Background Radiation exposure varies across neuroendovascular procedures, but the relative contributions of per-case dose and procedural volume to collective institutional radiation burden are incompletely understood. We aimed to characterize radiation exposure across contemporary neuroendovascular procedures and quantify procedure-specific contributions to cumulative institutional radiation burden. Methods In this single-center retrospective cohort study, consecutive diagnostic cerebral angiography and therapeutic neuroendovascular procedures performed at a high-volume academic neurovascular center from January 2021 through January 2023 were evaluated. The primary outcome was dose-area product (DAP); secondary outcomes were air kerma (AK), fluoroscopy time (FT), and cumulative institutional DAP. Results Of 2,198 procedures, 899 (40.9%) were diagnostic and 1,299 (59.1%) interventional. Interventional procedures had higher radiation exposure than diagnostic angiography: median DAP, 62.7 versus 58.3 Gy×cm²; AK, 635.0 versus 362.4 mGy; and FT, 17.5 versus 7.4 min (all p<0.001). Exposure varied by subtype; spinal vascular interventions had the highest median DAP (263.2 Gy×cm²). Cumulative DAP was 160,563 Gy×cm²; interventional procedures accounted for 63.0%. Although diagnostic procedures accounted for 37.0%, diagnostic cerebral angiography, analyzed as one aggregate category, was the largest individual contributor to cumulative DAP (59,357 Gy×cm²), exceeding every interventional subtype because of high procedural volume despite lower per-case exposure. Mechanical thrombectomy (34,564 Gy×cm²) and aneurysm treatment (26,395 Gy×cm²) were the largest interventional contributors. Conclusions Radiation exposure varies by procedure type and complexity. Radiation-optimization strategies should address both per-case dose and procedural volume.

Introduction: Delayed cerebral ischemia (DCI), a major complication of aneurysmal subarachnoid hemorrhage (aSAH), has been linked to impaired autoregulation. Disruptions in cerebral blood flow and metabolism may also manifest as impaired neurophysiology on EEG. However, the relationship between autoregulation and EEG biomarkers in aSAH remains poorly defined. This study aims to characterize this relationship and how DCI modifies it. Methods: In this study, DCI was defined as a new neurologic deterioration or infarction that could not be explained by other causes. DCI diagnosis was determined retrospectively by the consensus of at least two neurointensivists. Cerebral autoregulation was assessed by quantifying responses in regional oxygen saturation to changes in mean arterial pressure (MAP). Alpha-delta ratio (ADR) values were derived from spectral analysis of continuous EEG recordings, averaged across hemispheres, and plotted against 5-mmHg MAP bins for DCI and non-DCI patients. Inverse parabolic curves were fitted to the resulting scatter plots using quadratic regressions; the peaks and widths of these curves were compared to each other and to population-derived autoregulatory limits. A likelihood ratio test was used to determine whether including a MAP-DCI interaction term improves model fit when predicting ADR. Results: Seventy-seven patients, including 37 who developed DCI, with a median overlapping EEG-hemodynamic recording length of 113.4 hours (IQR 68.9–166.1) were included in the analysis. In patients with DCI, the ADR–MAP curve peaked at a higher MAP value (148 mmHg vs. 108 mmHg) and was broader (243.5 mmHg vs. 112.97 mmHg at half maximum) compared to non-DCI patients (Figs. 1&2). In DCI patients, the peak exceeded the median autoregulatory range (93.5–127.8 mmHg), whereas in non-DCI patients, the peak remained within its respective range (85.2–117.6 mmHg). Including the DCI–MAP interaction significantly improved model fit for predicting ADR ( χ 2 = 153.84, df = 3, p < 0.001; Table 1). Conclusions: Patients who developed DCI demonstrated maximum ADR values at MAPs higher than those of non-DCI patients and beyond the autoregulatory range. These findings suggest that DCI alters the relationship between autoregulation and EEG-based neurophysiology, revealing a novel physiological link that may inform new approaches to monitoring and preventing DCI.

BACKGROUND AND OBJECTIVES:The optimal blood pressure (BP) target after endovascular thrombectomy (EVT) remains elusive. The aim of our study was to assess the relationship between individualized autoregulation-based BP thresholds, secondary brain injury, and functional outcomes. METHODS:We conducted a prospective observational study of patients with acute ischemic stroke who underwent EVT. Simultaneous recordings of arterial BP and near-infrared spectroscopy were used to continuously monitor each patient's limits of autoregulation for up to 24 hours. Time outside limits of autoregulation was correlated with short-term clinical end points, radiographic biomarkers of secondary brain injury, and functional outcomes. RESULTS:Personalized BP targets were successfully computed in 199 patients. Percent time outside limits of autoregulation was independently associated with early neurologic deterioration (OR 1.2, 95% CI 1.1-1.4, p < 0.001) and worse modified Rankin Scale scores at 90 days (OR 1.22, 95% CI 1.09-1.36, p < 0.001). Patients with hemorrhagic transformation and symptomatic intracranial hemorrhage spent significantly more time above the upper limit of autoregulation compared with those without (18.7% vs 11%, p = 0.02, and 24.9% vs 12.3%, p = 0.024, respectively). Furthermore, time above the upper limit of autoregulation was correlated with net water uptake, a radiographic biomarker of cerebral edema (β = 1.6, 95% CI 0.4-2.8, p = 0.009). In nonrecanalized patients, every 60 minutes below the lower limit of autoregulation was associated with an infarct progression of 16.2 mL (p < 0.001). DISCUSSION:Deviations from personalized BP targets were associated with an increased risk of secondary brain injury and worse functional outcomes. The study proposes autoregulation-oriented BP management as a promising strategy for improving recovery after ischemic stroke.

Background: Understanding the molecular differences between embolic strokes caused by cardioembolism versus atheroembolism is key for identifying therapeutic targets and advancing precision medicine. We applied multiomics and integrative analyses to identify circulating proteins distinguishing atrial fibrillation (AF) from carotid atherosclerosis (CA) in large vessel occlusion strokes. Methods: We first analyzed the plasma proteome of UK Biobank ischemic stroke patients with AF (n=539) versus CA (n=127), comparing levels of 2,923 proteins (Olink platform; FDR<0.05). Second, in a Yale cohort, we examined differential expression of corresponding genes in thrombi from AF (n=7) and CA (n=7) patients, including cell-type–specific patterns. Third, we performed two-sample Mendelian Randomization (MR) using pQTLs to test causal links between proteins and stroke subtypes. Finally, pathway enrichment analyses identified biological processes associated with the proteins of interest. Results: Twelve proteins differed significantly between etiologies. AF was associated with higher NTproBNP, NPPB, and ACP5, and lower APCS, ANGPT2, PAMR1, PRCP, PROS1, LARP1, F7, F10, and LEO1 (all FDR<0.01, Figure 2). Single-cell analyses of embolic clots confirmed differential expression of ACP5, PRCP, LARP1, ANGPT2, and LEO1 (FDR<0.01) across multiple immune cell types (Figure 3). Pathway enrichment implicated coagulation and γ-carboxylation pathways in CA strokes, and natriuretic peptide signaling and riboflavin metabolism in AF strokes. MR supported causal roles for NTproBNP (OR 1.26, 95%CI 1.11–1.41), ANGPT2 (OR 1.17, 1.01–1.34), ACP5 (OR 1.06, 1.01–1.15), APCS (OR 1.14, 1.01–1.15), and PAMR1 (OR 1.11, 1.01–1.20), with no evidence of pleiotropy or reverse causation. Conclusion: This multimodal analysis reveals distinct proteomic signatures for AF- versus CA-related embolic strokes. Findings support established markers (NT-proBNP, F7) and highlight novel candidates with mechanistic plausibility. ACP5, a macrophage-derived enzyme linked to fibrosis, suggests a pathway for atrial cardiomyopathy in AF. The CA signature emphasizes local atherothrombosis, plaque inflammation (ANGPT2), and vascular dysregulation (PRCP). These proteins may improve etiologic classification and inform therapeutic development in ischemic stroke.

BACKGROUND:The aim of this study was to evaluate the preliminary experience of a combined middle meningeal artery embolization (MMAE) and burr hole evacuation approach for chronic subdural hematoma (cSDH) under a single anesthesia session. METHODS:We performed a retrospective review of all patients who underwent MMAE and burr hole surgery during the same admission at a single major academic institution between 2019 and 2024. Patients were dichotomized by those with both procedures performed under a single anesthesia session (combined) or two separate sessions (separate). Baseline demographics, comorbidities, and complications were compared. The primary outcomes were in-hospital and 90-day complication and reoperation rates. RESULTS:103 patients were included in the study (median age 74 (67-81) years), with 33.9% in the combined cohort. Demographics, comorbidities, and radiographic characteristics were similar between the cohorts. While cumulative procedure times were similar (separate 85 (71-110) min vs combined 96 (82-127) min), total anesthesia time was significantly longer for patients with separate procedures (separate 225 (193-264) min vs combined 165 (145-183) min, P<0.001). There were no differences in the rates of access site complications, reoperation, stroke, or mortality between the cohorts. The combined cohort trended to have shorter length of stay (separate 6 (5-8) days vs combined 5 (4-7) days, P=0.058). There were no differences in complication or reoperation rates within 90 days. CONCLUSION:The results of this study suggest that MMAE performed under a single anesthesia session with burr hole evacuation surgery is a safe and potentially resource-efficient approach for the management of cSDH.

BACKGROUND:Patients with idiopathic intracranial hypertension (IIH) represent a unique population in whom mechanical shunting can be challenging. Endovascular cerebrospinal fluid shunting via the eShunt system has emerged as a potential alternative, but it is not currently approved for this indication, and its feasibility in IIH remains unknown. METHODS:In this retrospective, single center study, radiographic images of consecutively treated patients with shunt responsive IIH were assessed. Radiographic parameters involving the inferior petrosal sinus (IPS) and cerebellopontine angle (CPA) cistern were measured. We also examined whether the presence of a ventricular shunt at the time of imaging influenced radiographic candidacy, given the plausibility of cisternal changes after shunting. RESULTS:Of 53 patients (median age 41 years, 81.1% women), 24 (45.2%) were previously shunted before MRI imaging. The average CPA cisternal depth was 4.8±1.8 mm (right) and 4.9±2.1 mm (left); IPS size 3.5±0.7 mm (right) and 3.4±0.8 mm (left). The average off-axis angle trajectory from the IPS to the cistern was 128.6±9.8° (right) and 125.2±9.3° (left). In our final model, pre-existing ventricular shunt was not independently associated with endovascular shunting candidacy (OR 2.01, 95% CI 0.65 to 6.40; P=0.227). Overall, endovascular shunting was feasible in at least one side for 55% of patients, increasing to as high as 74% when assessment was based only on venous anatomy. CONCLUSION:In this study, a sizeable proportion of patients with IIH were radiographic candidates for endovascular shunting, regardless of the presence of a pre-existing supratentorial shunt.

BACKGROUND:The Millipede AspiRation for Revascularization in Stroke (MARRS) pivotal study was a prospective, multicenter, single arm trial evaluating the safety and efficacy of the corrugated Millipede catheter system in patients with acute ischemic stroke due to large vessel occlusion. METHODS:Patients aged 18-85 years with internal carotid artery, M1, M2, or basilar artery occlusions treatable within 8 hours were eligible. Catheter selection was based on target vessel diameter (Millipede88 >2.7 mm; Millipede70 >2.2 mm). The primary efficacy endpoint was modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b within ≤3 passes without rescue therapy. Imaging and clinical outcomes were independently adjudicated. Secondary endpoints included first pass effect (mTICI ≥2c). RESULTS:180 patients were treated (57% US, 43% EU). Median age was 69 years, mean baseline National Institutes of Health Stroke Scale score was 17, and median Alberta Stroke Program Early CT Score was 9. M1 occlusion was the most common target lesion (62%). The primary endpoint was achieved in 160/180 patients (88.9%; 95% CI lower bound 84.3%) in the intention-to-treat cohort. Direct first pass aspiration was performed with Millipede88 and Millipede70 in 64% and 36% of patients, respectively. Navigation success was 96% with Millipede88 and 99% with Millipede70. Among Millipede88 patients, first pass mTICI ≥2c was achieved in 60%, increasing to 75% in the M1 subgroup. Final mTICI ≥2c was achieved in 85% of primary Millipede88 cases. Symptomatic intracranial hemorrhage occurred in 2.3%, intracranial dissection in 1.1%, no perforations occurred, and 90 day all cause mortality was 13.9%. CONCLUSIONS:The Millipede aspiration system demonstrated excellent deliverability and high rates of first pass and final mTICI ≥2c, particularly in M1 occlusions, with low rates of adverse events. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov NCT05714501.

ABSTRACT Optimal blood pressure management after thrombectomy remains uncertain, and individualized autoregulation-based targets typically require continuous neuromonitoring. We developed an angiography-derived autoregulatory metric using intraprocedural data and applied it retrospectively to a single-center cohort of patients who underwent thrombectomy for acute stroke. From 62 patients with 3-month functional outcomes, greater time within the predicted autoregulatory range during the first 24 hours after thrombectomy was independently associated with improved outcome after adjustment for covariates (odds ratio per 10% increase, 1.86; 95% CI, 1.31-2.66; P = .0006). These findings support routine angiography as a potential source of early, patient-specific hemodynamic targets after thrombectomy.

Introduction: Impaired cerebral autoregulation in large vessel occlusion (LVO) stroke has been associated with poor functional outcomes. However, the evolution of autoregulatory function in the immediate post-mechanical thrombectomy (MT) period has not been well defined. Methods: We conducted a prospective observational study of patients with anterior circulation LVO undergoing MT. To track patients’ cerebral autoregulatory function, cerebral oximetry index (COx)—a rolling correlation between mean arterial pressure and near-infrared spectroscopy–derived regional oxygen saturation—was continuously recorded for 24 hours post-procedure. Associations between mean COx and dichotomized 3-month functional outcomes (modified Rankin Scale [mRS] 0-2 vs > 2) were assessed using multivariable logistic regression and adjusted for relevant confounders. Temporal trajectories of COx were compared between hemispheres and stratified by outcome. Results: Among 196 patients (mean age 70.5 ± 16.1 years; admission NIHSS 13.7 ± 6.4), higher mean COx was independently associated with unfavorable outcomes (adjusted OR 1.29 per 0.1 increase; 95% CI 1.03–1.63; p < 0.05). Post-reperfusion, COx values were elevated in both outcome groups. Approximately 4 hours post-MT, patients with favorable outcomes exhibited a significant decline in COx in both hemispheres, whereas those with unfavorable outcomes maintained elevated COx levels. Over 24 hours, COx remained lower in patients with better recovery (Figure 1). Conclusions: Impaired autoregulation, indicated by higher mean COx, is associated with poor functional recovery following MT. Every 0.1 increase in mean COx during the first 24 hours correlates with a 29% higher likelihood of unfavorable outcome. Dysfunction emerges early post-reperfusion and involves both hemispheres, though less severely contralaterally. Tracking autoregulatory recovery may support individualized blood pressure targets and guide interventions to optimize stroke outcomes.

Background and Objectives The optimal blood pressure (BP) target after endovascular thrombectomy (EVT) remains elusive. The aim of our study was to assess the relationship between individualized autoregulation-based BP thresholds, secondary brain injury, and functional outcomes. Methods We conducted a prospective observational study of patients with acute ischemic stroke who underwent EVT. Simultaneous recordings of arterial BP and near-infrared spectroscopy were used to continuously monitor each patient's limits of autoregulation for up to 24 hours. Time outside limits of autoregulation was correlated with short-term clinical end points, radiographic biomarkers of secondary brain injury, and functional outcomes. Results Personalized BP targets were successfully computed in 199 patients. Percent time outside limits of autoregulation was independently associated with early neurologic deterioration (OR 1.2, 95% CI 1.1-1.4, p < 0.001) and worse modified Rankin Scale scores at 90 days (OR 1.22, 95% CI 1.09-1.36, p < 0.001). Patients with hemorrhagic transformation and symptomatic intracranial hemorrhage spent significantly more time above the upper limit of autoregulation compared with those without (18.7% vs 11%, p = 0.02, and 24.9% vs 12.3%, p = 0.024, respectively). Furthermore, time above the upper limit of autoregulation was correlated with net water uptake, a radiographic biomarker of cerebral edema (beta = 1.6, 95% CI 0.4-2.8, p = 0.009). In nonrecanalized patients, every 60 minutes below the lower limit of autoregulation was associated with an infarct progression of 16.2 mL (p < 0.001). Discussion Deviations from personalized BP targets were associated with an increased risk of secondary brain injury and worse functional outcomes. The study proposes autoregulation-oriented BP management as a promising strategy for improving recovery after ischemic stroke.

BACKGROUND:Despite increased awareness of diversity and inclusion in neurointerventional surgery, the representation of women in neurointerventional academic publishing has not been systematically quantified. We aimed to evaluate global and temporal gender trends among authors publishing in leading neurointerventional journals using natural language processing (NLP) tools. METHODS:We used the National Center for Biotechnology Information (NCBI) Entrez and Medline APIs (application programming interfaces) to extract metadata from all articles published between 2014 and 2024 in the Journal of NeuroInterventional Surgery and Interventional Neuroradiology, the only two journals dedicated exclusively to the field of neurointerventional surgery. For each publication, we identified the first and last authors, as well as their institutional affiliations. We applied the OpenAI GPT-4 API to infer the country of origin based on last author affiliations and to predict gender using first and last names. RESULTS:Across 4875 articles published between 2014 and 2024 in two leading neurointerventional surgery journals, female authorship increased modestly over time. In 2014, 10.2% of first authors and 6.1% of last authors were women, compared with 14.2% and 7.6%, respectively, in 2024. A significant upward trend in female first authorship was observed over time using the Cochran-Armitage test for trend (P=0.0002), with the strongest increases in the Americas and Asia. In contrast, no overall increase was seen in female last authorship (P=0.14), with a modest but significant trend observed only in Asia. Geographic disparities were also evident: Austria and Norway had the highest female last authorship rates (62.5% and 40.0%, respectively), whereas the US, despite contributing the most publications, had only 13.8%. The Gender Parity Index (GPI) further highlighted under-representation, with most countries falling well below parity, especially for last authorship. CONCLUSIONS:Analysis using artificial intelligence driven NLP methods suggests persistent gender inequalities in neurointerventional surgery authorship with variation across countries. Although female representation has improved over the past decade, progress is uneven. These findings underscore the need for targeted efforts to promote equity in academic vascular neurosurgery globally.

Innate immune cells contribute to both secondary brain injury and repair following intracerebral hemorrhage (ICH). However, the signaling pathways governing initial inflammatory and subsequent reparative myeloid programs in living patients remain poorly understood. To better characterize mononuclear phagocyte cell changes over time, we generated a single-cell transcriptomic dataset of paired hematoma clot evacuates and peripheral blood samples from 10 patients following ICH (5-290 h). We identified distinct populations of activated and TNF-low microglia, as well as a highly activated population of CD14+ monocytes in the hematoma. Perturbation analysis identified TNF signaling as the primary driver of hematoma monocyte activation. Custom temporal trajectory analysis using single-cell foundation model embeddings found that this TNF response in monocytes was transient, peaking early after hemorrhage and decreasing over the following 48 h as monocytes shifted to reparative transcriptional programs. Transiently activated microglia emerged as the likely acute source of TNF among analyzed populations, signaling through monocyte TNFR2. Surprisingly, acute TNF signaling in CD14+ monocytes was also associated with better severity-adjusted neurological outcomes both in our cohort and an independent validation cohort. These findings suggest acute TNF signaling between activated microglia and hematoma-associated monocytes, particularly through TNFR2, may contribute to recovery following ICH.

BACKGROUND Transcarotid artery revascularization (TCAR) has become an increasingly utilized surgical option for carotid disease, relying on flow reversal for distal embolic protection (DEP). However, anatomical variations, such as an isolated middle cerebral artery hemisphere, and severe carotid stenosis may compromise the safety of flow reversal intraoperatively. The authors describe the use of an adjunctive DEP device during TCAR as a “bailout” strategy for high-risk patients. OBSERVATIONS The authors present the case of an adult patient with high-grade symptomatic carotid stenosis who was surgically managed with TCAR, requiring the adjunctive use of a DEP device due to insufficient flow reversal. The patient had a contralaterally occluded internal carotid artery, and poor retrograde flow was observed angiographically. The NAV6 Embolic Protection System was deployed through the transcarotid system. The case was successfully completed. There was no stroke perioperatively nor within 1 year postprocedure. LESSONS For patients with poor flow reversal or isolated hemispheres during TCAR, adjunctive use of a DEP device may help mitigate the risks of distal embolization and periprocedural stroke. https://thejns.org/doi/10.3171/CASE25924

Unlocking perfusion metrics from routine digital subtraction angiography could transform how neurovascular disease is managed. Truncation artifact, defined as premature termination of image acquisition, is a key source of error in CT and MR perfusion imaging. However, length requirements for deriving perfusion metrics from angiography remain undefined. This study investigates the minimum image acquisition length required for interpreting mean transit time from digital subtraction angiography. We analyzed 55 outpatient angiograms performed for surveillance an average of 687 days after aneurysmal rupture. Truncation artifact was simulated by progressively shortening the angiography runs after bolus arrival. A gamma-variate function was used to assess if extrapolation of the truncated data could approximate full length acquisitions. Extrapolation of the truncated datasets with the gamma-variate function produced highly reliable estimates of the mean transit time with at least seven seconds of post-bolus data (mean difference between truncated/extrapolated MTT and original MTT 0.003 ± 0.047 s, mean ± SD). The fraction of pixels fit by the gamma-variate function was also sensitive to truncation and at least seven seconds of data was required to fit > 90

Introduction: Early antihypertensive (Anti-HTN) treatment after successful mechanical thrombectomy (MT) has been associated with worse outcomes, but the physiologic mechanisms and at-risk subgroups remain unclear. We hypothesized that anti-HTN use increases time outside the personalized autoregulatory range, thereby predisposing patients to secondary brain injury. Methods: From our prospectively maintained stroke database, we identified patients who underwent MT for large-vessel occlusion in the anterior circulation and received continuous cerebral autoregulation monitoring during the first 24 hours post-procedure. The cerebral oximetry autoregulatory index was derived as a moving correlation coefficient between arterial blood pressure and near-infrared spectroscopy–based cerebral oxygenation. This index was used to define each patient’s autoregulatory limits and optimal mean arterial pressure (MAPopt). We then compared (1) the absolute deviation between observed MAP and MAPopt and (2) the percentage of time spent outside the autoregulatory range between patients who received Anti-HTN and those who did not, using Mann–Whitney U test. Multivariable logistic regression was applied to assess the independent associations of Anti-HTN use and autoregulatory impairment with poor 3-month functional outcome (mRS > 2). Results: A total of 177 patients were included. Patients who received Anti-HTN therapy demonstrated significantly greater deviations between observed MAP and MAPopt (p=0.03, Table 1). They also spent a larger proportion of time outside the autoregulatory range over 24 hours, although this difference was not statistically significant (37.5% vs 33.4%, p=0.3). In multivariable logistic regression, both Anti-HTN treatment (adjusted OR 3.8; 95% CI 1.4–12.8; p=0.02) and time spent outside the autoregulatory range (adjusted OR 1.5; 95% CI 1.1–1.9; p=0.006) were independently associated with poor 3-month outcomes (Table 2). No interaction was observed between Anti-HTN use and autoregulatory impairment on outcome. Conclusions: Early Anti-HTN therapy after MT was associated with greater deviations from MAPopt and increased likelihood of poor functional recovery. These findings suggest that lowering blood pressure in the early post-reperfusion period may worsen outcomes by disrupting personalized autoregulatory physiology. Autoregulation-guided hemodynamic management may help identify patients at risk and inform tailored strategies to optimize recovery after stroke.

Background Gender disparities in academic surgery persist, particularly in authorship positions that signal leadership, mentorship, and scholarly influence. Comprehensive global analyses across surgical specialties remain limited. This study examined gender representation among first and last (senior) authors across surgical subspecialties, countries, and continents using natural language processing applied to bibliometric data. Methods In a cross-sectional bibliometric study of surgical publications indexed in MEDLINE (January 1, 2015, to December 31, 2024), articles were drawn from 30 high-impact journals across 15 subspecialties. Natural language processing tools inferred author gender and country of affiliation. After excluding entries with missing or unclassifiable data, 112,841 articles were analyzed. The main outcome was proportion of female first and last authors by specialty, region, article type, and journal. Secondary measures included temporal trends, Gender Parity Index (GPI), and results of χ2 and trend analyses. Results Of 112,727 articles, 32,909 (29.2%) had female first authors, and 22,505 (19.9%) had female last authors. Female first authorship increased from 26.1% in 2015 to 34.1% in 2024, and female last authorship increased from 17.8% to 22.8% (both P < .001). Obstetrics/gynecology (59.8%), pediatric surgery (42.5%), and transplant surgery (39.4%) had the highest female first authorship, whereas cardiothoracic surgery (17.6%) and neurosurgery (18.9%) had the lowest. Representation also varied by country (Australia 32.1% vs Japan 10.1%) and article type (editorials 34.6% vs technical reports 14.3%). Differences by specialty, region, and article type were significant (P < .001). Conclusion Despite modest progress, substantial gender disparities remain, especially in senior roles, technical specialties, and high-prestige article types. Targeted initiatives are needed to promote equity in surgical research and leadership worldwide.

INTRODUCTION: In 2018, the JC and AHA introduced a new stroke care certification for Thrombectomy-Capable Stroke Centers, increasing both access and the number of proceduralists performing endovascular thrombectomies(EVT) nationwide. However, dispersing the overall volume for centers located in close proximity may have unclear effects on patient outcome. METHODS: We performed a retrospective cohort study using the 2020 Florida State Inpatient Database. We included adult patients who had a diagnosis of AIS and underwent EVT during the same admission. The primary study outcome was in-hospital death. We used Youden’s Index to define an optimal threshold for number of EVT/year/provider. Based on this cut-point, the cohort was dichotomized into low and high proceduralist volume groups. We fit logistic regression models to mortality in the full cohort, both as univariate analyses and after adjusting for covariates. RESULTS: Amongst 3,143 AIS patients who underwent EVT, 1,907 patients across 59 hospitals and 106 providers met our inclusion criteria. Amongst the 106 providers, the median (interquartile range) number of EVTs performed was 13.5 (7-25). The optimal cut-point was 17 EVT. Demographics and comorbidities were similar between the cohorts. Compared to the low volume cohort, the high volume cohort had a significantly lower rate of in-hospital mortality (low volume: 11.0%vs.high volume 7.2%, p=0.005). After adjusting for potential confounders, high proceduralist volume remained significantly associated with lower odds of in-hospital death(OR: 0.52, 95% CI 0.36 – 0.76, p<0.05). Between the two cohorts, the difference in absolute risk of death was approximately 4.8% (p <0.05). CONCLUSIONS: Our study found that high proceduralist volume, as defined by =18 EVT/year, was associated with reduced in-hospital morality. Further research is necessary to understand the effects of proceduralist experience and benchmarks for technical proficiency with the aim of improving the overall care of AIS patients.