BACKGROUND:Definitive minimally invasive treatment of spontaneous intracranial hypotension (SIH) is challenging due to heterogeneous mechanisms and locations of spinal cerebrospinal fluid (CSF) leaks. We evaluated CT-guided percutaneous cyanoacrylate injection for spinal CSF leaks. METHODS:We retrospectively reviewed consecutive SIH patients with CT myelography-confirmed leaks treated at our institution (2016-2025). Under local anesthesia, leak-type-tailored approaches were used: transforaminal or interlaminar for type 1 (dural tears) and posterior foraminal for types 2 (lateral leaks) and 3 (CSF-venous fistulas). Outcomes included HIT-6 and Bern scores (follow-up brain MRI only; post-treatment spine MRI not routinely performed). Paired t-tests compared baseline with primary follow-up (last post-cyanoacrylate assessment preceding any subsequent intervention). RESULTS:Forty-four patients (mean age, 48.6 years, 25 women) underwent cyanoacrylate injection. Leak-type distribution: type 1 in 20/44 (45.5%), type 2 in 12/44 (27.3%), type 3 in 12/44 (27.3%). In total, 50 sites were treated; 5 patients (11.4%) had multiple sites addressed in one session. Mean procedure duration was 28.8 ± 6.5 minutes. No intraprocedural complications or neurologic deficits occurred. Transient (< 24 h) post-procedural locoregional pain occurred in 12/44 (27.3%). Mean follow-up was 16.3 ± 11.6 months. Mean HIT-6 decreased from 66.8 ± 2.9 to 40.0 ± 6.6 (p < 0.001), and Bern score from 7.2 ± 1.2 to 1.5 ± 1.5 (p < 0.001) on follow-up MRI (mean, 2.2 months). Favorable clinical outcomes occurred in 37/44 (84.1%): complete symptom resolution in 30 (68.2%) and subtotal in 7 (15.9%). Five (11.4%) with partial improvement underwent complementary posterior epidural blood patch at the index level and subsequently achieved favorable outcomes; 2/44 (4.5%) had no improvement and were referred for surgery. CONCLUSION:These findings support CT-guided percutaneous cyanoacrylate as a versatile, effective, and safe therapy across SIH leak types, with high rates of favorable clinical outcomes and concordant brain imaging improvement. Future studies with standardized post-treatment spine imaging are needed to enable assessment of an anatomic closure endpoint, validate efficacy by leak type, and define this technique's role relative to other therapies.

Abstract Background and aims Brain frailty, reflected by structural brain changes on CT, has been linked to heterogeneity in stroke presentation and recovery. In ESCAPE-NA1, CT-based brain frailty markers were associated with higher baseline stroke severity and poorer 90-day outcomes after thrombectomy. We aimed to validate these associations in the HERMES collaboration and determine whether brain frailty modifies thrombectomy treatment effects. Methods We performed a pooled analysis of individual patient data from the HERMES collaboration. Brain frailty imaging markers were assessed on baseline non-contrast CT. Associations with baseline National Institutes of Health Stroke Scale (NIHSS) score and 90d-modified Rankin Scale (90d-mRS) were evaluated using multivariable regression, and interaction with thrombectomy effect analyzed. Results Among 1,730 patients in the pooled HERMES dataset, baseline NIHSS was higher in patients with white matter disease (WMD, adjusted β = 0.54, 95%CI:0.01-1.08) and medial temporal atrophy (adjusted β = 0.39, 95%CI 0.02-0.76). Greater brain frailty was associated with lower odds of favorable 90d-mRS, including for WMD (aOR 0.62, 95%CI 0.50–0.77), global cortical atrophy (GCA; aOR 0.65, 0.55–0.78), medial temporal atrophy (OR 0.70, 0.60–0.80), posterior atrophy (aOR 0.69, 0.58–0.83), and cerebral small vessel disease (CSVD) burden (aOR 0.74, 0.64–0.86). EVT treatment effect modification for 90d-mRS was observed for GCA (P = 0.036) and presence of lacunes (P = 0.034, Figure 1). Conclusions CT-based brain frailty markers are associated with higher baseline stroke severity and worse 90d functional outcome. Thrombectomy remained beneficial across brain frailty strata, but treatment benefit was smaller for patients with greater atrophy and CSVD burden, particularly lacunes. Conflict of interest All authors: nothing to disclose.

To investigate the value of baseline CT imaging for the prediction of functional outcome and benefit of endovascular thrombectomy (EVT) for anterior large vessel occlusion (LVO). We used individual patient data from seven randomized EVT trials and included patients with available baseline CT imaging and outcome data. We developed a model to predict functional outcome and benefit of EVT, including baseline stroke-related and brain frailty CT imaging features alone. We compared the discriminative performance of our model for predicting good functional outcome (modified Rankin Scale [mRS] 0–2) and treatment benefit (difference between the probability of mRS 0–2 with vs without EVT) with MR PREDICTS by calculating the difference in C-statistics (delta C and delta C-for-benefit). We included 1391 patients (median age, 67 years, interquartile range 59–76; 53

Background: We investigate whether the NIHSS at 24 hours could serve as an alternative primary outcome measure in acute ischemic stroke trials, and whether combining 90-day modified Rankin Score (mRS) and 24-hour NIHSS in a hierarchical outcome could enhance detection of treatment effect, using EVT as an exemplary study intervention. Methods: Post-hoc analysis from the HERMES collaboration that pooled data from 7 randomized controlled EVT trials. Validity of 24-hour NIHSS as a surrogate outcome for 90-day mRS was assessed in a causal mediation model (Figure 1). A 7-point ordinal NIHSS score was generated by grouping 24-hour NIHSS, including death as a separate category (“ordinal” NIHSS). EVT effect sizes and sample sizes required for detecting EVT benefit with 80% power were compared when using granular 24-hour NIHSS, ordinal 24-hour NIHSS, 90-day mRS, and hierarchical outcome (win-ratio) that combines 90-day mRS and 24-hour NIHSS. Subgroup analyses were performed in patients with baseline NIHSS<10 and ≥25. Results: A total of 1720 patients were included. Median 90-day mRS in the EVT/control arms was 3.0(IQR:1.0-4.0)/4.0(IQR:2.0-5.0) and median 24-hour NIHSS was 9.0(IQR:3.0-17.0)/14.0(IQR:7.5-19.0), see Figure 2. 24-hour NIHSS mediated the association between EVT and 90-day mRS and met the criteria for a surrogate outcome. Effect sizes were highest and sample sizes required to detect EVT benefit smallest for the win ratio approach (228), followed by 90-day mRS(240) and ordinal 24-hour NIHSS(242), see Table 1. In subgroup analyses of patients with baseline NIHSS<10 and≥25, ordinal 24-hour NIHSS resulted in the highest effect size/ smallest sample size. Conclusion: 24-hour NIHSS may be a valid surrogate outcome for 90-day mRS in acute ischemic stroke patients undergoing EVT, with a similar EVT effect size compared to 90-day mRS. It could potentially enhance detection of EVT benefit in patient subgroups with very low or very high baseline NIHSS. Combining 90-day mRS and 24-hour NIHSS in an ordered hierarchical could improve detection of EVT treatment effect compared to 90-day mRS.

Endovascular treatment of brain arteriovenous malformations (AVMs) is complex due to the intricate angioarchitecture, requiring accurate identification of feeding arteries, draining veins, and the nidus. While 3D digital subtraction angiography (DSA) aids visualization, it lacks vessel-specific segmentation. Embo ASSIST (GE HealthCare, USA) is a software designed to enhance procedural planning and real-time guidance through automatic segmentation and 3D roadmap visualization. This study evaluates the feasibility and clinical utility of Embo ASSIST in brain AVM embolization, focusing on its impact on procedural planning, navigation, radiation exposure, and contrast media use. A retrospective analysis of 19 procedures in 14 patients was conducted between February and August 2021. Images from biplane DSA and cone-beam computed tomography (CBCT) were processed with Embo ASSIST for vascular segmentation. A structured survey, rated by two senior neuroradiologists, assessed the software's effectiveness. Results showed Embo ASSIST improved procedural planning, with a better understanding of angioarchitecture (3.8/5), pedicle definition (3.9/5), and embolization pathway selection (3.9/5). It allows a reduction of contrast media use (3.7/5), radiation exposure (3.8/5), and procedure time (3.8/5) according to the operators. The software was highly rated for ease of use (3.8/5), CBCT processing speed (4.2/5), and integration with fluoroscopic navigation (4.3/5). However, vein segmentation was limited (3.0/5), requiring manual corrections. In conclusion, Embo ASSIST significantly improved AVM embolization procedures, enhancing visualization, navigation, and efficiency. Future advancements in venous segmentation and AI-based dynamic vessel analysis could optimize treatment further.

Background Robust collateral circulation has been linked with better reperfusion and clinical outcomes. It remains unclear how individual assessments of collateral circulation may be translated into clinical practice. Methods The pooled Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) angiography dataset was analyzed by a centralized, independent imaging core blinded to other clinical data. Conventional angiography was acquired immediately prior to endovascular therapy. Collaterals were graded with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) system and associated with baseline patient characteristics, reperfusion, and day 90 modified Rankin Score (mRS). Both 90-day all-cause mortality and day 90 mRS were modeled via multivariable logistic regression. Results Angiography was available in 376/605 (62%) patients. Baseline ASPECTS (Alberta Stroke Program Early CT Score) (p=0.043), history of diabetes mellitus (p=0.048), site of occlusion (p<0.001), and degree of subsequent Thrombolysis in Cerebral Infarction (TICI) reperfusion (p<0.001) were associated with collateral grades. ASITN collateral grade was strongly associated with ordinal mRS from baseline to 90 days in an unadjusted analysis (p<0.001). Multivariable regression demonstrated that collateral status is a strong determinant of mRS outcome in the presence of other predictors (OR=1.37 per grade, 95% CI [1.05 to 1.74], p=0.018). By comparing ORs, 1 unit of ASITN was determined to be approximately equivalent to 4.5 points of NIHSS, 11 years of age, 1.5 points of ASPECTS, or 100 min less delay from onset to puncture, in terms of impact on mRS. Conclusions Individual collateral physiology may contribute significantly to reperfusion success and clinical outcomes after acute ischemic stroke. Building a consensus for the role of angiographic collateral assessment in the allocation of adjuvant reperfusion therapies may help galvanize a precision medicine approach in stroke.

Background We investigate whether the National Institutes of Health Stroke Scale (NIHSS) at 24 hours could serve as a primary outcome in acute ischemic stroke trials, and whether combining 90‐day modified Rankin Scale (mRS) and 24‐hour NIHSS in a hierarchical outcome could enhance detection of treatment effect, using endovascular treatment (EVT) as an exemplary study intervention. Methods This was a post hoc analysis of pooled data from 7 randomized EVT trials. Twenty‐four‐hour NIHSS as a surrogate outcome for 90‐day mRS was assessed in a causal mediation model. A 7‐point ordinal NIHSS score was generated by grouping 24‐hour NIHSS, including death as a separate category (“ordinal” NIHSS). EVT effect sizes and sample sizes required for detecting EVT benefit with 80% power were compared when using granular 24‐hour NIHSS, ordinal 24‐hour NIHSS, 90‐day mRS, and a hierarchical outcome (win ratio) that combines 90‐day mRS and 24‐hour NIHSS. Results A total of 1720 patients were included. Twenty‐four‐hour NIHSS mediated the association between EVT and 90‐day mRS and met criteria for a useful surrogate outcome. Effect sizes were highest and sample sizes required to detect EVT benefit smallest for the win ratio approach (228), followed by 90‐day mRS (240) and ordinal 24‐hour NIHSS (242). In patients with baseline NIHSS <10 and ≥25, ordinal 24‐hour NIHSS resulted in the highest effect size. Conclusions Twenty‐four‐hour NIHSS is a useful surrogate outcome for 90‐day mRS in patients with acute ischemic stroke undergoing EVT, with a similar EVT effect size compared with 90‐day mRS. It could potentially enhance detection of EVT benefit in patients with very low or high baseline NIHSS. An ordered hierarchical outcome could improve detection of EVT treatment effect.

Introduction: Clinicians need simple and highly predictive prognostic scores to assist practical decision-making and family discussion. We aimed to develop and validate a simple prediction score applied at 24 hours to assist prognostication in patients with anterior circulation ischemic stroke due to large vessel occlusion. Methods: Using the HERMES collaboration dataset (n = 1764), patients in the endovascular therapy (EVT) arm were divided randomly into a derivation cohort (n = 430) and a validation cohort (n = 441). From a set of candidate predictors, forward selection using c-statistics was employed to select a model which was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in both the EVT validation cohort and in the control arm (n = 893) for mRS ≤2 and ≤3. Results: In the derivation cohort, two significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale [NIHSS] score at 24 h and age [β-coefficient 0.34 and 0.06]) were selected. Incorporating other variables did not much improve model performance. Among models with different weights, we derived the HERMES score: age (years)/10 + NIHSS score at 24 h, based on model performance and simplicity. The HERMES score was highly predictive for mRS ≤2 in the derivation cohort, validation cohort-EVT, and control arm (c-statistics 0.907, 0.914, and 0.909, respectively). Evaluation of the score against mRS ≤3 as an alternative outcome yielded similar results (c-statistics 0.911, 0.903, and 0.885). Among 435 subjects (24.7%) with HERMES score ≥25, the observed probability was 3.1-3.4% for mRS ≤2 and 9.4-16.7% for mRS ≤3 in the derivation cohort, validation cohort-EVT, and control arm (Figure). Conclusions: The HERMES score is a simple validated score to predict outcomes in patients with anterior circulation large vessel occlusion ischemic stroke regardless of intervention. HERMES score should be helpful in prognostic discussion with families on day two.

BACKGROUND:We report the first case series of spontaneous intracranial hypotension (SIH) patients who underwent CT-guided percutaneous cyanoacrylate injection targeting the cerebrospinal fluid (CSF) leak.METHODS:A retrospective analysis was performed for all consecutive cases of SIH patients with CSF leak confirmed on CT myelography, treated by CT-guided percutaneous cyanoacrylate injection at our institution from 2016 to 2022. On pretreatment brain and spine MRIs, we analyzed signs of SIH according to the Bern score, and dichotomized cases into positive/negative for spinal longitudinal extradural CSF collection (SLEC-P or SLEC-N). The leaks detected on CT myelography were classified into three types according to Schievink et al. We collected the Headache Impact Test 6 (HIT-6) scores throughout a 6-month follow-up, with a brain CT scan at each visit.RESULTS:11 patients were included (mean age 48.4 years, six men). Five SLEC-P type 1, three SLEC-P type 2, and three SLEC-N type 3 leaks were identified. All patients had significant signs of SIH on pretreatment brain MRI (mean Bern score 7.8±1.1). Six patients underwent a foraminal puncture, and five patients had a cervical epidural approach. Two patients experienced mild and transient locoregional pain after cervical epidural injection. Mean HIT-6 score at baseline was 66.8±3.2 and at the 6-month follow-up was 38±3.6 (P<0.001). All patients achieved improvement in their symptoms, with 82% of them (9/11) having complete resolution of headaches and SIH findings on CT scans at 6 months. No clinical worsening or recurrence was observed.CONCLUSIONS:CT-guided percutaneous cyanoacrylate injection may be a potential therapeutic option for the different types of CSF leak causing SIH.

BACKGROUND: Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy. METHODS: Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614). RESULTS: In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879–0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886–0.944] and 0.909 [95% CI, 0.887–0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations. CONCLUSIONS: The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2.

Stenting of the dural venous sinuses has emerged as a therapeutic option for intracranial hypertension and pulsatile tinnitus. However, venous endovascular navigation faces challenges due to lower-quality roadmaps compared to arterial navigation. This study explores the application of three-dimensional (3D) rotational venography in assessing the cerebral venous vasculature and its potential for venous navigation. The methods involve venous 3D digital subtracted angiography (DSA) in patients with dural venous stenosis, with image acquisition using a biplane angiographic system. The results highlight the enhanced spatial resolution of 3D venous imaging, providing anatomical information crucial for precise characterization of stenosis and understanding cortical venous drainage. 3D venous roadmapping is shown to improve endovascular venous navigation, offering synchronized and rotatable 3D roadmaps, providing a comprehensive approach to optimize endovascular venous interventions.

BACKGROUND: Ischemic stroke lesion volume at follow-up is an important surrogate outcome for acute stroke trials. We aimed to assess which differences in 48-hour lesion volume translate into meaningful clinical differences. METHODS: We used pooled data from 7 trials investigating the efficacy of endovascular treatment for anterior circulation large vessel occlusion in acute ischemic stroke. We assessed 48-hour lesion volume follow-up computed tomography or magnetic resonance imaging. The primary outcome was a good functional outcome, defined as modified Rankin Scale (mRS) scores of 0 to 2. We performed multivariable logistic regression to predict the probability of achieving mRS scores of 0 to 2 and determined the differences in 48-hour lesion volume that correspond to a change of 1%, 5%, and 10% in the adjusted probability of achieving mRS scores of 0 to 2. RESULTS: In total, 1665/1766 (94.2%) patients (median age, 68 [interquartile range, 57-76] years, 781 [46.9%] female) had information on follow-up ischemic lesion volume. Computed tomography was used for follow-up imaging in 83% of patients. The median 48-hour lesion volume was 41 (interquartile range, 14-120) mL. We observed a linear relationship between 48-hour lesion volume and mRS scores of 0 to 2 for adjusted probabilities between 65% and 20%/volumes <80 mL, although the curve sloped off for lower mRS scores of 0-2 probabilities/higher volumes. The median differences in 48-hour lesion volume associated with a 1%, 5%, and 10% increase in the probability of mRS scores of 0 to 2 for volumes <80 mL were 2 (interquartile range, 2-3), 10 (9-11), and 20 (18-23) mL, respectively. We found comparable associations when assessing computed tomography and magnetic resonance imaging separately. CONCLUSIONS: A difference of 2, 10, and 20 mL in 48-hour lesion volume, respectively, is associated with a 1%, 5%, and 10% absolute increase in the probability of achieving good functional outcome. These results can inform the design of future stroke trials that use 48-hour lesion volume as the primary outcome.

Les anévrismes sacciformes du segments A1 proximal (ASA1P) sont rares, mais leur traitement est réputé difficile et peu décrit dans la littérature. Nous reportons les résultats cliniques et angiographiques immédiats et à long terme du traitement endovasculaire de ces anévrismes. Analyse rétrospective de tous les cas consécutifs d'ASA1P traités par voie endovasculaire dans notre centre entre 2003 et 2023. Les complications per-procédures ainsi que les résultats radio-cliniques ont été enregistrés prospectivement. Parmi 2468 patients suivis pour des anévrismes, 12 (0.49%) présentaient un ASA1P (âge moyen 53.8 ±9.6 ans, 9 femmes). La taille moyenne des ASA1P étaient de 3.3 ±0.4 mm, avec une orientation postérieure (100%). Dix des douze anévrismes étaient rompus (83.3%). En première intention, neuf anévrismes ont été traités par coiling simple ou coiling assisté par ballon (CS-ou-CAB), et trois par occlusion proximale focale du segment A1 porteur (OPFA1), avec un taux d'occlusion totale respectivement de 56% et 100%. Quatre perforations anévrismales ont été notés (33%), toutes survenues lors de CS-ou-CAB sur des anévrismes rompus. La durée moyenne de suivi était de 10.2 années (4-18 années). Six cas de recanalisation (50%) ont été notés, tous après CS-ou-CAB de première intention: trois étaient précoces (avant J15), dont un compliqué d'un resaignement grave ayant entrainé le décès. Aucune recanalisation après OPFA1 n'a été observée (cinq au total, dont deux en complément après CS-ou-CAB). Une bonne évolution clinique (mRS 0-2) était observée dans 91% des cas (11/12) lors du dernier suivi (figs 1,2) (tables 1,2) [1-5]. Le coiling sélectif du sac anévrismal est techniquement difficile en raison de leur petite taille et du trajet complexe du microcathétérisme. Cette méthode présente un risque non négligeable de perforation anévrismale, particulièrement dans les cas rompus, ainsi qu'un taux élevé de recanalisation. L'OPFA1, lorsque la collatéralité le permet, semble être une alternative thérapeutique fiable offrant de bons résultats cliniques à long terme.

BackgroundFunctional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with poor reperfusion were compared with patients with AIS-LVO treated with best medical management only. MethodsData are from the HERMES collaboration, a patient-level meta-analysis of seven randomized EVT trials. Baseline characteristics and functional outcomes (modified Rankin Scale (mRS) score at 90 days) were compared between patients with poor reperfusion (defined as modified Thrombolysis in Cerebral Infarction Score 0-1 on the final intracranial angiography run as assessed by the central imaging core laboratory) and patients in the control arm with multivariable logistic ordinal logistic regression adjusted for pre-specified baseline variables. Results972 of 1764 patients from the HERMES collaboration were included in the analysis: 893 in the control arm and 79 in the EVT arm with final mTICI 0-1. Patients with poor reperfusion who underwent EVT had higher baseline National Institutes of Health Stroke Scale than controls (median 19 (IQR 15.5-21) vs 17 (13-21), P=0.011). They also had worse mRS at 90 days compared with those in the control arm in adjusted analysis (median 4 (IQR 3-6) vs median 4 (IQR 2-5), adjusted common OR 0.59 (95% CI 0.38 to 0.91)). Symptomatic intracranial hemorrhage was not different between the two groups (3.9% vs 3.5%, P=0.75, adjusted OR 0.94 (95% CI 0.23 to 3.88)). ConclusionPoor reperfusion after EVT was associated with worse outcomes than best medical management, although no difference in symptomatic intracranial hemorrhage was seen. These results emphasize the need for additional efforts to further improve technical EVT success rates.

Background Saccular aneurysms of the proximal A1 segment (SAPA 1 ) are rare, but their treatment is challenging and scarcely described in the literature. We report the immediate and long term outcomes of their endovascular management. Methods We retrospectively analyzed all consecutive SAPA 1 cases treated endovascularly at our center between 2003 and 2023. Per procedural complications and radioclinical outcomes were prospectively recorded. Results Among 2468 patients followed up for aneurysms, 12 (0.49%) had an SAPA 1 (average age 53.8±9.6 years, 9 women). The SAPA 1 averaged 3.3 mm, all posteriorly oriented. Ten were ruptured (83.3%). Initial treatments included conventional coiling or balloon assisted coiling (CC/BAC) for nine aneurysms, and proximal A1 segment focal occlusion (PA 1 FO) for three. Initial occlusion was deemed satisfactory in all instances: total occlusion in eight cases (67%) and subtotal occlusion in four cases (33%). Four aneurysmal perforations occurred (33%), all during CC/BAC on ruptured aneurysms. Over a 10.2 year average follow-up, six recanalizations (50%) were noted, all after initial CC/BAC: three were early (≤14 days), with one causing fatal rebleeding. No recanalizations after PA 1 FO was observed (five in total, two as a complement after CC/BAC). Favorable clinical outcomes (modified Rankin Scale score of 0–2) were seen in 91% of cases (11/12) at the last follow-up. Conclusions Selective coiling of the aneurysmal sac is technically difficult due to their small size and the complex microcatheterization pathway. This method presents a significant risk of aneurysmal perforation, especially in ruptured cases, and a high rate of recanalization. PA 1 FO, when collateralization permits, appears to be a reliable therapeutic alternative offering favorable long term outcomes.

In patients with acute ischemic stroke (AIS) treated with endovascular therapy (EVT), the association of pre-existing cerebral small vessel disease (cSVD) with symptomatic intracerebral hemorrhage (sICH) remains controversial. We tested the hypothesis that the presence of cerebral microbleeds (CMBs) and their burden would be associated with sICH after EVT of AIS. We conducted a retrospective study combining cohorts of patients that underwent EVT between January 1st 2015 and January 1st 2020. CMB presence, burden, and other cSVD markers were assessed on a pre-treatment MRI, evaluated independently by two observers. Primary outcome was the occurrence of sICH. 445 patients with pretreatment MRI were included, of which 70 (15.7 http://www.clinicaltrials.gov ; Unique identifier: NCT01062698.

Diffusion-weighted imaging (DWI) b0 may be able to substitute T2*-weighted gradient echo (GRE) or susceptibility-weighted imaging (SWI) in case of comparable detection of intracranial hemorrhage (ICH), thereby reducing MRI examination time. We evaluated the diagnostic accuracy of DWI b0 compared to T2*GRE or SWI for detection of ICH after reperfusion therapy for ischemic stroke. We pooled 300 follow-up MRI scans acquired within 1 week after reperfusion therapy. Six neuroradiologists each rated DWI images (b0 and b1000; b0 as index test) of 100 patients and, after a minimum of 4 weeks, T2*GRE or SWI images (reference standard) paired with DWI images of the same patients. Readers assessed the presence of ICH (yes/no) and type of ICH according to the Heidelberg Bleeding Classification. We determined the sensitivity and specificity of DWI b0 for detection of any ICH, and the sensitivity for detection of hemorrhagic infarction (HI1 HI2) and parenchymal hematoma (PH1 PH2). We analyzed 277 scans of ischemic stroke patients with complete image series and sufficient image quality (median age 65 years [interquartile range, 54–75], 158 [57

Endovascular management of spinal dural arteriovenous fistula (DAVF) is arduous because of complex angioarchitecture and motion artifacts and is limited by the two-dimensional (2D) view. However, cone beam computed tomography (CBCT) acquisitions with selective injections allow 3D multiplanar reconstructions contributing to high diagnostic, anatomical and safety value. In this study, we described the use of virtual injection software (VIS) computed from CBCT acquisition and already used for prostatic and cerebral embolization, for the endovascular management of spinal DAVFs (EmboAssist, GE HealthCare, Chicago, USA). The VIS has been designed to facilitate the analysis of the patient's vasculature during the planning of embolization procedures to define the afferent pedicles to the shunt and the incidence of oblique projection, allowing for a better anatomical understanding and helping for the selection of 2D incidence. Combined with 3D roadmapping, VIS allows vessel tracking for selective catheterism and embolization. The VIS is a useful tool for planification and navigation during endovascular treatment of spinal DAVF with a safety value.

Background Analyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale (mRS) 0) versus predominantly mild pre-existing disability/symptoms (mRS 1-2) has not been well delineated. Methods The HERMES meta-analysis pooled data from seven randomized trials that tested the efficacy of EVT. We tested for a multiplicative interaction effect of pre-stroke mRS on the relationship between treatment and outcomes. Ordinal regression was used to assess the association between EVT and 90-day mRS (primary outcome) in the subgroup of patients with pre-stroke mRS 1-2. Multivariable regression modeling was then used to test the effect of mild pre-stroke disability/symptoms on the primary and secondary outcomes (delta-mRS, mRS 0-2/5-6) compared with patients with pre-stroke mRS 0. Results We included 1764 patients, of whom 199 (11.3%) had pre-stroke mRS 1-2. No interaction effect of pre-stroke mRS on the relationship between treatment and outcome was observed. Patients with pre-stroke mRS 1-2 had worse outcomes than those with pre-stroke mRS 0 (adjusted common OR (acOR) 0.53, 95% CI 0.40 to 0.70). Nonetheless, a significant benefit of EVT was observed within the mRS 1-2 subgroup (cOR 2.08, 95% CI 1.22 to 3.55). Conclusions Patients asymptomatic/without disability prior to onset have better outcomes following EVT than patients with mild disability/symptoms. Patients with pre-stroke mRS 1-2, however, more often achieve good outcomes with EVT compared with conservative management. These findings indicate that mild pre-existing disability/symptoms influence patient prognosis after EVT but do not diminish the EVT treatment effect.