BACKGROUND:Chronic subdural hematoma (cSDH) is common, with an incidence of up to 5/100,000, increasing with age. Surgery carries a recurrence risk of around 20%. Three randomized controlled trials demonstrated the benefit of middle meningeal artery embolization (MMAE) using ethylene vinyl alcohol (EVOH)-based embolics like Onyx (Medtronic) or Squid (Balt Group). Other agents, including particles and N-butyl cyanoacrylate (NBCA), are under investigation. N-hexyl cyanoacrylate (Magic Glue, Balt Group) is a newer NBCA-based embolic with slower precipitation, enabling potentially safer and more effective embolization. Unlike EVOH-based agents, Magic Glue does not require dimethyl sulfoxide (DMSO) flushing, which can cause discomfort and trigeminocardiac reflex and thus often necessitates general anesthesia. We present the first case series of MMAE with Magic Glue. METHODS:This retrospective study included patients from three neurointerventional centers treated with MMAE for cSDH using Magic Glue. Patient characteristics (age, sex, antiplatelet or anticoagulant use, symptoms) were assessed. The primary endpoint was the need for repeat surgery or MMAE for recurrence or progression. Secondary endpoints included technical complications, hematoma size reduction, and modified Rankin Scale (mRS) score at last follow-up. RESULTS:58 patients (48 male; mean age 73.9±10.3 years) were included. 31.0% received antiplatelets and 34.5% anticoagulants; 96.6% had symptoms. Repeat treatment was necessary in 15.5%. Technical complications occurred in 5.2%, none requiring intervention. Four procedure-related or presumably procedure-related complications occurred, including one ischemic stroke; all resolved by final follow-up. Initial cSDH size averaged 19.0±6.8 mm, with a mean reduction of 12.5±5.7 mm. CONCLUSIONS:This multicenter study suggests MMAE with Magic Glue may be a safe and effective alternative to established liquid embolics.

Abstract Background and aims Vasospasm occurs in up to 20% of patients with acute stroke undergoing ET, but its clinical impact remains controversial. Intraarterial nimodipine is administered occasionally to treat vasospasm, though its efficacy is uncertain. We aimed to identify factors associated with vasospasm, delineate the impact on clinical outcomes, and assess the effects of intraarterial nimodipine. Methods We used data from the German Stroke Registry-Endovascular Treatment, analyzing stroke patients who underwent ET at 25 centers between 06/2015 and 12/2023. Patients with and without vasospasm were analyzed, and among those with vasospasm, we compared outcomes based on intraarterial nimodipine use. Primary outcome was the mRS at 90 days. Secondary outcomes included 90-day mortality, early neurological deterioration (END) and sICH. Results 17,985 patients (mean age 73.6 years; 51.2% female) were included in the analysis. Of these, 578 (3.2%) had vasospasm, and 300 (58.4%) of those received intraarterial nimodipine. Vasospasm was associated with a shift toward worse mRS outcomes (aOR, 1.25 [95%CI, 1.02-1.53]) and higher mortality (36% versus 29.7%; aOR, 1.35 [95%CI, 1.05-1.75]). Intraarterial nimodipine was associated with less END (aOR, 0.54 [95%CI, 0.31-0.91]). Variables associated with vasospasm included younger age, active smoking, M2 occlusion, and multiple recanalization attempts. Conclusions Vasospasm during ET is associated with worse outcomes and increased mortality, and should be regarded as a serious procedural complication. Younger patients who are active smokers, with distal occlusions, requiring multiple recanalization attempts are at higher risk. Intraarterial nimodipine appears to be a sensible treatment as it may mitigate END without signals of potential harm. Conflict of interest JW, AR, CR, SW, TBB and HZ report no conflict of interest. MTB reports compensation from Stryker, Balt USA, LLC, and MicroVention, Inc. for consultant services. CHN received funding for travel or speaker honoraria from Alexion, AstraZeneca, Bayer, BMS and Pfizer outside of this work and reports compensation from Novartis for consultant services. LK received funding for travel or speaker honoraria from Alexion, AstraZeneca, Bayer Vital, Boehringer Ingelheim, Bristol-Meyer-Squibb, Daiichi Sankyo, Lilly and Pfizer outside of this study.

Mechanical recanalization of distal and small medium vessel occlusions (DVOs and MeVOs) is technically challenging and likely associated with higher complication rates. Previous studies have shown promising results using Q aspiration catheters in MeVOs. We report our experience with Q catheters in an even more distal cohort of DVOs and small MeVOs, focusing on safety and efficacy. We retrospectively reviewed our institutional stroke database for patients with DVOs or MeVOs treated using Q catheters. Baseline characteristics, technical outcomes including modified Thrombolysis in Cerebral Infarction (mTICI) score and modified first pass effect (mFPE), as well as clinical outcomes measured by the 90-day modified Rankin Scale (mRS) were analyzed. Outcomes were stratified by occlusion type and treatment technique. Periprocedural complications and their clinical impact were systematically assessed. 57 occlusions in 47 patients were included. Mean age was 75.5 ± 12.7 years. Median National Institutes of Health Stroke Scale score was 7.7 ± 4.6 at admission and 4.9 ± 5.5 at discharge, while the rate of 90-day- mRS ≤ 2 was 37

BACKGROUND:Among stroke syndromes, acute basilar artery occlusion (BAO) is associated with the worst outcomes and highest mortality. Existing studies suggest that endovascular thrombectomy (EVT) significantly improves functional outcomes at 90 days. While EVT is generally safe across ages and severities, additional data are needed to identify patients at risk of unfavourable long-term outcomes. METHODS:This prospective, registry-based, single-centre, cohort study spanning 18 years evaluated functional independence in BAO patients at 3 months (primary outcome) and 1 year (secondary outcome) post-intervention (n=149; median age 70 years). Patients from the recent 8-year period were individually analysed at discharge and 3 months (n=126; median age 77 years). Safety outcomes included reperfusion status, major complications, and mortality, with one-year outcomes assessed through standardised telephone interviews. RESULTS:Successful reperfusion was achieved in up to 91.9%. Favourable outcomes occurred in 34.2% of patients at three and 36.9% at 12 months. Overall mortality was 34.2% at 3 months and increased to 45.6% at 12 months, regardless of reperfusion success. Mortality was significantly higher in those aged ≥80, at 41.9% (3 m) and 62.8% (12 m), with only 14% achieving favourable outcomes at 12 months. An initial National Institutes of Health Stroke Scale (NIHSS) score ≥20 further predicted poorer outcomes, with no patient ≥80 with a score ≥20 (n=25) having favourable outcomes at one year, and 68% died. CONCLUSION:While EVT increases the chances of independent living one-year post-event in patients with favourable predictive factors, elderly individuals with significant initial deficits are at a high risk of severe disabilities and mortality. Prognoses based solely on the first three months may lead to overestimations of benefit in this demographic.

Flow diverter (FD) braid stability is crucial for optimal wall apposition, thereby reducing the risk of device-related complications following intracranial aneurysm treatment. We compared wall apposition characteristics across different FD designs to evaluate inter-device differences. Retrospective single-center analysis of 104 patients with 127 aneurysms treated with 121 FD (35 Derivo Embolization Devices (DED; Acandis, Pforzheim, Germany), 50 p64 (Phenox Wallaby, Bochum, Germany), 24 p48 (Phenox), 11 Silk (Balt, Montmorency, France), and 1 Pipeline (Medtronic, Dublin, Ireland)) between February 2013 and June 2023. The analysis focused on fish-mouthing-like deformities (≥ 10

Stroke remains a major global health burden (1,2), although outcomes have improved substantially through imaging-guided therapy and endovascular reperfusion (3,4). While CT and MRI are standard for estimating infarct core and penumbra (5), variability in threshold-based deconvolution of perfusion imaging (6) can lead to inconsistent lesion size estimates (7). Accurate modeling of infarct growth is therefore essential for optimizing transfer and treatment decisions (8). Advances in artificial intelligence (AI) have improved automated lesion detection, yet clinical translation requires large, well-annotated datasets. While recent large-scale cohorts including the Ischemic Stroke Lesion Segmentation Challenge (ISLES)'22 (n = 400) (9), Liew et al (n = 1271) (10), Liu et al (n = 2888) (11), and Absher et al (n = 1715) datasets (12) have expanded available imaging data, datasets pairing acute CT with follow-up MRI (13) remain limited. We address this gap by providing a publicly available dataset that combines hyperacute CT (< 24 h post onset) with acute postinterventional MRI (2-9 days after successful reperfusion; modified Treatment in Cerebral Ischemia 2c or 3) and structured clinical follow-up through 3 months. This combination enables analysis of infarct evolution and supports AI model development for postinterventional stroke care. © RSNA, 2026.

A multicenter longitudinal stroke dataset with hyperacute CT, acute MRI 2-9 days after reperfusion, and 3-month clinical outcomes is presented to support machine learning models for lesion identification and outcome prediction.

BACKGROUND:Accurate device sizing is crucial for successful flow diverter (FD) therapy in intracranial aneurysms. This study assesses the accuracy and clinical utility of the Ankyras virtual simulation software (Mentice AB, Gothenburg, Sweden) in predicting FD length across multiple device types and manufacturers. METHODS:We retrospectively analyzed 193 FDs (7 device types) deployed in 180 patients with 230 intracranial aneurysms. Simulation-based prediction of effective lengths (simulated length (SL)) and nominal manufacturer specifications (labeled length) were compared with measured in vivo lengths (measured length (ML)). Performance was evaluated using simulation accuracy (SA), absolute error (AE), relative error (RE), length ratio, and correlation analysis. RESULTS:Virtual simulation demonstrated good clinical usability, achieving a mean absolute deviation of only -1.38 mm at the proximal landing zone compared with ML. Simulation-based predictions showed significantly superior accuracy compared with nominal manufacturer specifications (SA 89.6±11.3% vs 81.8±13.7%, P<0.001), with mean AE reduced by 58% (-1.38 mm vs -3.34 mm) and mean RE by 42% (10.5% vs 18.2%). Strong correlations between SL and ML (r=0.900) validated predictive reliability across all tested device types. Centerline correction technology further enhanced parameters such as SA to 94.8±9.5%. CONCLUSION:Virtual simulation-based prediction of effective FD length using the Ankyras software showed reliable and clinically meaningful results, enabling accurate estimations of the proximal landing zone and overall length. Ankyras, along with comparable simulation platforms, may provide considerable potential to facilitate FD selection and implementation, especially in anatomically complex cases.

Introduction:Device-assisted endovascular treatment of ruptured aneurysms may require antiplatelet therapy, but bleeding risk is a concern. This retrospective propensity score-matched cohort study investigated whether tirofiban, including prolonged administration for ≥7 days, was associated with secondary bleeding complications. Methods:We analyzed 99 patients treated endovascularly aSAB between 2006 and 2024, including 51 patients receiving tirofiban and 48 controls selected using propensity score matching. Tirofiban patients were categorized into short-term treatment (<7 days) and prolonged treatment (≥7 days). Bleeding complications were classified using an adapted Heidelberg bleeding classification and categorized as spontaneous or surgery-associated. Results:For the main bleeding endpoints, evaluable data were available for 42 controls, 29 patients with short-term tirofiban, and 18 patients with prolonged tirofiban. Any spontaneous secondary bleeding occurred in 6/42 controls (14%), 2/29 short-term tirofiban patients (7%; p = 0.46), and 1/18 prolonged tirofiban patients (6%; p = 0.66). Surgery-associated bleeding occurred in 13/42 controls (31%), 11/29 short-term tirofiban patients (38%; p = 0.72), and 7/18 prolonged tirofiban patients (39%; p = 0.77). Clinically relevant bleeding occurred in 2/42 controls (5%), 0/29 short-term tirofiban patients (0%; p = 0.51), and 1/18 prolonged tirofiban patients (6%; p = 1.00). Median hospital duration was 21 days in controls, 18 days in short-term, and 31 days in prolonged tirofiban patients. Conclusion:In this small retrospective cohort, tirofiban, including prolonged administration for ≥7 days, was not associated with a statistically significant increase in spontaneous, surgery-associated, or clinically relevant secondary bleeding. These exploratory findings require confirmation in larger prospective studies.

BACKGROUND:Balloon guide catheters (BGCs) are used during mechanical thrombectomy to arrest or reverse blood flow in order to improve revascularization results. OBJECTIVE:STRAIT was an early post-market study of the new generation BOBBY BGC to evaluate performance and safety in the treatment of anterior circulation large vessel occlusion (LVO). METHODS:This prospective, core lab-controlled multicenter study was conducted across nine sites in Germany and Switzerland. Key inclusion criteria were LVO at the distal internal carotid article through proximal M2, symptom onset to treatment initiation within 8 hours, National Institute of Health Stroke Scale (NIHSS) ≥5, and Alberta Stroke Program Early CT Score (ASPECTS) ≥6. RESULTS:After having reached the primary endpoint in the planned interim analysis, enrollment was stopped early. Therefore, STRAIT enrolled 171 subjects from April 2022 to September 2023. Included patients were 49.7% female, median age was 73 years, and median NIHSS was 15. The primary endpoint of successful final reperfusion, as defined by Thrombolysis In Cerebral Infarction (TICI) 2b-3, was achieved in 94.7% of cases (n=161), and modified first pass effect (FPE) was 63.1%, with a median procedure time of 51 min. There were no device malfunction-related serious adverse events or adverse events. At final follow-up, 107/171 subjects (65.2%) had good neurological function (modified Rankin Scale ≤2) and an overall mortality of 8.5%. CONCLUSION:Mechanical thrombectomy using BOBBY BGC demonstrates high rates of FPE and overall success with a good safety profile, further supporting the additional benefit of the new generation BGCs in interventional stroke treatment. TRIAL REGISTRATION NUMBER:NCT05361187.

[This corrects the article DOI: 10.1016/j.heliyon.2023.e14508.].

Aneurysmal subarachnoid hemorrhage (aSAH) caused by mycotic intracranial aneurysms (MIAs) is a rare cerebrovascular condition resulting from bacterial infiltration and arterial wall damage due to systemic or local infections. Due to limited data - often restricted to case reports or small series - no standardized diagnostic or therapeutic strategies exist. Therefore, this study aimed to characterize clinical, radiological, microbiological, and histopathological features of aSAH due to MIAs and to analyze treatment approaches in a larger cohort. We conducted a retrospective analysis of consecutive patients with aSAH from MIAs treated at two neurovascular centers between 2007 and 2024. Inclusion required both suggestive aneurysm morphology (e.g., distal, dysplastic) and evidence of systemic or local infection. Twenty-five patients (64% male, median age 44.7 years) were included. Mean Glasgow Coma Scale on admission was 8 ± 5, with most patients presenting with Hunt and Hess (HH) grades 5 (40%) or 4 (28%). MIAs were most often located at the middle cerebral artery (44%), with a median aneurysm size of 5.9 mm. More than one-third of patients had multiple aneurysms, and 16% developed new MIAs during hospitalization. Infections were associated with prior intracranial surgery (16%) or secondary foci, particularly infective endocarditis (44%). Hospital mortality was 36%, and the mean GOS at discharge was 2, highlighting the severity of the condition.

To determine how automation bias (inclination of humans to overly trust-automated decision-making systems) can affect radiologists when interpreting AI-detected cerebral aneurysm findings in time-of-flight magnetic resonance angiography (TOF-MRA) studies. Nine radiologists with varying levels of experience evaluated twenty TOF-MRA examinations for the presence of cerebral aneurysms. Every case was evaluated with and without assistance by the AI software © mdbrain, with a washout period of at least four weeks in-between. Half of the cases included at least one false-positive AI finding. Aneurysm ratings, follow-up recommendations, and reading times were assessed using the Wilcoxon signed-rank test. False-positive AI results led to significantly higher suspicion of aneurysm findings (p = 0.01). Inexperienced readers further recommended significantly more intense follow-up examinations when presented with false-positive AI findings (p = 0.005). Reading times were significantly shorter with AI assistance in inexperienced (164.1 vs 228.2 s; p < 0.001), moderately experienced (126.2 vs 156.5 s; p < 0.009), and very experienced (117.9 vs 153.5 s; p < 0.001) readers alike. Our results demonstrate the susceptibility of radiology readers to automation bias in detecting cerebral aneurysms in TOF-MRA studies when encountering false-positive AI findings. While AI systems for cerebral aneurysm detection can provide benefits, challenges in human–AI interaction need to be mitigated to ensure safe and effective adoption.

Throughout the pandemic, it has become evident that COVID-19 should be recognized as a systemic disease that can affect the coagulation system, potentially resulting in arterial thrombotic events (ATE) with partially bulky free-floating clots. This study aimed to investigate the incidence and imaging characteristics of ATE in hospitalized patients with COVID-19 using clinical and imaging data. From January 2020 to May 2021, databases of five German tertiary care centers were retrospectively screened for COVID-19 patients with coincidental ATE. ATE were analyzed for localization, time of occurrence, imaging characteristics, and associations with clinical data and laboratory parameters. Out of 3267 patients, 110 ATE (102 patients, mean age, 72.01 ± 15.64 years; 63 men) were observed in the presence of COVID-19 (3.1

Background/Objectives: The p48 MW HPC is a novel low-profile flow diverter covered by a hydrophilic polymer coating with antithrombogenic properties, which may reduce ischemic complications and enable a single antiplatelet therapy after insertion of the stent. In this single-center experience, we describe the efficacy of this device, focusing on the illustration of different therapeutic indications and the outcome in various clinical settings with regard to vessel anatomy, bleeding state, and aneurysm configuration. Methods: We retrospectively reviewed our database for all patients being treated with a p48 MW HPC flow diverter between February 2019 and July 2021. The efficacy of the treatment was evaluated according to the O'Kelly-Marotta (OKM) scale in the last digital subtraction angiography (DSA) follow-up. Information on complications and medications were collected from our medical records. In addition, to illustrate different indications and clinical settings, we present six of these cases in closer detail. Results: 18 aneurysms in 14 patients were treated with the p48 MW HPC flow diverter and in one case with an additional Derivo device. Periprocedural events occurred in 28.6% of the treated patients, which were all successfully resolved within the same session. Follow-up examination information was available for 67% of patients, of which 75% showed complete occlusion of the aneurysm and 83.3% showed a favorable occlusion result (OKM C-D). Two patients with ruptured aneurysms received a single antiplatelet therapy with ASA without thrombotic complications, at least in the short term. New braid deformation patterns were observed in 16.6% at the follow-up examination, but none with subsequent clinical significance. Conclusions: The p48 MW HPC is safe and effective in the treatment of a wide spectrum of differently configurated, ruptured, and unruptured aneurysms. Single antiplatelet therapy might be an option in selected cases.