Background: Studies have suggested that administering antithrombotics—oral anticoagulants (OACs) and antiplatelets (APLT)—after acute ischemic stroke(AIS) with hemorrhagic transformation (HT) is safe and can reduce ischemic recurrence. However, the safety of their early initiation after HT remains unclear. Method: This study utilized data from nine centers across several countries. The study population included patients with AIS who subsequently experienced HT. Patients with a specific HT type—hemorrhagic infarction(HI) or parenchymal hematoma(PH)—were categorized based on the time between HT and antithrombotic initiation, and their outcomes were compared. Outcomes included 30-day HT exacerbation and composite outcomes of recurrent stroke and systemic emboli, as well as 90-day vascular death and functional outcome. Results: Of 748 patients,496 received APLT, and 252 were prescribed OACs after HT. The median HT-to-APLT time was significantly shorter among HI patients than PH patients(1[IQR:0-2] vs. 3[IQR:1-5] days,p<0.001). The rates of 30-day HT exacerbation and composite outcomes, as well as 90-day vascular death and unfavorable functional outcomes, did not significantly differ between patients who received same-day, early (HI:<1day;PH:<3days), or late (HI:>1day;PH:>3days) APLTs after either HI or PH. Among patients who received OACs, those with HI had a significantly shorter median HT-to-OAC time than PH (7[IQR:2-15] vs. 15[IQR:7-32] days,p<0.001). However, 30-day HT exacerbation rates were comparable between early (HI:<7days;PH:<15days) and late (HI:>7days;PH:>15days) OAC initiation among patients with either HI or PH, late initiation among patients with PH was associated with higher rates of 30-day composite outcomes than early initiation(20.7% vs. 3%,p=0.044). Based on regression models adjusted for NIHSS and stroke severity, early initiation of APLTs or OACs was not associated with increased risk of HT exacerbation. Conclusion: Findings suggest that the same-day initiation of APLTs after HI or PH-1, and within 1-3days following PH-2, might not be associated with HT exacerbation or worsening outcomes. Similarly, OACs initiated 2-7days after HI and 7-15days after PH may not be associated with worsened patients' outcomes, whereas delays beyond these timeframes can be associated with higher thromboembolic risk.

Early reperfusion (ER) following intravenous thrombolysis improves outcomes in large vessel occlusion stroke (LVOS). Tenecteplase (TNK) has been associated with higher ER rates than alteplase (TPA), but findings across studies remain inconsistent, possibly due to limited adjustment for thrombus burden, characteristics, and collateral status. We compared TNK and TPA in a real-world cohort incorporating imaging-based assessment of thrombus and collateral status. We retrospectively analyzed consecutive anterior circulation LVOS patients who received intravenous thrombolysis prior to thrombectomy at two U.S. comprehensive stroke centers (2020–2024). ER was defined as eTICI ≥ 2b50 on initial angiography or confirmed recanalization in clinically improving patients who did not undergo thrombectomy. Imaging review included clot burden score, thrombus length, thrombus permeability, and collateral status (Tan scale). Multivariable logistic regression identified predictors of ER. Ordinal logistic regression assessed the association between ER and 90-day modified Rankin Scale (mRS) shift. Among 299 patients (TNK 201, TPA 98), ER occurred in 60 (20.1

BACKGROUND:Timely reperfusion is a critical determinant of favorable outcomes in basilar artery occlusion (BAO) stroke. We aimed to examine whether the choice of thrombolytic agent predicts early reperfusion (ER) in BAO stroke managed with tenecteplase versus alteplase before endovascular treatment. METHODS:This was a retrospective, multicenter US cohort of consecutive patients with BAO from 14 stroke centers treated with tenecteplase or alteplase within 4.5 hours of last known well before endovascular treatment. The primary end point was ER, defined as angiographic ER (expanded Thrombolysis in Cerebral Infarction grade 2b to 3 on the first diagnostic angiogram), or clinical ER, defined as substantial neurological improvement precluding endovascular treatment and a good functional outcome (modified Rankin Scale score 0-3). RESULTS:Among 163 patients with BAO and a median last known well-to-needle time of 135 minutes (interquartile range, 100-193) and last known well-to-puncture time of 228 minutes (interquartile range, 166-307), ER was observed in 27 (16.6%) patients. Rates of ER were comparable between tenecteplase (14/75, 18.7%) and alteplase (13/88, 14.8%; adjusted odds ratio, 1.082 [95% CI, 0.444-2.631]; P=0.862). In addition, rates of angiographic ER and clinical ER subgroups did not differ between thrombolytic agents. Higher Basilar Artery on Computed Tomography Angiography scores and a nonatherothrombotic cause independently predicted ER. In multivariable analysis, a good functional outcome was associated with younger age, lower stroke burden, and shorter last known well-to-puncture time. CONCLUSIONS:In BAO treated within 4.5 hours of last known well, tenecteplase and alteplase produced comparable early reperfusion rates. Achieving ER did not modify the association between thrombolytic agent and good functional outcome, consistent with rapid thrombectomy in patients with no ER.

Background Early reperfusion and first‐pass effect are key procedural end points in large‐vessel occlusion stroke thrombectomy. Because of greater fibrin specificity, tenecteplase may achieve higher early reperfusion rates compared with alteplase, yet impact of thrombolytic agents on first‐pass effect remains unclear. Methods Consecutive patients with anterior circulation large‐vessel occlusion stroke receiving intravenous thrombolysis before endovascular treatment at 2 US stroke centers were reviewed. Early reperfusion was defined as extended Thrombolysis in Cerebral Infarction ≥2b50 on initial angiography. First‐pass effect was defined as extended Thrombolysis in Cerebral Infarction 2c‐3 after a single pass. Multivariable logistic regression identified predictors of early reperfusion and first‐pass effect. Ordinal logistic regression assessed associations of thrombolytic agent, early reperfusion, and first‐pass effect with 90‐day modified Rankin Scale shift. Results Among 299 patients (tenecteplase 201, alteplase 98), early reperfusion occurred in 60 (20.1%) and was more frequent with tenecteplase compared with alteplase (24.4% versus 11.2%; adjusted odds ratio [OR], 2.31 [95% CI, 1.07–4.98]). Patients without early reperfusion were evaluated for first‐pass effect. Of 237 patients, first‐pass effect was less frequent with tenecteplase compared with alteplase (30.3% versus 40.2%; adjusted OR, 0.42 [95% CI, 0.23–0.79]). Early reperfusion and first‐pass effect each independently predicted better functional outcome, but functional outcomes were similar between tenecteplase and alteplase overall. Conclusions We observed higher early reperfusion rates with tenecteplase, but greater first‐pass effect with alteplase, while functional outcomes were comparable. This may suggest that the early reperfusion advantage of tenecteplase could be offset by downstream procedural variables such as first‐pass effect, highlighting the importance of jointly evaluating both reperfusion and procedural efficiency when comparing thrombolytic strategies.

BACKGROUND:Evidence to guide the optimal timing of antiplatelet and oral anticoagulants (OACs) therapy after hemorrhagic infarction (HI) versus parenchymal hematoma (PH) is limited and inconsistent, leading to substantial variation in practice. This study's goal was to study the practice pattern and compare clinical outcomes associated with early-versus-delayed initiation of antiplatelet/OACs after hemorrhagic transformation (HT). METHODS:This multicenter, retrospective, cross-sectional study included patients with acute ischemic stroke and HT. Patients with an HI or PH were categorized by HT to antithrombotic initiation time, and their outcomes-30-day HT exacerbation, composite outcomes of recurrent stroke/systemic emboli, 90-day vascular death, and functional outcomes-were compared. RESULTS:Of 748 patients, 496 received antiplatelets, and 252 received OACs after HT. The median HT-to-antiplatelet time was significantly shorter after HI than PH (1 [interquartile range, 0-2] versus 3 [interquartile range, 1-5] days; P<0.001). There were no statistically significant differences in HT exacerbation and composite outcomes (30-day), as well as vascular death and unfavorable functional outcomes (90-day), between patients who received same-day, early (HI, <1 day; PH, <3 days), or late (HI, >1 day; PH, >3 days) antiplatelets after either HI or PH. Among patients on OACs, those with HI had shorter median HT-to-OAC time than PH (7 [interquartile range, 2-15] versus 15 [interquartile range, 7-32] days; P<0.001). Although HT exacerbation rates (30-day) were comparable between early (HI, <7 days; PH, <15 days) and late (HI, >7 days; PH, >15 days) OAC initiation after either HI or PH, late initiation after PH was accompanied by higher rates of composite outcomes (30-day) than early initiation (20.7% versus 3%; P=0.044). Regression models adjusted for demographics, National Institutes of Health Stroke Scale, and stroke severity showed no statistically significant association between early initiation of antiplatelets or OACs with HT exacerbation risk. CONCLUSIONS:Our study found no statistically significant difference in HT exacerbation between early and late initiation of antiplatelets or OACs among patients with HI/PH, while prolonged delay among patients with PH were accompanied by increased systemic thromboembolic events. Although these findings offer preliminary clinical insight, prospective studies are needed.

Background The Monopoint reperfusion system (Monopoint; Route 92 Medical, San Mateo, California, USA) is a large bore (0.088 or 0.070 inch inner diameter) aspiration thrombectomy platform designed to minimize ledge effect and improve neurovascular navigation and embolectomy. We aimed to describe a multicenter, real world experience of the safety and performance of the Monopoint system in first line aspiration thrombectomy for large vessel occlusions (LVOs), outside of the recently completed SUMMIT MAX (A Randomized, Controlled Trial to Evaluate the Safety and Effectiveness of the Route 92 Medical Reperfusion System) clinical trial.Methods Adults with acute anterior circulation LVO stroke between January 2019 and December 2024 consecutively treated with first line aspiration thrombectomy using the Monopoint at 10 centers were retrospectively reviewed. The primary outcome was first pass effect (FPE, modified Thrombolysis in Cerebral Infarction (mTICI) 2C/3 on first pass) and modified FPE (mFPE, mTICI 2B/2C/3 on first pass). The primary safety outcome was the rate of intraprocedural complications attributed to the Monopoint system.Results In 193 included patients, median age was 67 years (IQR 67-78), and 46.6% (90/193) were women. Successful delivery of the aspiration catheter to the clot site occurred in 96.2% (185/193) of patients. FPE was achieved in 57.5% (111/193) and mFPE was achieved in 68.4% (132/193) of patients. Of 10 (5.2%) total complications, most were vasospasm treated with intra-arterial verapamil (8/193, 4.1%); major complications included one dissection (1/193, 0.5%) and one perforation (1/193, 0.5%).Conclusion This multicenter study of the Monopoint reperfusion system for LVO thrombectomy outside of the SUMMIT MAX trial demonstrated a high FPE rate and a low rate of major complications.

BACKGROUND AND PURPOSE:Early neurologic improvement (ENI) following mechanical thrombectomy (MT) has been a topic of substantial interest. The literature has more than 40 ENI definitions, yet no consensus has been reached. In this Delphi study, we sought to investigate experts' perspectives on the available ENI definitions and determine whether a consensus can be achieved. MATERIALS AND METHODS:The Delphi approach assessed experts' perspectives on available ENI definitions. Following a systematic literature review, the first survey round was prepared and sent to 20 experts using a Web-based anonymous survey platform (qualtrics.com). The first round of questions was publicly shared on the letsgetproof.com platform to gather perspectives of neurointerventionalists worldwide on ENI definitions. Expert and volunteer answers formed the basis of subsequent rounds, in which closed-ended questions were sent only to experts. Consensus was defined as an agreement of ≥70% for binary closed-ended questions and ≥50% for closed-ended questions with >2 response options. RESULTS:Experts completed 3 survey rounds. They recognized that the heterogeneity in ENI definitions is the most critical factor limiting the use of ENI in clinical practice and stroke research. All experts acknowledged that stroke physicians need a standardized universal ENI definition. Consensus was reached on the notion that a unified ENI definition should focus on predicting functional independence at 3 months. They agreed that NIHSS improvement of ≥8 points at 24 hours could serve as the unified ENI definition. They acknowledged that incorporating prestroke comorbidities, occlusion location, baseline NIHSS scores, and procedure-related parameters would complicate the ideal ENI definition and limit its use in clinical settings. The experts could not reach a consensus on the potential utility of ENI as a primary end point in MT trials. CONCLUSIONS:In our Delphi analysis, experts agreed on an ENI definition. They did not endorse using different ENI criteria for patients with comorbidities, posterior circulation occlusions, or high baseline NIHSS scores. Further prospective studies are needed to validate or refine ENI definitions and to address the paucity of data on the prognostic utility of ENI in specific clinical scenarios.

BACKGROUND AND OBJECTIVES:Middle meningeal artery embolization (MMAE) is a safe and efficacious adjunct to surgical evacuation for symptomatic chronic subdural hematoma (cSDH). We evaluated the concomitant performance of MMAE with surgical evacuation in a single anesthetic session rather than a staged approach. METHODS:In this retrospective, multicenter cohort study, patients with cSDH who underwent MMAE and surgical evacuation during 1 anesthetic session from January 2020 through August 2024 were included. The primary endpoints were feasibility (technical success), safety (complication and mortality rates), and efficacy (radiographic improvement and modified Rankin Scale score ≤2). RESULTS:Among 157 patients (median age 74 years), 66% had unilateral cSDH and 34% had bilateral disease. Technical success was achieved in 153 patients (97.4%), with no major intraprocedural failures. The overall complication rate was 10.8%, including intraprocedural complications (ie, vessel injuries, cardiac arrest) in 4 patients (2.5%) and periprocedural adverse events in 13 patients (8.3%), including seizures, hemorrhages, respiratory failure, ischemic events, infections, and recurrent hematomas. The overall mortality rate was 12.7% (6 [3.8%] early postoperative deaths, 13 [8.3%] late unrelated deaths). Radiographic improvement was observed in 91.7% of patients, with 63.1% achieving ≥50% reduction in hematoma thickness at last available follow-up. At median follow-up of 54 days, 99/118 (83.9%) patients achieved or maintained functional independence (modified Rankin Scale ≤2). CONCLUSION:Single-session MMAE with concomitant surgical evacuation proved feasible and safe. Radiographic and clinical outcomes were favorable, without higher complication rates compared with staged approaches. Future prospective studies should clarify the long-term benefits, assess the impact on resource use and cost-minimization, and determine ideal patient-selection criteria for this integrated treatment strategy.

OBJECTIVE:Surgical evacuation is the mainstay of treatment for patients with chronic subdural hematoma (cSDH) who have symptomatic mass effect, yet it carries a recurrence risk of up to 20%. Recent randomized trials have shown that adding middle meningeal artery embolization (MMAE) can significantly reduce both reoperations and overall treatment failures. However, whether performing MMAE and surgical evacuation in a single session impacts treatment efficacy remains an open question. METHODS:The authors retrospectively identified 429 patients across 14 institutions who underwent MMAE plus surgical evacuation of cSDH. Patients were stratified into single-session (MMAE and evacuation under the same anesthesia session) or staged (separate sessions) cohorts. Baseline demographic, procedural, and imaging data were collected. Propensity score matching was performed to balance key baseline variables. Primary outcomes included hematoma recurrence, hospital length of stay (LOS), and functional independence (modified Rankin Scale score ≤ 2). RESULTS:Of 429 patients, 205 (47.8%) received single-session treatment. In the unmatched analysis, single-session patients showed a lower rate of cSDH reaccumulation and repeat surgery (4.7% vs 10.7%, p = 0.010) and a shorter median LOS (6 vs 7 days, p < 0.005). After matching, reaccumulation rates were not significantly different, but LOS remained significantly shorter (5 vs 7 days, p = 0.002). Functional outcomes and overall mortality were similar in both groups. Complication rates did not differ, and MMAE-related adverse events were rare. CONCLUSIONS:Single-session MMAE plus surgical evacuation appears to be safe and shortens LOS compared with a staged approach. The rates of functional outcomes, re-evacuation, and mortality did not differ significantly from those observed in patients who underwent staged procedures.

ABSTRACT Objective To compare the effectiveness and safety of tenecteplase (TNK) versus alteplase (TPA) in patients with basilar artery occlusion prior to endovascular treatment (EVT). Methods In this retrospective multicenter study (BAO‐TNK), we analyzed consecutive BAO patients from 14 U.S. stroke systems who received TNK or TPA within 4.5 h of last known well and were referred for EVT (01/2020‐08/2024). Multivariable logistic regression models were adjusted for age, sex, NIH Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early CT Score (pc‐ASPECTS), last‐known‐well‐to‐door time, and stroke etiology. Outcomes included 90‐day modified Rankin Scale (mRS), reperfusion rates, and intracranial hemorrhage (ICH) per Heidelberg classification. Results Of 163 BAO patients, 75 (46.0%) received TNK and 88 (54.0%) received TPA. Rates of 90‐day good functional outcome (mRS 0–3) were comparable between groups (TNK: 61.8% vs. TPA: 48.8%, adjusted odds ratio [aOR] 1.372, 95% CI 0.616–3.054, p = 0.439). No significant differences were observed in rates of pre‐thrombectomy early reperfusion (18.7% vs. 14.8%, aOR 0.933, 95% CI 0.369–2.359, p = 0.884), post‐thrombectomy final reperfusion (97.3% vs. 92.0%, aOR 2.133, 95% CI 0.376–12.116, p = 0.393), 90‐day mortality (32.4% vs. 39.5%, aOR 0.989, 95% CI 0.436–2.244, p = 0.979), or symptomatic ICH (4.0% vs. 4.5%, aOR 1.319, 95% CI 0.245–7.114, p = 0.747). Predictors of favorable outcome included younger age, lower NIHSS, higher pc‐ASPECTS, shorter LKW‐to‐puncture time, and non‐atherothrombotic stroke etiology. Interpretation In BAO stroke, TNK and TPA administered within 4.5 h pre‐EVT were associated with similar functional outcomes, reperfusion success and hemorrhage rates.