework increased mAP from 0.77 to 0.93 and increased AUC-ROC [95% confidence intervals] from 0.854 [0.816–0.889] to 0.966 [0.951–0.980] ( p -value = 3.91 × 10 −12 ). Conclusions The deep learning model accurately detected intracranial haemorrhage and improved in performance following specific implementation techniques, demonstrating clinical potential as a decision support tool and an automated system to improve radiologist workflow efficiency. Key points • The deep learning model detected intracranial haemorrhages on computed tomography with high accuracy. • Image preprocessing, such as windowing, plays a large role in improving deep learning model performance. • Implementations which enable an analysis of interslice dependencies can improve deep learning model performance. • Visual saliency maps can facilitate explainable artificial intelligence systems. • Deep learning within a triage system may expedite earlier intracranial haemorrhage detection.

OBJECTIVES:Haemorrhoidal disease (HD) is a common anorectal disorder which can substantially impair quality of life. Rectal artery embolisation (RAE) is a recently described technique for the management of HD, however, its clinical efficacy and safety are unclear at present. The objective of this systematic review and meta-analysis is to evaluate the clinical outcomes following RAE.METHODS:The PubMed, MEDLINE and EMBASE databases were searched for studies specifying the management of haemorrhoids with RAE from January 2000 to October 2021. Primary outcomes were: French bleeding score (FBS), Visual analogue scale (VAS) for pain, general quality of life (QoL) score, and the Goligher prolapse score (GPS). Secondary outcomes were technical success, clinical success, postoperative complications, and technical outcomes. A random-effects meta-analysis was conducted. Study heterogeneity was evaluated, and sensitivity analysis was performed.RESULTS:Thirteen eligible studies were identified including 381 patients. Rectal artery embolisation was associated with improvements in the FBS (mean difference [MD] 2.66; 95% confidence interval [CI] 2.10-3.23), VAS (MD 1.92; 95% CI 1.58-2.27) and QoL (MD 1.41; 95% CI 1.20-3.80), although the grade of internal haemerrhoids increased with uncertain clinical significance (MD 0.30; 95% CI 0.23-0.36). Technical success was achieved in almost all procedures (99%; 95% CI 94-100%) however clinical efficacy was lower (82%; 95% CI 73-89%). Procedural duration and radiation exposure were heterogeneous. No major complications occurred.CONCLUSION:RAE demonstrates early clinical efficacy with low rates of peri-procedural complications or morbidity. RAE is a promising addition to the treatment options available for HD and warrants ongoing research.

To meet the growing demand for interventional radiology (IR), more hospitals are investing in state-of-the-art angiography suites, but these are expensive investments. Both the initial construction cost and the ongoing operational costs are significant. For health services, it is important to commission an angiography suite that can satisfy both present and future healthcare demands to maximize the value of the initial expenditure and the opportunities provided by this ongoing investment. Smart angiography suites (SAS) could be the solution that future-proof angiography services. Similar to the smart operating theatre, SAS refers to the incorporation of audio-video technology and internet connectivity into the angiography suite.1 SAS has the ability to record high resolution audio-visual data from the angiography suite and stream it to a remote audience at low latency to enable bi-directional communication and collaboration. SAS, alongside other telemedicine concepts, have also gained new-found interest and relevance in light of the global coronavirus pandemic and the travel restrictions associated with this. We reviewed the current literature to provide an overview of the SAS, its potential, and associated legal and ethical considerations. For hospitals, SAS can be as rudimentary as a webcam or as advanced as a comprehensive commercial solution such as Olympus MedPrescence, Proximie, Tegus Medical, Sony Nucleus or InTouch Health VisitOR. In general, commercial solutions will include audio-video equipment setup, internet streaming and broadcasting setup, and an end-user viewing software. Most commercial solutions are compatible with pre-existing equipment (vendor neutral) (see figure 1 for an example solution). Different solutions also offer varying features of different video layouts, video freezing, telestration with or without augmented reality, integration with picture archiving and communication system, and security. The cost of a commercial SAS solution varies with each company offering a different type of license. Figure 1 An example of a smart angiography suite solution, from …

Detailed study of tenecteplase (TNK) in patients older than 80 years is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients older than 80 years with large vessel occlusion.We performed a pooled analysis of the EXTEND-IA TNK randomized controlled trials (n = 502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25 mg/kg, TNK 0.40 mg/kg, and alteplase 0.90 mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin Scale (mRS) score, all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIH Stroke Score, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models.In patients >80 years (n = 137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, adjusted common odds ratio (acOR) 2.70, 95% CI 1.23-5.94) and reduced mortality (acOR 0.34, 95% CI 0.13-0.91) vs 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, acOR 2.28, 95% CI 1.03-5.05) vs alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, 1 patient treated with alteplase, and 0 patients treated with TNK 0.25 mg/kg. In patients ≤80 years, no differences in 90-day mRS, mortality, or symptomatic ICH were observed among TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg.TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients older than 80 years. No differences among the doses were observed in younger patients.NCT02388061, NCT03340493.This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg.