BackgroundRapid prehospital identification of acute ischemic stroke secondary to large vessel occlusions (AIS-LVO) has been successful in triaging patients, but the use of stroke screening scales often varies. This study aims to compare different stroke screening scales for the detection of anterior and posterior circulation AIS-LVO and AIS secondary to medium vessel occlusions (AIS-MeVO).MethodsWe prospectively analyzed stroke alert activations at a comprehensive stroke center between August 1, 2022 and December 31, 2023. We applied eight stroke screening scales (BE-FAST, LAMS, PASS, FAST-ED, EMS RACE, 3-ISS, VAN, and NIHSS) to each stroke alert in the emergency department (ED) and inpatient wards. The final diagnosis was classified as AIS-LVO or AIS-MeVO, AIS without LVO or MeVO, intracranial hemorrhage, transient ischemic attack, or stroke mimic.ResultsA total of 198 patients were analyzed. The mean age was 63.9±15.3 years, 62.1% were female (n=123), and 84.3% were African American/black subjects (n=167). The LAMS scale had a strong performance (area under the curve (AUC) 0.750 (95% CI 0.668 to 0.831)), closely followed by the FAST-ED (AUC 0.736 (95% CI 0.649 to 0.822)) and the VAN (AUC 0.735 (95% CI 0.651 to 0.818)) scales. Cut-off points selected from coordinates of the receiver operating characteristic curves were 3, 3, and a positive VAN, respectively.ConclusionThis is the first prospective cohort study to compare the performance of eight different screening scales among stroke alerts for detection of AIS-LVO and AIS-MeVO. We found LAMS to be the most discriminative tool, followed by FAST-ED and VAN. However, the findings were non-significant, reinforcing existing retrospective literature that these validated screening scales perform similarly and one is not superior.

We present a case of an adult patient with a large symptomatic fusiform basilar artery aneurysm. This video demonstrates the ease of deploying the new Pipeline™ Vantage Flow Diverter compared to the Flex model in the same vessel. The Flex and Vantage have different deployment techniques—as using the Flex maneuvering technique on the Vantage may damage the braid. The Vantage stent does not require resheathing, dragging, or system loading. The video shows the operator's hands making multiple adjustments to deploy the Flex, while they deploy two Vantage stents and a LOBO® device occluder before fully deploying the Flex. The Vantage appears to offer a simpler, more streamlined deployment process of mostly unsheathing compared to the Flex flow diverter. Also, the Vantage design might offer a higher aneurysmal occlusion rate with a shorter course of anti-platelet regimen. 1 Of note, the Pipeline™ Shield may be a more appropriate option in some cases.

BACKGROUND:There is a lack of substantial evidence supporting the safety and effectiveness of endovascular thrombectomy in treating distal medium vessel occlusions (DMVOs). OBJECTIVE:To summarize the current evidence regarding endovascular thrombectomy for DMVOs. METHODS:We conducted a narrative review of key articles related to the diagnosis and management of DMVOs. We manually searched PubMed and Google Scholar from January 2010 to July 2023, and only included articles published in the English language. RESULTS:While diagnosing and treating DMVOs is tricky due to access limitations and potential limited benefit from mechanical clot removal, recent improvements in catheter and retrieval technology suggest that endovascular thrombectomy might be a potential treatment option. However, more high-quality research is needed to confirm its effectiveness for DMVOs. CONCLUSION:Experts disagree on how to classify DMVOs and what the best mode of endovascular treatment is.

Introduction: There are several pathogenic mechanisms that have been theorized for cocaine-related ischemic strokes (CRIS). However, there are limited studies to date that have classified them under a subtype of the Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria. This study aims to describe CRIS by the TOAST criteria, treatment, and clinical outcomes. Methods: A retrospective chart review was performed at our comprehensive stroke center from 2020-2022 to identify patients with acute ischemic stroke (AIS) with a cocaine-positive status on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, TOAST criteria, location of stroke, home medications, comorbidities, medical management, and inpatient outcomes including modified Rankin Score (mRS) were reported. Results: A total of 74 patients were identified to have a positive cocaine status on admission with a diagnosis of new AIS from 2020-2022. The mean age was found to be 60.8 years old with a majority male population at 73.0%. Seventy-eight percent were found to be cocaine positive on admission via urine toxicology with the remaining endorsing a history of cocaine use. The most common category under the TOAST criteria was large artery atherosclerosis (39.2%). Among the cocaine-positive cohort, 10.8% of patients received thrombolytics and 18.9% underwent endovascular thrombectomy. The majority of patients had intracranial atherosclerotic disease (62.2%) on imaging and in the area of the stroke (55.4%). Overall mortality was low (97.3% alive) and modified Rankin score (mRS) at discharge was less than 3 for 59.5% of patients. Conclusion: Our data suggests that CRIS may have a higher association with large artery atherosclerosis. This study highlights the importance of future larger studies to investigate atherosclerosis as a contributor to cocaine-induced ischemic strokes.

Introduction Preoperative embolization is a known and acceptable adjunct to surgical resection of carotid body tumors (CBTs). Current literature depicts devascularization primarily through the transarterial route with superselective catheterization and embolization of feeding vessels by use of liquid or particle embolic agents. Less commonly used practices include percutaneous direct tumor puncture, coil embolization, a combined percutaneous and transarterial approach, and covered stent placement. Few studies have reported on embolization techniques that utilize balloon occlusion for assistance. We present our initial experience in pre‐treatment of CBTs using a combined approach of established embolization techniques and balloon occlusion of the external carotid artery (ECA) via the EMBOGUARD ™ Balloon Guide Catheter. Methods We performed a retrospective review of medical records from March 2023 to February 2024. The study included patients over 18 years old diagnosed with a carotid body tumor who had pre‐operative embolization using the the EMBOGUARD ™ Balloon Guide Catheter. The primary outcome measure was the degree of angiographic devascularization achieved, categorized as either near‐total or total occlusion of the tumor's feeding arteries. Safety outcomes included procedural complications, such as non‐target embolization into previously uninvolved territories and cranial nerve deficits affecting the glossopharyngeal, vagus, hypoglossal, or sympathetic chain. Results Three patients were included in this retrospective study, all of whom were female (100.0%, n=3/3). The median (standard deviation [SD]) age was 29.0 (±17.4) years. Two patients underwent transarterial embolization using a combination of Onyx, n‐butylcyanoacrylate, and coils. One patient had percutaneous direct tumor puncture embolization. In all cases, the external carotid artery (ECA) trunk was completely occluded using a balloon catheter during embolization. Near‐total angiographic devascularization of the tumor was achieved in all three patients (100.0%). There were no immediate complications or neurological deficits related to the embolization procedures. However, one patient experienced vocal cord paresis that persisted for six months following surgical resection of the tumor. Conclusions Using the EMBOGUARD ™ Balloon Guide Catheter to temporarily occlude the ECA during embolization of CBTs offers several advantages: prevents retrograde reflux of embolic particles into the internal carotid artery and intracranial circulation, reducing the risk of stroke; blocks anterograde flow in the ECA minimizing the chances of embolic material migrating into the ECA branches and causing complications like cranial nerve palsies; and stagnates blood flow to allow for more controlled and precise delivery of embolic agents into the tumor vasculature, which can improve the degree of angiographic devascularization achieved.

Background The use of statins following intracranial hemorrhage (ICH) is disputed. Prior studies have found inconsistent effects of statins on the risk of subsequent ICH and other outcome measures. Moreover, many previous studies do not distinguish between post‐ICH statin treatment in patients resuming previous statin therapy versus initiation in statin‐naïve patients. This meta‐analysis consolidates the evidence surrounding the use of therapies following ICH, with a focus on mortality in these two subgroups. Methods A comprehensive search of MEDLINE, EMBASE, and The Cochrane Library was conducted up to 2024 to identify studies on statin initiation or resumption versus no statin use in intracerebral/intraparenchymal hemorrhage patients, yielding 8 studies meeting inclusion/exclusion criteria. The protocol was registered with PROSPERO, and data were analyzed using a Pairwise Meta Analysis on R, applying common and random effects models with heterogeneity assessed via I² statistics. Mortality outcomes were categorized into “short‐term” (≤90 days) and “long‐term” (>90 days to 1 year) mortality. Results Mortality events occurred in 2946 out of 9501 patients (31.0%) in the control group, 123 out of 2248 patients (5.5%) in the statin initiation group, and 787 out of 3944 patients (20.0%) in the statin resumption group. For the ≤90 days timeframe, the random effects model showed a significant reduction in mortality with statin initiation, with a relative risk (RR) of 0.15 (95% CI [0.081; 0.26], p < 0.0001), and with statin resumption, the RR was 0.32 (95% CI [0.18; 0.55], p < 0.0001). Heterogeneity was high, with an I² of 84.3%. For the >90 days up to 1 year timeframe, statin initiation was associated with a reduction in mortality, with an RR of 0.39 (95% CI [0.29; 0.53], p < 0.0001). Statin resumption also showed a reduction in mortality, with an RR of 0.65 (95% CI [0.46; 0.92], p = 0.0145). Heterogeneity was moderate, with an I² of 41.7%. Conclusion Statin therapy following ICH, whether through initiation or resumption, is associated with a significant reduction in mortality both within 90 days and beyond 90 days up to one year. Interestingly, statin initiation showed a stronger effect compared to resumption. These findings support the continuation or initiation of statins in the acute phases of ICH management regardless of previous statin use.

BackgroundMiddle meningeal artery (MMA) embolization for subdural hematomas (SDH) and dural arteriovenous fistulas (dAVFs) has gained momentum in the neuroendovascular space. However, there is variability in the technique for safe and effective embolization. The aim of this report is to describe the technical feasibility and clinical performance of using Zoom™ 45 catheter for MMA access to facilitate embolization.MethodsWe analyzed all cases of MMA embolization in which the Zoom™ 45 catheter was used and performed in our institution from February 2021 to March 2023 for SDH and dAVFs.ResultsA total of 32 patients were included. Mean age was 64.0 ± 18.0 years, 75.0% (4/32) were male, and 56.7% (17/30), were black. The technical success was achieved in 93.8% (30/32) of cases, with selective embolization utilizing microcatheter directly into frontal and parietal branches for most patients (96.9%, 31/32). Identification of dangerous collaterals, such as lacrimal and petrous branches, prior to embolization, was achieved in most patients (96.9%, 31/32). Bilateral MMA embolization was done in 50.0% (16/32) of patients. The transradial approach and transfemoral approach were used in 53.1% (17/32) and 46.9% (15/32) of patients, respectively. The most common embolization material was n-butyl cyanoacrylate (84.4%, 27/32). There were no access site complications or complications related to the MMA embolization procedures and used devices.ConclusionsThe use of Zoom™ 45 Catheter seems to be technically feasible, safe, and effective for facilitating MMA access for embolization in the context of SDH and dAVFs.

BACKGROUND:Acute ischemic stroke (AIS) due to intracranial atherosclerotic disease (ICAD) carries a high risk of recurrence despite aggressive medical management. The aim of our study is to present our initial experience with the Onyx Frontier™ balloon-mounted drug-eluting stent (Medtronic, Santa Rosa, CA) for AIS due to ICAD. METHODS:We conducted a multicenter retrospective cohort study describing the technical feasibility, safety, and performance of using the Onyx Frontier™ balloon-mounted drug-eluting stent in patients with acute intracranial vessel occlusion due to ICAD across three comprehensive stroke centers in the United States. RESULTS:We included 23 patients in our study (mean age 67.3 [10.7]; females: n = 13/23, 56.5%). Most patients were Black (n = 14/23, 60.9%). The most common site of vessel occlusion was the M1 branch of the middle cerebral artery (MCA) (n = 14/23, 60.9%), followed by the vertebrobasilar system (n = 5/23, 21.7%), and the internal carotid artery (n = 3/23, 13.0%). Treatment with the Onyx Frontier™ stent was associated with a final mTICI score ≥2b for 100% of patients, with no vessel perforations or distal embolization. None of the patients had any restenosis or re-treatment over a median follow-up of 3.5 months (interquartile range [IQR] 7.8). All cases required a single stent except for one, where two were deployed. Transfemoral access was used in most cases (n = 18/23, 78.3%), with one in-hospital death due to access site complication (n = 1/23, 4.3%). CONCLUSIONS:This is the largest multicenter cohort study demonstrating the feasibility and safety of using the Onyx Frontier™ balloon-mounted zotarolimus-eluting stent to treat symptomatic AIS due to ICAD.

Introduction The use of ticagrelor in the management of acute stroke is becoming a more common practice, however, the appropriate dosing regimen has not been extensively studied. Further, the effectiveness of ticagrelor relative to clopidogrel has not been extensively studied in observational settings. This study evaluates two different dosing strategies of ticagrelor compared to the standard practice clopidogrel dosing and associated outcomes. Methods We completed a retrospective chart review of patients diagnosed with acute ischemic stroke at a large academic comprehensive stroke center from September 1, 2020, to July 1, 2022. Three separate anti‐platelet groups (i.e. treatment groups) were created, low‐dose ticagrelor (45 mg or 60 mg twice a day), full‐dose ticagrelor (90 mg twice a day), and clopidogrel (75 mg daily). We collected and compared baseline demographic (age, sex, and race) and clinical (mrS and NIHSS at baseline, CT/MRI initial results, relevant medication history, and the Elixhauser index score based on comorbidities) characteristics. We used a Lasso model to select those sufficiently associated to a treatment. Then, we include the selected covariates to estimate a propensity score for each binary treatment (1. any ticagrelor vs. clopidogrel and 2. low‐dose vs. full‐dose ticagrelor) and balance the corresponding analytic samples via inverse propensity score weighting (IPW) to more appropriately assess and compare outcome measures: in‐hospital mortality, 90‐day mortality, functional independence defined as modified Rankin Score (mRS) of 0‐2, at discharge and 90 days, treatment groups. All data was analyzed using R software, version 4.3.2. Results A total of 363 patients were included in our study. The mean age was 66.1 ± 12.7 years and most patients were male (51.7%). The most common ethnicity was African American (83.9%). Fifty‐eight patients were discharged on low‐dose ticagrelor, 37 on full‐dose ticagrelor, and 342 on clopidogrel. Having adjusted for selected baseline demographic and clinical baseline characteristics, mortality at 90 days was found to be lower for patients prescribed with any ticagrelor versus those prescribed with clopidogrel (OR [95%CI]: 0.51 [0.28, 0.93]), while there was no significant difference in functional independence at 90 days between both groups. There was no statistical difference in terms of mortality or functional independence at 90 days between patients with low versus high ticagrelor dosage. Conclusion After appropriate adjustment of baseline factors, our study demonstrates a benefit for the use of any dose of ticagrelor over clopidogrel in long‐term outcomes, but also establishes no significant difference in outcome between a lower dose of ticagrelor.

Background The Pipeline (TM) Vantage embolization device (Medtronic, Irvine, CA) is the fourth generation of Pipeline flow diverter devices, offering numerous technical improvements. This study aimed to assess the feasibility and safety of The Pipeline (TM) Vantage embolization device (Medtronic, Irvine, CA).Methods This was a single-center retrospective study describing the use of The Pipeline (TM) Vantage embolization device for the treatment of intracranial aneurysms. Technical feasibility and safety were assessed in terms of intra and postprocedural complications, as well as neurological morbidity upon follow-up. Both ruptured and unruptured aneurysms were included.Results We included 12 patients in our study (mean age 62; females: n = 9/12, 75%). Aneurysm morphology varied between saccular (41.6%), fusiform (41.6%), blister (8.3%), and pseudoaneurysm (8.3%). Three cases (25%) involved ruptured aneurysms treated in the acute setting. A transradial access was used in 10 cases (83.3%). There was a 100% success in deployment. Seven cases (58.3%) were treated with adjunct embolization device other than a flow diversion. Eight cases (66.6%) were treated with a single flow diversion, three cases (25%) were treated with two flow diversion, and one case (8.3%) was treated with three flow diversion stents. There were no intraoperative complications. There was one postprocedural complication in a dissecting ruptured PICA aneurysm that was ultimately treated with two flow diversion stents and an intrasaccular device.Discussion To our knowledge, this is the first US series assessing the periprocedural safety and feasibility of consecutive patients with intracranial aneurysms treated with the Pipeline (TM) Vantage device (Medtronic, Irvine, CA).

BACKGROUND:The use of covered stent grafts for the treatment of carotid rupture is increasingly being used given their ability to preserve the parent artery while simultaneously occluding the fistula or rupture point. METHODS:This case series describes the technical feasibility of using, and the performance of, the PK Papyrus covered coronary stent (Biotronik, Inc., Lake Oswego, Oregon, USA) in six patients with carotid rupture, including carotid cavernous fistulas, between July 2021 and October 2023 in a single-center institution in the USA. RESULTS:The median decade of life was 5 (IQR 3) with a 1:1 male-to-female ratio. The majority were black patients (n=5/6, 83.3%). The most common disease pathology was carotid cavernous fistula (n=4/6, 66.7%), followed by traumatic carotid rupture (n=2/6, 33.3%). All the stent embolization procedures were successfully treated with the PK Papyrus covered coronary stent. None of the patients had any recurrence or re-treatment. The number of stents required ranged from 1 to 3. A balloon guide catheter was used in 66.7% of cases (n=4/6). In-hospital mortality was 0.0% (n=0/6). No in-stent thrombosis was observed, but there was one case of cangrelor-associated hemorrhagic stroke conversion. Transfemoral access was used in all cases with one access site complication. Median follow-up time was 1.8 months (IQR 3.5). CONCLUSIONS:To our knowledge, this is the largest case series in the USA demonstrating the feasibility and safety of using the PK Papyrus covered coronary stent for the treatment of carotid rupture, including carotid cavernous fistulas.

Introduction Patients with subarachnoid hemorrhages (SAH) with external ventricular drains (EVD) can develop chronic hydrocephalus (HCP), requiring permanent cerebrospinal fluid (CSF) diversion via an external shunt. Two different strategies have been used to assess for dependence on EVD: 1) prompt closure, and 2) gradual weaning. Gradual weaning of EVDs is performed by increasing drainage resistance to outflow over days. However, when to start one strategy or the other is up to the physician. No uniform guidelines exist raising a question: Are standardized criteria necessary to initiate the EVD weaning process for SAH patients to increase the safety of EVD discontinuation and reduce the need for a shunt? This study shares criteria used to initiate EVD weaning that displayed increased safety of EVD discontinuation for patients with subarachnoid hemorrhage requiring EVD, particularly with regards to length of hospital stay (LOS), hospital-acquired infection rates, and ventriculoperitoneal shunt/endoscopic third ventriculostomy (VPS/ETV) placement. Methods One hundred and fifty-one SAH patients from January 2016 to January 2019 were analyzed. 60 aneurysmal SAH (aSAH) and 18 non-aneurysmal nontraumatic SAH (naSAH) patients required EVD placement. A gradual EVD weaning protocol was initiated if patients met the following criteria: 1. The reason for EVD placement has resolved or is resolving, 2. The quantity of CSF output is <250mL over 24 hours, 3. Quality of CSF is nonbloody, 4. Intracranial Pressure (ICP) must be within normal limits, and 5. The patient must be neurologically stable. It was acceptable to initiate the weaning process when the patient had mild cerebral vasospasm, but not moderate to severe cerebral vasospasm. EVD weaning was performed by increasing the drain (chamber) height by 5 millimeters of mercury every 24 hours if the criteria were met. Charts were reviewed for LOS, infection rates, and rate of VPS/ETV. Gender, age, race, wean failure incidence, Hunt-Hess scores, modified Fisher scores, and syndrome of inappropriate antidiuretic hormone/cerebral salt wasting (SIADH/CSW) rates were obtained. Results The average LOS for aSAH patients with EVD was 20.35 days. The incidence of VPS/ETV was 11%. A chisquare analysis revealed that aSAH patients had higher rates of VPS/ETV placement (p<0.001) and EVD wean failures (p<0.001) than naSAH patients. aSAH patients had a lower incidence of VPS/ETV placement of 11% compared to 21% nationally. Conclusions Standardized criteria to initiate EVD weaning provided a reduction in VPS/ETV placement among aSAH patients compared to national averages and provided a uniform approach to EVD management. Comparable infection rates and LOS for SAH patients requiring EVDs compared to national averages were found.

Background: The risk of recurrent atherosclerotic vascular events in patients with stroke due to intracranial atherosclerotic disease (ICAD) is high. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) can dramatically lower low-density lipoprotein (LDL) levels when added to statins, but are not currently indicated for patients with ICAD. Methods: In this secondary analysis of the SAMMPRIS trial, we estimated the association between LDL reduction (enrollment to day 30, by quartiles) and recurrent cerebral infarction or myocardial infarction (MI) beyond 30 days (primary outcome). Estimates were assessed using adjusted Cox proportional hazards regression accounting for age, sex, race, Hispanic ethnicity, baseline LDL, vascular comorbidities, and statin use prior to enrollment. We applied relative LDL reduction estimates from PCSK9i trials to project adjusted incidence rate differences of the primary outcome observed in SAMMPRIS with an equivalent LDL reduction. Semiparametric Cox models estimated the annualized relative risk of primary events if PCSK9i were used in the SAMMPRIS population. Results: Of the 451 patients from SAMMPRIS, 378 met inclusion criteria. By day 30, LDL levels fell significantly (absolute change -19mg/dL, IQR -41 to -2). In unadjusted Cox regression compared to the lowest quartile, patients in the highest quartile of LDL improvement trended toward a lower rate of the primary outcome (Q4 vs. Q1 hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.35-1.26), achieving significance after multivariable adjustment (adjusted HR 0.38, 95% CI, 0.16-0.89). Every 10 mg/dL improvement in 30-day LDL was associated with a 9% lower rate of the primary outcome (adjusted HR 0.91, 95% CI, 0.83-0.997). Assuming an average projected effect of PCSK9i, with half of SAMMPRIS patients having been treated, PCSK9i use could reduce the annualized risk of the primary outcome by 33.2%. Conclusions: More aggressive LDL lowering in patients with stroke due to ICAD is associated with lower rates of recurrent stroke or MI, and this can be achieved with PCSK9i use. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement There was no funding for this secondary analysis. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The SAMMPRIS trial protocol was approved by the institutional review boards of participating sites, US Food and Drug Administration, and Data and Safety Monitoring Board appointed by the NIH. Informed consent was obtained from each participant prior to enrollment. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data from the SAMMPRIS trial will be made available by the NINDS upon reasonable request.

Introduction Chronic subdural hematomas (SDH) are common in older adults due to increased risks of falls, cerebral atrophy, and antithrombotic therapy, leading to higher bleeding risks. Current randomized clinical trials are evaluating the safety and efficacy of middle meningeal artery (MMA) embolization for chronic SDH. These trials, such as EMBOLISE, MAGIC‐MT, and STEM, have reported preliminary promising results using different embolic agents. This study examines the safety and efficacy of MMA embolization using liquid embolic materials and coils at a single institution, comparing outcomes with the aforementioned trials. Methods We conducted a retrospective review of 66 patients who underwent MMA embolization for subacute and chronic SDH at a single institution from February 2021 to March 2024. Data were collected from electronic medical records, including demographics, clinical data, imaging, procedural details, use of antiplatelet or anticoagulation medications, and outcomes at discharge and follow‐up. Patients aged 18 or older with subacute or chronic SDH who underwent MMA embolization were included. Follow‐up assessments were conducted at multiple intervals post‐procedure. Descriptive statistics were used for data analysis. Results The median age of the cohort was 71 years, with a predominance of males (64.71%) and African Americans (54.90%). Eighteen patients had prior SDH interventions, and 62.75% were on antithrombotic therapy before diagnosis. The median time from symptom onset to diagnosis was one day, with most SDHs being traumatic (60.78%). Elective MMA embolizations were performed in 64.71% of cases, primarily using a femoral approach. N‐butyl cyanoacrylate (n‐BCA) was used in 97.37% of procedures, and coils in 27.63%. Complications were rare, with two cases (3.92%) of MMA rupture and access site hematoma. The technical success rate was 97.37%. The median hospital stay was seven days, with most patients discharged home (70.59%). The in‐hospital mortality rate was 1.96%, with seven post‐discharge deaths unrelated to MMA embolization or SDH. The median follow‐up duration was 130 days, with two patients (3.92%) requiring repeat MMA embolization and three (5.88%) needing SDH evacuation. Compared to EMBOLISE, MAGIC‐MT, and STEM trials, our study showed a recurrence rate of 9.8% for all patients, with 6.45% in the MMA embolization alone group and 15% in the surgery with adjunctive MMA embolization group. EMBOLISE reported a 4.10% recurrence rate with surgical evacuation with adjunctive MMA embolization, MAGIC‐MT showed 1.90% recurrence with MMA embolization alone and 4.70% with surgery and adjunctive MMA embolization, and STEM found 19.10% recurrence with MMA embolization alone and 12.30% with surgery with MMA embolization. Discussion Our study suggests that selective distal embolization using n‐BCA is effective, with a low complication rate. Distal embolization may prevent cranial nerve injuries and strokes associated with proximal embolizations. The ongoing trials will provide further insights into optimal embolization sites and agents, and the timing for restarting anticoagulation. Conclusion MMA embolization using liquid embolic materials and coils is a promising treatment for subacute and chronic SDH, with low recurrence and complication rates. Comparison with current trials indicates favorable outcomes. Further research is needed to refine embolization techniques and optimize patient management strategies, potentially revolutionizing chronic SDH treatment.

Introduction Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke that can be difficult to treat. Endovascular thrombectomy techniques have evolved over time, but evidence behind the efficacy and safety of these techniques for CVST is still lacking. The Penumbra Indigo® Aspiration System (Penumbra, Inc., Alameda, California, USA) is designed to remove emboli from the peripheral arteries and veins and can potentially restore blood flow in cases of limb ischemia and venous thrombosis. We report our initial experience in the treatment of CVST using the Penumbra Indigo® Aspiration System. Methods A 35‐year‐old African American male with no major past medical history presented to the hospital with altered mental status. Computed tomography (CT) showed multiple areas of venous infarction. CT vessel imaging revealed extensive dural venous sinus thrombosis involving the superior sagittal sinus (SSS), torcula, left transverse sinus, right paramedian transverse sinus with partial filling defects in the left sigmoid sinus and distal right transverse sinus with a matched defect in the left paramedian anterior frontal lobe corresponding to the area of evolving infarct. Continuous low‐dose heparin infusion was started. Cerebral angiogram revealed evidence of extremely slow perfusion to the brain with no significant drainage through the dural sinuses with complete occlusion of the distal portion of the SSS and bilateral transverse sinuses. Furthermore, angiogram of the right internal jugular (IJ) vein displayed complete occlusion of the bilateral transverse sinuses. Results An Aristotle® 24, 200‐cm Guidewire (Scientia Vascular, Salt Lake City, Utah, USA) was inserted into a 160‐cm‐long Zoom 35™ catheter (Medtronic, Minneapolis, Minnesota, USA), and this system was then advanced within the CAT12 aspiration catheter within a right IJ 12 French Sheath under fluoroscopic guidance across the occlusion to the superior sagittal sinus, Multiple aspiration attempts were then performed. The CAT 12 Aspiration was performed in the SSS and bilateral transverse sinuses. Afterwards, CAT8 and then CAT7 were then advanced into the thrombus more proximally in the SSS and multiple aspiration attempts were performed in the SSS with the aid of the separator device. There was evidence of partial recanalization of the SSS with significant improved flow of bilateral sigmoid sinuses and bilateral transverse sinuses. A decision was made to stop the intervention. There were no complications related to these procedures. Conclusions The Penumbra Indigo® Aspiration System has been used in various arterial and venous systems but this is the first report to demonstrate its technical feasibility in thrombectomy for CVST. Further feasibility studies are necessary to inform its applicability in CVST.

Introduction There is clinical equipoise behind bridging intravenous thrombolysis (BT) with endovascular thrombectomy (EVT). We performed a cost‐effectiveness analysis comparing EVT and BT versus EVT alone. Methods We conducted a model‐based cost‐utility analysis comparing the cost‐effectiveness of EVT alone vs. EVT and BT for patients with acute ischemic stroke. We used a decision tree to examine the short‐term costs and outcomes at 90 days after the index stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1‐year, 5‐year, and 20‐year time horizons. Treatment costs were based on administrative data. Clinical outcome inputs were derived from literature included in our systematic review. We considered the impact of disability and recurrent stroke on mortality risk, health‐related quality of life, and costs. We estimated total and incremental cost, quality‐adjusted life years (QALYs), and incremental cost‐effectiveness ratio (ICER), expressed as an incremental cost per QALY gained of EVT and BT compared with EVT alone.Probabilistic analysis was used to calculate the reference case estimates. Results The average costs per patient were estimated to be $55,503, $57,814, $68,183, and $84,946 for EVT only strategy, and $47,311, $49,556, $59,625, and $75,898 for EVT and BT over 90‐day, 1‐year, 5‐year, and 20‐year, respectively. The cost saving of EVT only strategy was driven by the avoided medication costs of IVT (ranging from $8,193 to $9,048). The additional thrombolytics led to slight decrease in QALY estimate during the 90‐day time horizon (loss of 0.0016 QALY), but a small gain over 1‐year, 5‐year, and 20‐year time horizons (0.0108, 0.0638, and 0.1481 QALY). With similar outcomes and less cost, the EVT only strategy was cost‐effective compared with EVT and BT. Analyses with longer time horizon show lower probabilities of EVT only strategy being cost‐effective. At a fixed willingness to pay threshold of $50,000, the probabilities of EVT only to be cost‐effective were 100%, 100%, 99.0%, and 65.9% over 90‐day, 1‐year, 5‐year, and 20‐year time horizons. At the willingness to pay thresholds of $100,000 per QALY, the probabilities of EVT only strategy being cost‐effective was 22.8% over the 20‐year time horizon. Conclusions Our cost‐effectiveness model suggested that bridging with thrombolytics may not be cost‐effective for patients with acute ischemic stroke secondary to large vessel occlusion.