BACKGROUND:The use of balloon guide catheter (BGC) has been associated with better reperfusion and clinical outcomes in mechanical thrombectomy (MT) for large vessel occlusion stroke. However, the impact of BGC on angiographic and clinical outcomes in patients with distal medium vessel occlusion (DMVO) strokes undergoing MT has not been extensively investigated. METHODS:This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients with anterior circulation DMVO due to middle cerebral artery (MCA) M3/M4 or anterior cerebral artery (ACA) A1/A2-3 were included. The cohort was divided into BGC and non-BGC groups. Multivariable logistic regression and inverse probability of treatment weighting (IPTW) were used for comparison. The primary outcome was first pass effect (FPE) defined as modified treatment in cerebral infarction (mTICI) grade 2C/3 after single device pass. RESULTS:Among 199 patients who were eligible for analysis, 81 (40.7%) were female. The median age was 69 (60-81) years, and National Institutes of Health Stroke Scale score was 13 (7-18). The BGC group (n=73) had higher rates of FPE (53.4% vs 13.7%; IPTW aOR 5.63, 95%CI (2.43 to 13.10), P<0.001) compared with the non-BGC group (n=126). The BGC group had higher rates of modified Rankin Scale (mRS) 0-1 (42.9% vs 27.1%; IPTW aOR 2.78, 95% CI (1.10 to 7.07), P=0.031), mRS 0-2 (60.3% vs 41.5%; IPTW aOR 4.31, 95% CI (1.66 to 11.19), P=0.003), and lower rates of mortality at 90-days (12.7% vs 25.4%; IPTW aOR 0.32, 95% CI (0.11 to 0.98), P=0.047) compared with the non-BGC group. The rates of successful reperfusion at the end of the procedure and symptomatic intracerebral hemorrhage were comparable between both groups. CONCLUSION:The present study suggests that the use of BGC in DMVO undergoing MT may be associated with improved angiographic and clinical outcomes with no safety concerns. Prospective studies are warranted.

Background The efficacy and safety of endovascular treatment (EVT) in patients with basilar artery occlusion (BAO) stroke and low (score <10) National Institutes of Health Stroke Scale (NIHSS) score are unclear. Purpose To assess whether EVT improves outcomes in patients with low-scoring NIHSS BAO stroke. Materials and Methods A retrospective cohort study of the Nationwide Re-admissions Database (NRD; January 2016 to December 2022) was conducted. Adults with acute BAO stroke and NIHSS score 1-9 were identified and grouped by EVT (thrombectomy, angioplasty, and/or stenting) versus medical management (MM). Primary outcomes were routine discharge to home with self-care and in-hospital mortality. Propensity score matching was performed to balance EVT and MM cohorts, accounting for demographics, comorbidities, symptoms, stroke etiology, and other factors. Subgroup analyses were performed to identify sources of treatment-effect heterogeneity. χ2 tests and logistic regression analyses were used to compare outcomes. Results Among 9461 patients (median age, 68 years; IQR, 58-77 years; 5842 males), 1807 were administered EVT. After propensity score matching, 2888 and 1632 patients with MM and EVT, respectively, remained. Rates of routine discharge were similar (MM vs EVT, 34.0% vs 34.0%; P = .24), but the EVT arm had higher in-hospital mortality (16.0% vs 7.1%; P < .001). In subgroup analyses, EVT was associated with higher odds of routine discharge among patients with NIHSS score of 6-9 (odds ratio [OR], 1.42; 95% CI: 1.07, 1.90; P = .02), whereas it was not associated with higher odds of mortality among those with embolic stroke etiology (OR, 1.42; 95% CI: 0.71, 2.86; P = .32) or those who were 75 years or older (OR, 1.63; 95% CI: 0.79, 3.39; P = .19). Conclusion EVT was not associated with better outcomes but was associated with increased mortality among patients with low-score NIHSS BAO stroke; however, NIHSS score, stroke etiology, and patient age may be sources of clinically significant treatment effect heterogeneity. © RSNA, 2026 Supplemental material is available for this article.

BACKGROUND:Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. METHODS:We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. RESULTS:Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). CONCLUSIONS:After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.

BACKGROUND:Cervical artery dissection (CeAD) may result in dissecting aneurysm (DA) formation. We aimed to characterize risk factors and clinical outcomes associated with DA in a large, international CeAD cohort. METHODS:We performed a secondary analysis of STOP-CAD (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), an international, multicenter, retrospective cohort. Patients with spontaneous CeAD were assessed for DA at baseline and de novo DA formation. Significant covariates in univariable analysis were included in multivariable regression models aiming to identify factors associated with DA formation. Logistic regression and Cox proportional hazards models evaluated the association of DA with ischemic and hemorrhagic outcomes. RESULTS:Among 4008 patients with CeAD, 546 (13.6%) had a DA at baseline, and 221/2938 (7.5%) patients developed a de novo DA during follow-up, of which 172/221 (78.2%) were detected in the first 180 days. Patients with DA had a mean age of 47 years, and 383 (49.9%) were women. Baseline or de novo DA was associated with a history of connective tissue disorder (adjusted odds ratio [aOR], 2.02 [95% CI, 1.22-3.36]), fibromuscular dysplasia (aOR, 1.69 [95% CI, 1.28-2.25]), and multiple vessel dissection (aOR, 1.53 [95% CI, 1.19-1.98]). Lower odds of DA were seen in Hispanic ethnicity (aOR, 0.64 [95% CI, 0.43-0.97]) and ischemic stroke presentation (aOR, 0.41 [95% CI, 0.34-0.49]). Fibromuscular dysplasia was associated with de novo DA formation (aOR, 2.30 [95% CI, 1.52-3.49]). DA was not associated with ischemic stroke (hazard ratio, 0.71 [95% CI, 0.44-1.16]; P=0.173) or intracranial hemorrhage (HR, 1.09 [95% CI, 0.42-2.84]; P=0.86) by day 180. CONCLUSIONS:DAs are relatively common manifestations of CeAD, typically occurring within 6 months of CeAD diagnosis. DA was not associated with an increased risk of subsequent ischemic stroke or intracranial hemorrhage.

OBJECTIVE:Cervical artery dissection (CeAD) may be limited to the extracranial extradural space or extend to the intradural space. Intradural extension can potentially increase the risk of stroke and subarachnoid hemorrhage. However, the factors associated with intradural extension and its impact on clinical outcome remain unclear. METHODS:This was a secondary analysis of the STOP-CAD observational, multi-center study. Patients with CeAD and intradural extension (CeADid) were compared with those with pure CeAD extradural dissections (CeADed) using multiple regression analyses. RESULTS:Of 4,023 patients with CeAD, 534 (13.3%) had CeADid. In comparison to patients with CeADed, those with CeADid more often had clinical overt stroke or transient ischemic attack (TIA) at presentation, acute infarcts on imaging, a vertebral artery affected, and severe stenosis of the involved vessel (p < 0.001 for all). In contrast, carotid involvement and complete occlusions were more frequent in patients with CeADed (p < 0.001 for both). CeADid was associated with a shift in the distribution of scores on the modified Rankin Scale (mRS) toward worse functional outcome (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.62-0.92) but the odds for favorable outcomes (mRS = 0-2) did not differ between the groups after appropriate adjustments on multivariate analysis. CeADid was independently associated with higher mortality at 180 days on multivariate analysis (adjusted OR = 2.84, 95% CI = 1.50-5.38). INTERPRETATION:CeADid is associated with more severe clinical presentation, a shift toward less favorable outcomes, and higher mortality rates. These findings suggest that CeADid may represent a high-risk type of CeAD. ANN NEUROL 2026;99:1189-1197.

BACKGROUND:Although the embolic stroke of undetermined source (ESUS) construct was proposed as a unifying concept for embolic-appearing strokes without an identified cause, it includes patients with diverse and often unrecognized underlying mechanisms. This study investigates the differential rate of recurrent stroke according to the completeness of neurodiagnostic testing in a diverse multicenter cohort. METHODS:This was a retrospective analysis of a multicenter observational cohort study (n=27 sites). ESUS was categorized into 3 groups: (1) established mechanism after further workup (ESUS-E), (2) comprehensive diagnostic workup without an identified cause (ESUS 2.0), and (3) no advanced workup. The primary outcome of recurrent ischemic stroke was compared between ESUS with established mechanism and ESUS 2.0 versus ESUS with no advanced workup and was assessed using adjusted Cox proportional hazards models. RESULTS:Among 2281 patients, the mean age was 65 years, and 50.1% were men. 694 (30.4%) classified as ESUS-E, 1,243 (54.5%) classified as ESUS-NAW, and 344 (15.1%) as ESUS 2.0. The ESUS 2.0 group had a significantly lower risk of recurrent stroke than both the group with ESUS with no advanced workup (adjusted hazard ratio [aHR], 0.31 [95% CI, 0.13-0.76]) and the group with ESUS with established mechanism (aHR, 0.35 [95% CI, 0.15-0.85]). Within the group with ESUS with established mechanism, cancer (aHR, 5.33 [95% CI, 2.09-13.63]) and nonstenosing atherosclerotic disease or arch atheroma (aHR, 3.40 [95% CI, 1.18-9.83]) were associated with significantly increased risk of recurrence when compared with the group with ESUS 2.0. CONCLUSIONS:These findings demonstrate a lower risk of recurrent stroke in patients classified as ESUS 2.0 than reported in prior ESUS trials and highlight the importance of age-appropriate advanced diagnostic evaluation. REGISTRATION:URL: https://www.clinicaltrials.gov. Identifier: NCT06398366.

OBJECTIVE:The optimal treatment for distal medium vessel occlusion (DMVO) stroke remains uncertain, and evidence comparing endovascular therapy (EVT) with medical management (MM) is limited. We aimed to develop and validate a predictive modeling tool to assess individual treatment benefit in DMVO stroke using explainable counterfactual treatment estimation. METHODS:Adults with isolated DMVO stroke (M3-M4, A2-A3, or P1-P2) were retrospectively identified from 7 stroke centers. To estimate individualized probabilities of favorable outcome (modified Rankin Scale [mRS] = 0-2 at 90 days), we developed a Penalized Logistic Regression (Elastic Net) model. This framework was selected a priori over other explored machine learning algorithms (Decision Tree, Support Vector Classifier, and XGBoost) for its superior interpretability and ability to handle multicollinearity among interaction terms. Inverse Probability of Treatment Weighting (IPTW) was implemented to address confounding by indication in the observational data. Internal validation used repeated K-fold cross-validation and bootstrapping; external validation was performed on an independent cohort (n = 86). RESULTS:Of 321 eligible patients, 179 received EVT (55.8%) and 142 received MM (44.2%). Adjusted models showed no significant overall group differences in favorable outcome (adjusted OR [aOR] = 1.32, 95% confidence interval [CI] = 0.97-1.80), mortality (aOR = 1.20, 95% CI = 0.78-1.85), or symptomatic hemorrhage (aOR = 0.57, 95% CI = 0.21-1.58). However, the model identified significant treatment effect heterogeneity; EVT benefit was amplified in patients with higher National Institutes of Health Stroke Scale (NIHSS) and attenuated with increasing treatment delay. Internal validation demonstrated strong performance (area under the receiver operating characteristic curve [AUC] = 0.77, 95% CI = 0.71-0.82). External validation confirmed generalizability (AUC = 0.74, 95% CI = 0.63-0.84). Individualized treatment estimates showed high concordance with a benchmark causal T-Learner model (Pearson r = 0.97 internal and r = 0.98 external). INTERPRETATION:Although aggregate outcomes did not differ significantly, the validated Distal and Medium Vessel Occlusion Stroke (DUSK) Tool enables individualized estimation of EVT benefit in DMVO stroke. This explainable counterfactual treatment estimation framework supports precision decision making by identifying specific patient subgroups most likely to benefit from EVT over MM. ANN NEUROL 2026;99:1198-1209.

Introduction:Prevention of early recurrence of ischemic stroke after an initial event is a clinically important problem that has been the subject of a number of large clinical trials testing acute treatment interventions. Datasets of clinical trials provide a rich source of information beyond the primary research questions addressed. Merging of datasets, providing greater statistical power and wider applicability for novel exploratory analyses, requires careful harmonization of similar data elements. Methods:The Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES), Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke Trial (POINT), and Acute STroke or Transient IscHaemic Attack Treated with TicAgreLor and ASA for PrEvention of Stroke and Death (THALES) trials each examined the effects of early administration of enhanced antiplatelet therapy versus aspirin alone within 12-24 hours following minor ischemic stroke or transient ischemic attack. Results:The datasets of these 3 trials have been harmonized and merged into a single large data table comprising 26319 subjects with 75 clinical and demographic variables, 196 concomitant medication descriptors, and event flags and event timing variables for 20 clinical outcome events. A high degree of data completeness was attained for most variables. Conclusion:This merged data table provides a powerful resource of pooled clinical trial data to enable future large-scaled analyses for the study of stroke recurrence risks, and is now curated and available for other investigators.

Background Perioperative ischemic stroke is uncommon overall but frequent in cardiac, major vascular, and neurosurgical procedures. Existing calculators often exclude these settings and rarely incorporate cerebrovascular disease markers available in routine electronic health record data. Methods We assembled a retrospective cohort of adults undergoing procedures at 3 hospitals (January 2016-June 2024). The model was derived at Rhode Island Hospital (255 850 procedures) and externally validated at 2 affiliated hospitals (The Miriam Hospital/Newport Hospital; 189 095 procedures). Candidate predictors included age, vascular comorbidities, documented carotid stenosis and intracranial atherosclerosis, procedure setting (ambulatory versus inpatient/emergency), and procedural service (including vascular versus nonvascular neurosurgery and open versus interventional cardiovascular procedures). We fit a multivariable logistic regression model with internal validation using 1000 bootstrap resamples and assessed calibration by observed versus predicted risk across deciles. External validation applied locked derivation coefficients without refitting. Results Strokes occurred in 1235/255 850 derivation procedures (0.48%) and 418/189 095 validation procedures (0.22%). Independent predictors included older age, prior stroke or transient ischemic attack (adjusted odds ratio [aOR], 6.66), inpatient/emergency setting (aOR, 4.25 versus ambulatory), vascular neurosurgery (aOR, 6.70 versus general surgery), and open cardiovascular procedures (aOR, 4.14). Discrimination was high (derivation area under the curve, 0.87 [95% CI, 0.87-0.88]; optimism-corrected area under the curve, 0.87; validation area under the curve, 0.86 [95% CI, 0.84-0.87]) with good calibration. Prespecified risk strata (<1%, 1-5%, >5%) separated observed event rates in both cohorts. Conclusion A pragmatic, electronic health record-derived model integrating procedural category and cerebrovascular disease accurately predicts 30-day periprocedural ischemic stroke across diverse procedures and is available as a web-based calculator to support counseling and targeted prevention.

Background:Balloon guide catheters (BGCs) have demonstrated benefits in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), including improved recanalization rates and reduced distal embolization. The EMBOGUARD™ balloon guide catheter (Johnson & Johnson Neurovascular, Irvine, CA) represents a novel design with enhanced flexibility and compatibility with large-bore aspiration catheters. This study aims to evaluate the safety and efficacy of the EMBOGUARD™ BGC compared with non-BGC approaches. Methods:We conducted a retrospective multicenter study to analyze patients with AIS due to anterior large vessel occlusions (LVOs) who underwent MT between January 2022 and December 2024. Patients were divided into two groups: those treated with t☺he EMBOGUARD™ BGC and those treated without BGC. Primary outcomes included first-pass effect (FPE), successful recanalization (mTICI ≥2b), procedural time, number of passes, and distal embolization. Secondary outcomes included 90-day functional outcome (modified Rankin Scale [mRS] 0-2), mortality, and symptomatic intracranial hemorrhage (sICH). Results:A total of 178 patients were included (EMBOGUARD: n = 135, 75.8%; non-BGC: n = 43, 24.2%). The EMBOGUARD™ group demonstrated comparable rates of FPE (33.3% vs. 37.2%, p = 0.68) and successful recanalization (86.7% vs. 86.0%, p = 0.92). Procedural time was significantly shorter in the EMBOGUARD™ group (median 32 min vs. 49 min, p = 0.004). Distal embolization rates were similar between groups (4.4% vs. 4.7%, p = 1.00). The EMBOGUARD™ group showed significantly higher rates of favorable functional outcome at 90 days (48.6% vs. 28.1%, p = 0.04) and non-significantly lower 90-day mortality (13.7% vs. 16.7%, p = 0.6). Although favorably trending, multivariate logistic regression analysis did not confirm that EMBOGUARD™ was associated with greater odds of FPE (adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 0.65-6.41, p = 0.2), mRS 0-2 at 90 days (aOR 1.36, 95% CI 0.35-5.34, p = 0.7) or lower odds of mortality at 90 days (aOR 0.32, 95% CI 0.05-1.85, p = 0.2). Conclusion:The EMBOGUARD™ balloon guide catheter demonstrated comparable technical efficacy with reduced procedural times and improved clinical outcomes compared with non-BGC techniques in endovascular thrombectomy for acute ischemic stroke. These findings support the use of EMBOGUARD™ as a reasonable tool for flow arrest in stroke intervention.

Sex-related differences in outcomes after mechanical thrombectomy (MT) for distal medium vessel occlusion (DMVO) stroke remain uncertain. While unadjusted differences have been reported in stroke populations, it is unclear whether biological sex independently influences outcomes after accounting for major prognostic factors. We performed a retrospective, multicenter analysis of the MAD-MT registry. Patients with acute DMVO who underwent MT were included. Propensity score matching (PSM) was employed. The primary outcome was functional independence (modified Rankin Scale [mRS] score 0–2) at 90 days. Secondary outcomes included excellent outcome (mRS 0–1), day 1 NIHSS shift, and reperfusion success. Safety outcomes included mortality and symptomatic intracerebral hemorrhage. Before matching, 1147 females and 1062 males were included. After 1:1 PSM (748 patients in each group), the groups were balanced in baseline characteristics. The median age was 75 years in both groups. At 90 days, 51

Optimal treatment for acute ischemic stroke due to distal medium-vessel occlusion (DMVO) in the middle cerebral artery (MCA) remains uncertain. While mechanical thrombectomy (MT) may pose higher risks in DMVO, intra-arterial thrombolysis (IAT)—with or without intravenous thrombolysis (IVT)—could be a safer alternative. To compare functional outcomes and safety profiles of IAT versus MT in acute ischemic stroke caused by MCA DMVO (M2–M4 segments). We performed a retrospective, propensity score-matched study across 37 centers (Asia, Europe, North America) using the MAD-MT registry. Patients with MCA DMVO (M2–M4) treated with IAT or MT (with/without IVT) were included. Propensity score matching adjusted for confounders. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0–1 at 90 days). After matching, 184 patients were analyzed (19 IAT, 165 MT). Baseline characteristics were balanced. At 90 days, excellent functional outcomes occurred in 38

BACKGROUND:The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear. METHODS:This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW). RESULTS:Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80-2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, -1 [95% CI, -2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36-13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35-0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86-28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14-32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90-11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT (Pinteraction=0.025). CONCLUSIONS:IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

BACKGROUND:Recent randomized trials showed no benefit of mechanical thrombectomy (MT) for ischemic stroke due to distal medium vessel occlusion (DMVO). We sought to understand the use of MT for DMVO stroke treatment before and after the publication of these trials. METHODS:We conducted an email survey of 47 comprehensive stroke centers across the United States, which are participating in a National Institutes of Health-funded randomized controlled trial (RCT; Unique identifier: NCT05948566). The questionnaire was developed and modified with expert feedback. Site principal investigators were asked to discuss the DMVO RCT results with their local clinical teams and to subsequently respond to survey questions in a manner that reflected team-based decision-making regarding MT for DMVO before and after the publication of the RCTs, considering the location of the vessel occlusion (nondominant M2 versus M3/M4/A1/A2). If the site principal investigator was responsible for >1 site with the same stroke team, only 1 survey response was tallied. RESULTS:Of the 43 site principal investigators surveyed representing 47 unique sites, 40 (93%) representing 44 unique sites completed the survey. Before the DMVO RCTs, 95% of respondents were treating nondominant M2 occlusions with MT. Only 15% will continue to be treated with MT, while 57.5% said that treatment was dependent on at least ≥1 variable following presentation of the DMVO RCTs. For all other anterior circulation DMVOs, 50% were treating DMVOs with MT before RCT results' presentation. Only 7.5% will continue to treat with MT, while 32.5% said that treatment was dependent on at least 1 other variable following presentation of the DMVO RCTs. The most common variable named by survey respondents as important to treatment decision was symptom severity. CONCLUSIONS:In this survey of comprehensive stroke centers, the DMVO RCT results created a significant practice change in how stroke teams approach anterior circulation DMVO stroke with MT.

Endovascular thrombectomy is standard for acute large-vessel occlusion stroke, but the value of endovascular thrombectomy in patients with large ischemic regions remains uncertain from a US healthcare payer perspective. This study evaluated the cost effectiveness of endovascular thrombectomy plus medical management (MM) versus MM alone in patients with large ischemic regions, synthesizing data from a recent meta-analysis of all available randomized trials. We developed a decision tree linked to a Markov model to perform a cost-utility analysis of endovascular thrombectomy plus MM versus MM alone from a US healthcare payer perspective over 90-day, 1-year, 5-year, and 20-year horizons. The target population was adults with acute ischemic stroke from large-vessel occlusion and Alberta Stroke Program Early CT Score (ASPECTS) < 6 or infarct core volume ≥ 50 mL. Clinical inputs came from a systematic review of randomized trials. The primary outcome was the incremental cost-effectiveness ratio, expressed as cost per quality-adjusted life-year (QALY) gained. Scenario analyses (90-day, 1-year, 5-year, and 20-year horizons) and sensitivity analyses evaluated uncertainty. Over 20 years, endovascular thrombectomy plus MM yielded 0.44 additional QALYs and US dollars 19,611 higher costs versus MM alone, with an incremental cost-effectiveness ratio of US dollars 45,117 per QALY. Endovascular thrombectomy plus MM was cost effective in 59.4

BACKGROUND:Patients with cervical artery dissection (CeAD) may experience a recurrent dissection, but its frequency, risk factors, and clinical implications are not well defined. We aimed to determine the risk, associated factors, and clinical impact of recurrent CeAD. METHODS:The STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection) was a multicenter international retrospective observational study of patients with CeAD treated between January 2015 and June 2022. Recurrent dissection was defined as a CeAD occurring at least 7 days after the diagnosis of the index event that affects a different artery or a different segment of the same artery. Patients were followed from day 7 up to 2 years. The absolute risk of recurrent CeAD over time was calculated using Kaplan-Meier survival estimates. Multivariable logistic and Cox regression models were used to assess predictors of CeAD recurrence. RESULTS:Of the 4023 patients included in STOP-CAD, 3836 (median age 46 years, 45% women) were eligible for this analysis. During a median (interquartile range) follow-up of 295 (97-720) days, 88 (2.29%) patients had a CeAD recurrence. Median time-to-recurrent CeAD was 53 (interquartile range, 18-157) days. The estimated risk of recurrent CeAD at 2 years was 3.22% (95% CI, 2.59%-4.00%). In multivariable analyses, younger age (adjusted odds ratios, 0.98 [95% CI, 0.96-0.99]), migraine (adjusted odds ratio, 1.88 [95% CI, 1.14-3.07]), and fibromuscular dysplasia (adjusted odds ratio, 2.90 [95% CI, 1.66-5.06]) were associated with CeAD recurrence, while presenting with an ischemic stroke was associated with a lower likelihood of recurrence (adjusted odds ratio, 0.47 [95% CI, 0.29-0.75]). These associations with CeAD recurrence over time were confirmed by Cox regression analyses. Among the 88 patients with recurrent CeAD, only 5 had accompanying ischemic events (3 strokes, 2 transient ischemic attacks). CONCLUSIONS:In this retrospective study, recurrent CeAD was uncommon, approximately half of the events were diagnosed within the first 2 months of the index event, and recurrent events rarely caused new ischemic events. Younger age, migraine, absence of ischemic stroke at presentation, and signs of fibromuscular dysplasia may help identify high-risk patients.

Importance:Given the high costs of treatment with proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) and the limited US Food and Drug Administration label for these treatments in patients with stroke due to atherosclerotic disease, it is unknown whether these agents are cost-effective for reducing recurrent stroke events. Objective:To estimate the theoretical cost-effectiveness of currently available PCSK9i for the prevention of recurrent stroke in patients with high-risk intracranial arterial stenosis. Design, Setting, and Participants:This economic evaluation was a post hoc trial-based cost-effectiveness analysis of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial from a health care sector perspective. Adult patients with stroke due to intracranial arterial stenosis were included in SAMMPRIS and randomized to aggressive medical management with or without intracranial arterial stenting. Patients from the SAMMPRIS trial with complete covariate data were included in this secondary analysis. Data were analyzed from January to December 2025. Exposure:A base-case assumption of 32% relative risk reduction for stroke among PCSK9i based on its low-density lipoprotein-lowering effect. Main Outcomes and Measures:Based on trial-estimated transition probabilities, annual direct-to-consumer prices for 3 PCSK9i (alirocumab: $6600; evolocumab: $7200; and inclisiran: $7920) and estimated US-based stroke care costs in 2025 US dollars, a decision-analytic Markov cohort model was developed to estimate the cost-effectiveness of PCSK9i for reducing recurrent stroke over a 5-year time horizon, with a 7% annual drug discontinuation rate and a 3% discount rate for future costs and quality-adjusted life-year (QALYs). From 1000 Monte Carlo simulations, the probability of cost-effectiveness of 3 PCSK9i was estimated at a $120 000/QALY threshold. Sensitivity analyses evaluated at an alternative threshold ($50 000/QALY), treatment efficacy (20% to 50%), and stroke care costs (50% to 150% of base estimates). A patient perspective analysis reflecting patients' out-of-pocket costs with insurance coverage was also conducted. Results:Of the 367 patients from the SAMMPRIS included in this study, 88 were Black (24.0%), 260 were White (70.8%), and 19 Asian, Native Hawaiian or Pacific Islander, more than 1 race, or other (5.2%), and the median (IQR) age at enrollment was 59 (52-69) years. At current direct-to-consumer prices, the probability of cost-effectiveness at a willingness-to-pay threshold of $120 000/QALY over a 5-year horizon was 58.6% (95% CI, 55.5%-61.6%) for alirocumab, 53.8% (95% CI, 50.7%-56.9%) for evolocumab, and 36.7% (95% CI, 33.8%-39.7%) for inclisiran. Conclusions and Relevance:This theoretical framework suggests that alirocumab and evolocumab were cost-effective for preventing recurrent stroke in patients with severe intracranial atherosclerosis, with all agents cost-effective under current cost-sharing programs offered by commercial and Medicare plans.

Left ventricular (LV) systolic dysfunction, defined here as reduced LV ejection fraction ≤40% or left wall motion abnormality, is commonly found in patients with ischemic stroke. Although there is an increased risk of incident and recurrent embolic stroke among patients with LV dysfunction without thrombus detected, the data supporting anticoagulation in these patients are limited. In this scientific statement, we summarize the latest evidence regarding the risk of incident and recurrent stroke in patients with LV dysfunction as well as best practice recommendations regarding the management of this population after stroke. We provide a narrative summary and meta-analysis of secondary analyses of randomized clinical trials that evaluated outcomes following anticoagulation versus nonanticoagulation strategies. Whereas anticoagulation is associated with a lower risk of incident stroke in patients with LV dysfunction without thrombus, there remains no net benefit of this strategy over a nonanticoagulant strategy for primary stroke prevention. For patients with stroke and LV dysfunction, anticoagulation may be associated with a lower risk of recurrent stroke and a net benefit when compared with antiplatelet therapy. Anticoagulation treatment decisions in these patients may involve individualized consideration, shared decision-making between patients and healthcare professionals upon discussing risks and benefits, and multidisciplinary collaboration between cardiology and neurology clinicians to optimize cardiac and brain health. As a key modifiable stroke risk factor and therapeutic target, LV dysfunction represents a target for future research.

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.

Introduction: Delays in endovascular therapy for acute large vessel occlusion (LVO) stroke can contribute significantly to disability following successful recanalization. The implementation of an automated intelligence LVO detection and interdisciplinary communication platform can shorten times to treatment. Methods: We conducted a multicenter retrospective observational cohort study of consecutive adults with acute occlusion of the internal carotid, proximal middle cerebral, or basilar artery. Hub-and-spoke networks implementing Viz.ai queried electronic medical records 6 months prior to and 6 months following implementation of Viz.ai. Patients were included if they had a National Institutes of Stroke Scale (NIHSS) score ≥6, pre-stroke modified Rankin Scale 0-1, and presented within 24 hours of last known well (or unknown). The primary outcome was time from initial hospital contact to arterial puncture, which was compared between study periods using descriptive statistics, regression with robust standard errors clustered by site, and adjusted inverse probability of treatment weighting (IPTW) in which probability weights were used to reduce imbalance between study periods in a causal inference model. The model was adjusted for age, NIHSS, sex, comorbidities, overnight arrival, hub versus spoke arrival, academic quarter, and pre-stroke modified Rankin Scale which was imputed when missing using chained equations as an ordinal covariate. Results: Of the 474 included patients across 7 sites (n=215 post-Viz, 45.4%), the median age was 67 years (interquartile range [IQR] 57-77) and median NIHSS was 17 (IQR 11-22). Using descriptive statistics, there was a trend toward a shorter time from hospital contact to puncture during the post-Viz period (median 103min, IQR 68-146, vs. 106min, IQR 76-169, p=0.10). In unadjusted regression with robust errors, clustered by site, the trend persisted (β -26.3, 95% confidence interval [CI], -53.7 to 1.3, p=0.058). In the adjusted IPTW model, arrival during the post-Viz period was associated with a shorter adjusted average treatment effect (time difference) of 31 minutes (95% CI, 14 to 48 minutes, p<0.001) when compared to arrival during the pre-Viz period. Conclusions: Implementation of the Viz.ai platform led to a significant decrease in time to arterial puncture for patients with acute LVO. The degree to which these changes contributed to better clinical outcomes is being explored in subsequent analyses.