BACKGROUND AND PURPOSE:Stent-assisted coiling (SAC) is a well-defined and widely performed endovascular technique used to treat wide-neck aneurysms. The Low-Profile Visualized Intraluminal Support (LVIS) EVO stent is a newly-developed, low-profile, braided stent with a composite wire structure providing full stent visibility under fluoroscopy. Although the initial and midterm results of patients with intracranial aneurysms treated with LVIS EVO-assisted coiling have been reported, no published long-term aneurysm occlusion or complication data exist for the LVIS EVO stent. This retrospective study aimed to evaluate the long-term safety and durability of the SAC procedure using an LVIS EVO stent for the treatment of wide-neck and complex aneurysms. MATERIALS AND METHODS:A retrospective review of databases of 4 centers was performed to identify the patients with aneurysms treated with LVIS EVO-assisted coiling. Patients with a clinical and angiographic follow-up duration of at least 12 months were included. The technical success of the procedure and the immediate clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were evaluated. Follow-up angiographic and clinical outcomes were investigated. Preprocedural and follow-up neurologic statuses were assessed using the mRS. The aneurysm occlusion status was assessed using the Raymond-Roy (RR) classification. RESULTS:A total of 158 patients (96 women; mean age, 54.4 [SD, 11.9] years) with 158 aneurysms were included. The technical success of the procedure was 99.4%. Immediate postprocedural angiography showed complete occlusion in 71.5% of patients. Every patient underwent at least 2 angiographic follow-ups. The last follow-up angiography evaluation showed a complete aneurysm occlusion (RRI) in 85.4% and an adequate occlusion (RRI-RRII) in 96.8% of patients. Recanalization was observed in 8.2% of the patients. Two patients (1.3%) required retreatment. In addition, 8.9% of patients had complications resulting in a morbidity rate of 4.4% (mRS scores, 1-3). At the last follow-up, 91.8% of the patients had an mRS score of ≤1. CONCLUSIONS:The results of this case series demonstrated the long-term safety and durability of the LVIS EVO-assisted coiling procedure for the treatment of wide-neck and complex aneurysms.

The aim of this study was to reveal our preliminary experience related to the technical success and safety of the Titan aspiration catheter in acute ischemic stroke (AIS) patients. Forty-eight consecutive AIS patients (mean age 62.6 ± 13.8 years) treated with Titan aspiration catheter, using both the ADAPT technique or combined approach with a stent retriever, were included in the study. The primary outcome was successful recanalization (mTICI ≥ 2c-3), and the secondary outcomes were complication rates and 90th day clinical outcomes. The mean NIHSS score of the patients was 14.63 ± 3.04, and the mean time from groin puncture to recanalization was 24.72 ± 12.48 min. Successful recanalization was achieved in 35 (72.91

Objective: To compare the results of stenting and medical therapy in patients with intracranial atherosclerotic disease (ICAD). Methods: Twenty patients treated between August 2021 and April 2024 were retrospectively analyzed. Results: Age, occlusion site, dual antiplatelettherapy and score-ICAD were statistically significant in patients who underwent intracranial stenting. Conclusion: Due to the innovations in interventional medicine, stenting may be a better option than medical treatment for patients with ICAD.

PURPOSE:Endovascular treatment (EVT) of posterior cerebral artery (PCA) strokes is uncertain. We present our single-center experience with acute ischemic strokes (AIS) caused by PCA occlusion. METHODS:This study included consecutive patients with PCA occlusion presenting within 24 hours of time last well-known from January 2017 to June 2024. Patients treated with EVT, or medical management (MM) were compared with multivariable logistic regression and inverse probability of treatment weighting. The primary outcome was the 90-day modified Rankin Scale (mRS) score. The safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. RESULTS:Overall, 53 patients were treated with MM and 16 with EVT. The 90-day mRS score of 0-2 was seen in 43.8 % of the EVT and 67.3 % in the MM group (p = 0.90). There was a higher rate of early decrease in NIHSS score ≥ 2 points was observed in the EVT group, but this was not statistically significant. Vision recovery was similar between groups. One patient had symptomatic ICH, and one patient underwent decompression due to edema. The proportion of patients with non-symptomatic ICH was higher in the EVT group (p = 0.025). Admission NIHSS > 6 was significantly associated with poor prognosis and mortality(p < 0.001). CONCLUSION:Our results show no difference in functional outcome at 90 day between EVT and MM groups. We could not demonstrate a significant difference in sICH and mortality. EVT can be safe in PCA occlusion especially with admission NIHSS > 6.

Background The optimal endovascular approach for tandem lesions (extracranial internal carotid artery and intracranial large vessel occlusion) is not clear. Aims: The aim was to evaluate the follow-up results of stroke patients with tandem lesions who underwent emergent stenting of extracranial lesions with antithrombotic therapy combined with intracranial MT Methods Outcomes and predictors of poor prognosis and mortality compared with those of good prognosis at 90 days, 1 year, and 2 years were assessed. A modified Rankin scale (mRS) score was used. Symptomatic intracranial hemorrhage (sICH), National Institutes of Health Stroke Scale (NIHSS) scores at admission and at 24 h, successful recanalization, asymptomatic ICH, embolization, malignant infarction, decompression, in-stent restenosis and extracranial complications were also evaluated. The best age cutoff for predicting mortality was analyzed Results A total of 71 subjects were included. Using patients with a good prognosis as a reference, the independent variables predicting a poor prognosis were a high 24-h NIHSS score and extracranial complications at all timepoints (3-month, 1-year, and 2-year follow-up). The most appropriate age cutoff for predicting 1-year mortality was 67 years [AUC = 0.802 (95% CI = 0.684–0.920); p < .001]. The age cutoff determined for the first year was correlated with the prediction of mortality in the third month and the second year. No significant association was observed between sICH and the groups Conclusion In this study, the 24-h NIHSS score after reperfusion and age were predictors of poor prognosis and mortality in stroke patients with tandem lesions who underwent emergent stenting during thrombectomy.

Treating ruptured wide-necked bifurcation aneurysms (WNBAs) presents challenges. 1 The WovenEndoBridge (WEB, Microvention) device is often utilized for WNBAs but is typically inadequate for large (≥10 mm) aneurysms. 2 , 3 The WEB-assisted coiling technique may enable the use of the WEB device as an adjunct in coiling large WNBAs, particularly when the very wide neck precludes remodeling techniques. 4 , 5 Understanding of this technique is derived from a limited number of cases, with scant comprehensive technical insights available. 4 , 5 The technical video (online supplemental material) demonstrates the WEB-assisted coiling technique for treating a ruptured large basilar tip aneurysm (height: 14.6 mm; width: 10 mm; neck: 6.8 mm) in a 53-year-old male patient. Steps include (1) catheterization of the aneurysm sac with a coil microcatheter and a Via catheter for WEB deployment; (2) jailing the coil microcatheter and deploying the WEB to act as a cork against the aneurysm neck; (3) coiling the residual aneurysm dome, followed by removal of the coil catheter and detachment of the WEB. This technique has the potential to simplify the treatment of ruptured large WNBAs in the acute setting without using neck remodeling and anti-aggregation. Subsequently, it may allow the physician to manage the case electively under dual anti-aggregation with stenting, as described here and by Simgen et al. 5

Background The safety and efficacy of mechanical thrombectomy (MT) for proximal large vessel occlusion after acute ischemic stroke (AIS) have been demonstrated. Clinical investigations of endovascular approaches for treating AIS due to M2 occlusions have been ongoing. Purpose To assess the outcomes of M2 occlusions according to treatment modality and anatomical division. Methods A total of 113 consecutive M2 occlusions treated with endovascular treatment (EVT) at our tertiary stroke center between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into three groups: mechanical thrombectomy (MT); intravenous thrombolysis plus MT (IVT + MT); and IVT alone. The primary outcomes were good prognosis (mRS = 0–2) and mortality (mRS = 6) on day 90. The secondary outcome was to determine the differences in outcomes between lesions in the superior and inferior branches of M2. Results In total, 55 (48.7%) patients underwent MT. In 42 (37.2%) patients, bridging IVT was performed with MT, and IVT alone was applied in 16 (14.2%) patients. Neither the prognosis at 90 days nor the mortality rate significantly differed among the groups. The outcomes did not significantly differ between occlusions in the superior and inferior branches of M2. Conclusion MT was found to be safe and effective for treating M2 occlusions in this series.

Introduction Wide-necked bifurcation aneurysms pose significant challenges for endovascular treatment. A recent innovation, the stent plus balloon-assisted coiling technique, combines a stent and a balloon to address these aneurysms effectively. Purpose To evaluate the safety and efficacy of the stent plus balloon-assisted coiling for the treatment of wide-necked bifurcation aneurysms. Methods We conducted a retrospective review of our endovascular database to identify patients who were treated with this technique and had a satisfactory angiographic follow-up of at least 24 months. Technical success, initial clinical and angiographic outcomes, procedural complications, and follow-up results were analyzed. Angiographic and clinical outcomes were assessed using Modified Raymond-Roy Classification and Modified Rankin Scale, respectively. Results Our study included 37 aneurysms in 36 patients (26 females) with a mean age of 56.6 years. Mean aneurysm and neck sizes were 7.3 ± 3.5 mm and 3.7 ± 1.0 mm, respectively. Technical success reached 97.2%, with an immediate occlusion rate of 65.7%. At a mean follow-up of 36.5 ± 9.7 months, final angiographic follow-up showed a 91.9% complete occlusion rate. Three aneurysms did not achieve complete occlusion; however, none required retreatment. Complications developed in 32.4% of the procedures. Mortality and morbidity rates were 5.4% and 2.7%, respectively. A good clinical outcome was observed in 91.9% of patients. Conclusion Our results showed that stent plus balloon-assisted coiling technique allows good angiographic outcomes for wide-necked bifurcation aneurysms. However, overall complication rate is high. Subgroup analysis indicated promising safety and efficacy for MCA bifurcation aneurysms, suggesting this technique could be a valuable option for select aneurysms.

Crossing Y-stent-assisted coiling (CYSAC) is a feasible yet technically challenging technique for the treatment of wide-neck bifurcation aneurysms (WNBAs). To present mid-term results of Y-stent-assisted coiling (YSAC) using the LVIS EVO stent and to describe our “drill turn” technique for stent crossing. This retrospective, observational study included 37 consecutive patients treated with YSAC using LVIS EVO stents at five centres between September 2020 and March 2023. Immediately after treatment, 31 of the 37 patients (83.8

The predicting bleeding complications in patients undergoing stent implantation and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients with dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCIs). Patients with carotid artery stenting (CAS) are also treated with DAPT. In this study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting bleeding in patients with CAS. Patients who had CAS between January 2018 and December 2020 were retrospectively enrolled. The PRECISE-DAPT score was calculated for each patient. The patients were divided into two groups based on their PRECISE-DAPT score: low < 25 and high ≥ 25. Bleeding and ischemia complications and laboratory data among the two groups were compared. A total of 120 patients with a mean age of 67.3 ± 9.7 years were included. Forty-three patients had high PRECISE-DAPT scores, and 77 patients had low PRECISE-DAPT scores. Six patients developed bleeding events during the six-month follow-up, and five of them were in the PRECISE DAPT score ≥ 25 group. The difference between the two groups regarding bleeding events at six months was significant (P = 0.022). The PRECISE-DAPT score might be used for predicting the bleeding risk in patients with CAS, and the bleeding rate was significantly higher in patients with a PRECISE-DAPT score ≥ 25.

Purpose: To compare outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) taking warfarin or direct oral anticoagulants (DOACs).Methods: A total of 71 consecutive patients with AF who underwent MT due to AIS between January 2018 and December 2021 were retrospectively analyzed. Patients were grouped as warfarin versus DOAC group. CHA2DS2VASc, HAS-BLED, The National Institutes of Health Stroke Scale (NIHSS) at the time of admission and at 24 h, successful recanalization, post- MT complications and technical properties of MT were evaluated. Patients were divided into a good prognosis group, and a mortality group according to the 90th day mRS.Results: HAS-BLED score was significantly higher in DOAC group (p = 0.006) There were no significant differences in stroke severity, successful recanalization rates, post-procedural complications and mRS 90th day scores between patients with warfarin and DOACs. CHA2DS2-VASc, NIHSS at admission and NIHSS on the 24th hour scores were significantly lower in the good mRS group (p = 0.012, p = 0.002, p < 0.001, respectively).Conclusion: MT is safe and effective in patients receiving warfarin or DOACs. HASBLED and CHA2DS2-VASc scores can help to predict functional outcome after MT.

Background & Objective: Data about outcomes of endovascular treatment (EVT) in basilar artery occlusion (BAO) are limited. The aim of this study is to evaluate the predictors of functional outcome and to investigate the benefit of bridging intravenous thrombolysis (IVT) and the impact of first-pass effect (FPE) on prognosis. Methods: A total of 57 consecutive BAO patients who received EVT at our tertiary stroke center between January 2018 and March 2021 were retrospectively analyzed. The primary outcome was to evaluate excellent prognosis (mRS 0-1) and mortality (mRS 6) at day 90. The secondary outcome was to define the benefit of bridging IVT and the impact of FPE on prognosis. The safety outcome was symptomatic intracranial hemorrhage (sICH). National Institutes of Health Stroke Scale (NIHSS) at admission and at 24 hours, collateral scores, successful recanalization, asymptomatic ICH, embolization, malignant infarction and decompression were also evaluated. Results: The mean age of the patients was 64.1 ± 14.5 years. Male-to-female ratio was 1.7. Hypertension (HT) was the most common risk factor. Bridging IVT was performed in nine patients (15.8%). The FPE rate was 56.1%. NIHSS scores at admission and at 24 hours were found to be statistically significant predictors of prognosis (P=0.023 and P<0.001, respectively). Bridging IVT, FPE, successful recanalization and collateral status did not significantly predict outcome. Conclusion: Lower NIHSS scores at admission and at 24 hours were significantly associated with excellent prognosis. NIHSS scores at admission and at 24 hours were significantly higher in mortality group. sICH did not predict mortality.

Background: Currently, there is still no clear consensus on bridging thrombolysis (BT) before mechanical thrombectomy (MT). In this study, we aimed to compare clinical and procedural outcomes and complication rates of BT versus direct mechanical thrombectomy (d-MT) in anterior circulation stroke. Methods: A total of 359 consecutive anterior circulation stroke patients who received d-MT or BT in our tertiary stroke center between January 2018 and December 2020 were retrospectively analyzed. The patients were divided into two groups as Group d-MT (n = 210) and Group BT (n = 149). The primary outcome was the impact of BT on clinical and procedural outcomes, whereas the secondary outcome was the safety of BT. Results: The incidence of atrial fibrillation was higher in the d-MT group (p = 0.010). The median duration of the procedure was significantly higher in Group d-MT than in Group BT (35 vs 27 min, respectively; P = 0.044). The number of patients achieving good and excellent outcomes was significantly higher in Group BT (p = 0.006 and P = 0.03). The edema/malign infarction rate was higher in the d-MT group (p = 0.003). Successful reperfusion, first-pass effects, symptomatic intra-cranial hemorrhage, and mortality rates were similar between the groups (p > 0.05). Conclusions: In this study, BT seems to yield better clinical and procedural outcomes with lower complication rates than d-MT. These findings may support the additional value of intravenous alteplase in anterior system strokes. Further large-scale, prospective, randomized-controlled studies will clarify the gray lines in this consensus, but this paper is important for reflecting the real-world data in developing countries.

BACKGROUND: The Low Profile Visible Intraluminal Support EVO (LVIS EVO) is a self-expandable braided stent, which was recently introduced for the treatment of intracranial aneurysms. Full visibility of the stent and a relatively high metal coverage ratio are the unique features of the LVIS EVO. OBJECTIVE: To assess the safety, efficacy, and midterm durability of LVIS EVO stent-assisted coiling for the treatment of wide-necked intracranial aneurysms. METHODS: The endovascular databases were reviewed to identify patients treated with LVIS EVO–assisted coiling. The technical success and immediate clinical/angiographic outcomes were assessed. Periprocedural and delayed complications were evaluated. The follow-up angiographic/clinical outcomes were investigated. The preprocedural/follow-up neurological statuses were assessed with the modified Rankin Scale. RESULTS: One hundred three aneurysms in 103 patients (63 females) with a mean age of 54.9 ± 11.3 years were included. The mean maximum sac diameter was 6.2 ± 2.9 mm. The procedural technical success rate was 100%. Immediate postprocedural angiography showed complete occlusion in 77.7%. The mean duration of the angiographic follow-up was 8.8 ± 3.6 months. Follow-up angiography showed complete aneurysm occlusion in 89% of the 82 patients with angiographic follow-up. Recanalization was observed in 7.3% of 82 patients. Two patients (2.4%) required retreatment. In addition, 8.7% of the patients had at least 1 complication, and 2.9% of the patients developed a permanent morbidity. All patients had mRS scores ≤2. CONCLUSION: The results of this study demonstrate that SAC with LVIS EVO is a relatively safe, efficient, and durable treatment for wide-necked and complex intracranial aneurysms.

The use of deep learning (DL) techniques for automated diagnosis of large vessel occlusion (LVO) and collateral scoring on computed tomography angiography (CTA) is gaining attention. In this study, a state-of-the-art self-configuring object detection network called nnDetection was used to detect LVO and assess collateralization on CTA scans using a multi-task 3D object detection approach. The model was trained on single-phase CTA scans of 2425 patients at five centers, and its performance was evaluated on an external test set of 345 patients from another center. Ground-truth labels for the presence of LVO and collateral scores were provided by three radiologists. The nnDetection model achieved a diagnostic accuracy of 98.26% (95% CI 96.25–99.36%) in identifying LVO, correctly classifying 339 out of 345 CTA scans in the external test set. The DL-based collateral scores had a kappa of 0.80, indicating good agreement with the consensus of the radiologists. These results demonstrate that the self-configuring 3D nnDetection model can accurately detect LVO on single-phase CTA scans and provide semi-quantitative collateral scores, offering a comprehensive approach for automated stroke diagnostics in patients with LVO.

INTRODUCTION: Silent ischemic lesions(CIL) frequently occur after carotid artery stenting(CAS) and are associated with poor long-term prognosis. The effect of blood triglyceride (TG) level on CIL after CAS is yet clear. We investigated the effect of serum TG level on post-procedure CIL in patients undergoing CAS. METHODS: 57 patients who underwent CAS were included in the study, and diffusion-weighted magnetic resonance imaging was conducted before and after CAS. The primary endpoint was new CILs after CAS. The effects of pre-procedural TG, total cholesterol, HDL, and LDL levels on the primary endpoint were investigated. RESULTS: Of the patients 46 (80.7%) were male, median age was 69(60-73) years, and 27 (47.3%) were symptomatic. After the procedure, ipsilateral new CILs were detected in 28 (49.1%) patients. NASCET stenosis %, being symptomatic and using aspirin before the procedure were associated with the presence of new ipsilateral CILs. In multivariate logistic regression analysis, pre-procedural TG level was the only independent predictor of ipsilateral new CILs after the procedure. DISCUSSION AND CONCLUSION: Our study reveals that high TG level is an independent risk factor for new CILs after CAS. Since CILs increase the risk for future ischemic events, TG as a simple, inexpensive, effective, and modifiable marker, can provide information for intense medical treatment, early intervention, and the prognosis.

To investigate the performance of a joint convolutional neural networks-recurrent neural networks (CNN-RNN) using an attention mechanism in identifying and classifying intracranial hemorrhage (ICH) on a large multi-center dataset; to test its performance in a prospective independent sample consisting of consecutive real-world patients. All consecutive patients who underwent emergency non-contrast-enhanced head CT in five different centers were retrospectively gathered. Five neuroradiologists created the ground-truth labels. The development dataset was divided into the training and validation set. After the development phase, we integrated the deep learning model into an independent center’s PACS environment for over six months for assessing the performance in a real clinical setting. Three radiologists created the ground-truth labels of the testing set with a majority voting. A total of 55,179 head CT scans of 48,070 patients, 28,253 men (58.77%), with a mean age of 53.84 ± 17.64 years (range 18–89) were enrolled in the study. The validation sample comprised 5211 head CT scans, with 991 being annotated as ICH-positive. The model's binary accuracy, sensitivity, and specificity on the validation set were 99.41%, 99.70%, and 98.91, respectively. During the prospective implementation, the model yielded an accuracy of 96.02% on 452 head CT scans with an average prediction time of 45 ± 8 s. The joint CNN-RNN model with an attention mechanism yielded excellent diagnostic accuracy in assessing ICH and its subtypes on a large-scale sample. The model was seamlessly integrated into the radiology workflow. Though slightly decreased performance, it provided decisions on the sample of consecutive real-world patients within a minute.

BACKGROUND:Self-expandable stents have been increasingly used for endovascular treatment of intracranial aneurysms. Because the usage of intracranial stents has increased overall, total numbers of complications associated with these devices have increased. Thrombosis, distortion, or incomplete opening of stents are potential complications that may result in occlusion of the parent artery. In such cases, removal of the stent (stentectomy) may be the only solution to avoid serious clinical consequences.OBJECTIVE:To investigate the feasibility and efficacy of a novel stentectomy technique for removal of thrombosed self-expandable stents.METHODS:A retrospective review was performed of patients who underwent the stentectomy procedure. Initial and follow-up imaging and clinical outcomes were assessed. Immediate postprocedural and follow-up clinical statuses were assessed using the modified Rankin scale.RESULTS:Seven patients were included in this study (mean age: 54.1 years). The stentectomy was successful in 6 of 7 patients (85.7%). Seven stents in 6 patients were successfully removed to treat the acute in-stent thrombosis that was resistant to alternative bail-out treatments. The removed stents were self-expandable braided in 2 patients, flow diverters in 2 patients, and laser cut open-cell stents in 2 patients. Stentectomy failed to retrieve a thrombosed braided stent in 1 patient. The modified Rankin scale score of all patients who underwent a success stentectomy was ≤1.CONCLUSION:The stentectomy procedure using the defined technique is feasible to retrieve thrombosed stents and effective to restore the blood flow. It can be considered a last resort option to treat acute in-stent thrombosis resistant to alternative bail-out treatments.

There is little evidence on the applicability of deep learning (DL) in the segmentation of acute ischemic lesions on diffusion-weighted imaging (DWI) between magnetic resonance imaging (MRI) scanners of different manufacturers. We retrospectively included DWI data of patients with acute ischemic lesions from six centers. Dataset A (n = 2986) and B (n = 3951) included data from Siemens and GE MRI scanners, respectively. The datasets were split into the training (80%), validation (10%), and internal test (10%) sets, and six neuroradiologists created ground-truth masks. Models A and B were the proposed neural networks trained on datasets A and B. The models subsequently fine-tuned across the datasets using their validation data. Another radiologist performed the segmentation on the test sets for comparisons. The median Dice scores of models A and B were 0.858 and 0.857 for the internal tests, which were non-inferior to the radiologist's performance, but demonstrated lower performance than the radiologist on the external tests. Fine-tuned models A and B achieved median Dice scores of 0.832 and 0.846, which were non-inferior to the radiologist's performance on the external tests. The present work shows that the inter-vendor operability of deep learning for the segmentation of ischemic lesions on DWI might be enhanced via transfer learning; thereby, their clinical applicability and generalizability could be improved.