Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 27 appraisals
Neurosurgical review
Mechanical thrombectomy for pediatric large-vessel occlusion: a systematic review and meta-analysis with post hoc analysis
OBJECTIVE: To investigate the outcome of pediatric large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). INTRODUCTION: Pediatric LVO is a rare subtype of ischemic stroke. In adults, MT is recommended; however, the efficacy and safety of MT in pediatric LVO are less explored. The available studies are mostly observational studies; yet, these studies show inconsistent findings. METHOD: This review adhered to the PRISMA 2020 guideline. Studies comparing MT with medical management in pediatric with LVO were included. The primary endpoint was the favourable outcome. The mortality rate was sought as well. Subgroup analysis compared MT with intravenous thrombolysis (IVT) and conservative management. Post hoc exploratory analyses comprised Bayesian inference and trial sequential analysis (TSA). RESULT: Six studies comprising a total of 230 MT-treated and 206 non-MT patients were included. In the primary analysis, favourable outcome did not differ significantly between the MT and medical management groups (OR 1.83; 95% CI 0.97-3.43), while supported by exploratory Bayesian inference (OR 1.75; 95% CrI 1.05-2.67; BF10 5.05). Subgroup analysis showed favourable outcomes of MT over IVT (OR 2.39; 95% CI 1.19-4.79) and conservative treatment (OR 2.22; 95% CI 1.41-3.51), although the Bayesian model did not support these findings. The available evidence was insufficient to detect or exclude a difference in mortality between MT and medical management (OR 1.32; 95% CI 0.45-3.89). TSA indicated that the required information size was not reached and that additional trials are needed to reach the minimum sample requirements. CONCLUSION: In this synthesis of observational data, the MT may be associated with favourable outcome in pediatric LVO, however, these findings are hypothesis-generating only. Adequately powered prospective studies are needed before MT can be recommended for pediatric LVO. CLINICAL TRIAL NUMBER: not applicable.
13 July 2026
Read appraisal →Translational stroke research
Quantitative Cerebrovascular Analysis for Improved Prediction of Post-Stroke Complications
Endovascular thrombectomy (EVT) has transformed the treatment of acute ischemic stroke (AIS). However, a substantial proportion of AIS patients experience poor outcomes despite successful recanalization, often due to severe neurological deterioration or life-threatening complications. Early identification of these high-risk patients remains a major unmet need. In this study, we developed and validated machine-learning (ML) models that integrate automated quantitative brain arterial morphology and collateral grading with demographic, clinical, laboratory, and imaging variables to predict major post-EVT complications and early neurological outcomes. Using a prospectively collected database of 727 AIS patients that underwent EVT, we developed ML models to incorporate patient-specific vascular morphometry with conventional clinical, laboratory, and imaging data to predict emergence of early neurological deterioration (END), symptomatic intracranial hemorrhage (sICH), malignant brain edema (MBE) requiring surgical decompression, and neurogenic respiratory failure and dysphagia requiring tracheostomy/gastrostomy (TC/PEG). Our analysis of morphological features, including increased tortuosity and reduced vessel diameter, showed strong associations with complications. Morphology-informed (MI) models consistently outperformed baseline-clinical (BC) models for patients with END (AUROC 0.81 for MI model vs. 0.73 for BC), sICH (AUROC 0.68 MI vs. 0.56 BC model), MBE (AUROC 0.67 MI model vs. 0.56 BC), or patients who underwent TC/PEG (AUROC 0.66MI vs. 0.58 BC model). Statistical testing confirmed significant AUROC improvements for END, sICH and mRS (p < 0.05), Finally, patient-specific calibrated probability profiles enabled individualized, multidimensional risk stratification, revealing distinct complication-specific risk patterns across patients. These findings demonstrate that cerebrovascular structure-an often overlooked yet physiologically fundamental determinant of ischemic injury and reperfusion dynamics-provides significant predictive information that is not captured by standard clinical or visual imaging assessments. Automated vascular segmentation and collateral grading techniques enable rapid and objective integration of cerebrovascular metrics into prognostic models, offering a scalable tool for precision risk stratification, supporting earlier intervention, targeted monitoring, and improved post-EVT management.
9 July 2026
Read appraisal →Journal of neuro-oncology
Endovascular treatment of tumor-related dural sinus stenosis, venous outflow obstruction, and secondary intracranial hypertension: a systematic review of the literature.
INTRODUCTION: Tumors involving dural venous sinuses can lead to venous outflow obstruction and secondary intracranial hypertension. While surgical resection can decompress the sinus, such procedures carry significant risks. With the success of endovascular interventions for idiopathic intracranial hypertension (IIH), venous sinus stenting (VSS) and angioplasty have emerged as potential treatments for tumor-related sinus stenosis. However, evidence remains limited and dispersed. This systematic review aimed to synthesize the available literature on the safety and efficacy of endovascular treatment for tumor-related venous sinus obstruction. METHODS: A systematic search of PubMed, Embase, and Web of Science was conducted from database inception to November 2025. Eligible studies included any report describing endovascular treatment (VSS and/or angioplasty) for tumor-related venous sinus obstruction, whether due to tumor invasion or compression, or even stenosis following surgery or radiotherapy. Data on patient demographics, tumor characteristics, procedural details, and outcomes were extracted and summarized descriptively. RESULTS: Twenty studies comprising 57 patients were included. Most patients were female (65%) with a mean age of 48 years. Meningioma represented the most common underlying tumor (75%). The majority of obstructions resulted from tumor compression or invasion (86%), and most patients underwent VSS alone (74%), while the rest underwent VSS and angioplasty (23%). No periprocedural complications were reported. Mean trans-stenotic pressure gradient decreased by 10 ± 9 mmHg post-treatment and mean lumbar opening pressure decreased by 11 ± 12 cmH2O. Clinical improvement was reported in 63% of patients, including resolution or improvement of papilledema in 94% and vision changes in 94%. Repeat intervention was required in 28% of cases, and only about half of patients achieved further improvement after reintervention. CONCLUSION: Endovascular therapy for tumor-related venous sinus stenosis appears safe and effective, leading to meaningful pressure reduction and symptomatic improvement in two-thirds of patients. These findings support VSS as a viable adjunct or alternative to surgery in selected patients. Nonetheless, the certainty of evidence remains very low, and current data cannot establish definitive conclusions.
28 June 2026
Read appraisal →Journal of neurology, neurosurgery, and psychiatry
Impact of an artificial intelligence-driven triage system on workflow and transfer efficiency: stratified analysis of 4548 admissions to four thrombectomy hubs receiving transfers from sixty spokes.
BACKGROUND: We aimed to evaluate the impact of implementing an artificial intelligence (AI)-enabled acute ischaemic stroke triage system on workflow efficiency and transfer optimisation in a large academic healthcare network. METHODS: A prospectively maintained database was reviewed comparing equivalent time periods before and after AI-enabled triage platform implementation (January 2021-December 2022). The primary analysis compared workflow metrics between AI-enabled and non-AI spokes during the same calendar period (2022) to control for temporal confounding. Benjamini-Hochberg correction was applied for multiple comparisons, and analyses were adjusted for age and baseline National Institutes of Health Stroke Scale. Evaluated outcomes included door-in-door-out (DIDO) times, door-to-puncture (DTP) times, endovascular therapy (EVT) utilisation rates, cost analysis and clinical outcomes at discharge. RESULTS: The study included 4548 admissions with 844 EVT patients (394 pre-implementation, 450 post-implementation) across four hub centres. In the primary same-period analysis (2022), AI-enabled spokes demonstrated significantly shorter DIDO times compared with non-AI spokes (median 103 (92-118) vs 134 (103-162) min; adjusted difference -41.6 min (95% CI -60.9 to -24.1); p<0.001, Q<0.001) and shorter DTP times (21 (14-43) vs 40 (18-65) min; adjusted difference -10.9 min (95% CI -17.9 to -3.7); p=0.003, Q=0.009). A difference-in-differences analysis demonstrated that DIDO improvements were specific to AI-enabled spokes (-27 min; 95% CI -62 to -4; p=0.029). EVT utilisation was also significantly higher in AI-enabled versus non-AI spokes where AI-enabled spokes had increased EVT rates by +17.8% (39.3% to 57.1%) compared with +1.1% in non-AI spokes (41.3% to 42.4%, Pinteraction=0.006). DTP improvements were more pronounced at community hubs (86 (48-108) to 51 (22-77) min; adjusted difference -24.9 min; p=0.021, Q=0.041) compared with academic hubs (60 (23-87) to 55 (22-73) min; adjusted difference -15.5 min; p<0.001, Q=0.002). Subgroup analyses demonstrated consistent DIDO benefits across age, stroke severity and sex strata with no significant treatment effect heterogeneity (all P-interaction >0.05). Probabilistic cost analysis estimated savings of $3.6 million (95% CI $1.5M to $6.1M) per 1000 AI-enabled spoke transfers. Clinical outcomes, including functional status and mortality at discharge, were similar between groups (all Q>0.05). CONCLUSION: Implementation of an AI-enabled triage platform was associated with significant reductions in workflow times and increased EVT utilisation, with effects specific to AI-enabled spokes rather than secular trends alone. The proportion of transfers who did not proceed to EVT decreased in AI-enabled spokes, though counterfactual outcomes for non-transferred patients remain unknown. Clinical outcomes at discharge were unchanged.
14 June 2026
Read appraisal →Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation
Association of intensive blood pressure lowering with health-related quality of life after endovascular thrombectomy: a post-hoc analysis of the ENCHANTED2/MT trial
BACKGROUND AND PURPOSE: Intensive blood pressure (BP) targets of less than 120 mm Hg have been shown to worsen functional outcomes after endovascular thrombectomy (EVT) for acute ischemic stroke. However, their effects on self-reported health-related quality of life (HRQoL) remain uncertain. METHODS: This post-hoc exploratory analysis used data from ENCHANTED2/MT, an open-label, blinded-endpoint randomized trial conducted in 44 Chinese hospitals. Adults with elevated BP within 3 h after successful reperfusion were randomized to intensive (< 120 mmHg) or less intensive (140-180 mmHg) systolic BP targets. HRQoL at 90 days was assessed using the EQ-5D-3 L and EQ visual analogue scale (EQ VAS). Functional outcome was measured by the modified Rankin Scale (mRS). Treatment effects were estimated using adjusted regression models, and causal mediation analysis was performed to explore indirect and direct pathways. RESULTS: Of 816 randomized patients, EQ-5D data were available in 685. At 90 days, both EQ-5D index (0.66 vs. 0.72) and EQ VAS (73.01 vs. 76.84) were lower in the more intensive BP group. Adjusted mean differences favored the less intensive treatment group: 0.06 (95% CI, 0.01 ~ 0.11; P = 0.017) for EQ-5D index and 3.49 (95% CI, 0.38 ~ 6.60; P = 0.028) for EQ VAS. Mediation analysis showed that the association of intensive BP lowering with worse HRQoL was mainly indirect via worse mRS outcomes. CONCLUSIONS: Intensive BP lowering after EVT was associated with modestly worse HRQoL at 90 days. The observed differences were small in magnitude, particularly for EQ VAS relative to commonly reported thresholds for clinical importance. These findings are consistent with less intensive BP targets after EVT and highlight the importance of incorporating patient-reported outcomes in acute stroke trials. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov number, NCT04140110 the Registration Date, 22/10/2019.
7 June 2026
Read appraisal →Neurosurgical review
Management of pediatric brain arteriovenous malformation: a systematic review of retrospective studies
INTRODUCTION: Pediatric brain arteriovenous malformations (bAVMs) are a major cause of hemorrhagic stroke in children, yet management decisions rely largely on heterogeneous cohorts. Contemporary retrospective studies were systematically reviewed to summarize outcomes across treatment modalities and to characterize interstudy variability. METHODS: PubMed/MEDLINE was searched over the past decade for retrospective pediatric intracranial bAVM cohorts. Eligible studies reported management with observation/conservative care, endovascular embolization, microsurgical resection, stereotactic radiosurgery (SRS), or multimodality therapy. Screened studies had data extracted using a standardized form. Outcomes included obliteration, hemorrhage (first presentation and post-treatment), functional outcomes, complications, and recurrence after apparent cure. Treatment categories were harmonized into mutually exclusive groups for descriptive synthesis. RESULTS: Of 113 identified records, 20 retrospective cohort studies met the inclusion criteria. Hemorrhage was the most common presentation. Across cohorts reporting Spetzler-Martin (SM) grade, low-grade lesions (SM I-II) comprised 740 patients (44.1%), SM III 645 (38.4%), and SM IV-V 293 (17.5%). Treatment strategies varied substantially; among 1,973 classifiable patients, cohorts reported microsurgery-only, SRS-only, endovascular-only, multimodality, and conservative approaches. Definitions of obliteration and assessment methods were inconsistent (DSA-confirmed vs. MRI-based). Microsurgical series reported obliteration rates of 81%-100% in selected populations (unweighted mean ~ 93% across reporting cohorts), whereas SRS-only cohorts demonstrated obliteration rates of 51%-68.5% in the three largest unselected pediatric series (range 36%-84% across all SRS-inclusive cohorts), with latency-period hemorrhage rates of approximately 1.1%-3.2% per series. Recurrence after apparent cure was reported in 7 cohorts, with rates ranging from < 1% to 29%, occurring years after angiographic obliteration. CONCLUSIONS: Contemporary retrospective pediatric bAVM data indicate that modality-specific outcomes are strongly influenced by lesion selection, outcome definitions, and follow-up duration. Recurrence after apparent cure is not uncommon and supports explicit long-term surveillance. Standardized definitions and harmonized reporting are needed to improve interpretability and comparative inference.
29 May 2026
Read appraisal →Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
The relation between cerebral arteriovenous malformations and heart diseases in the pediatric population: a systematic review and meta-analysis
Cerebral arteriovenous malformations (AVMs) and congenital heart diseases (CHDs) are rare, complex conditions that often present diagnostic and therapeutic challenges-especially when they coexist in pediatric patients. Though individually uncommon, their association raises important questions about shared developmental origins, systemic implications, and long-term outcomes. Understanding this relationship is crucial for improving early recognition, tailoring treatment strategies, and reducing morbidity and mortality in affected children. This systematic review and meta-analysis explored the relationship between AVMs and CHDs in the pediatric population, analyzing 139 studies published between 1971 and 2023. Together, these studies included data from 1042 patients. The co-occurrence of these two conditions highlights a potential interplay between cerebral and cardiac vascular development. By clarifying their association, this study aims to support earlier recognition, improve multidisciplinary management, and ultimately enhance clinical outcomes. The results revealed important patterns in how specific types and locations of AVMs relate to different forms of heart disease. AVMs located in infratentorial regions-such as the brainstem and cerebellum-were generally associated with lower risks of complications, while those in deep cerebral areas showed stronger links to adverse outcomes. Among the heart conditions evaluated, atrial septal defects (ASDs), cardiomyopathies, and high-output cardiac failure were most frequently associated with AVMs, suggesting overlapping embryologic and hemodynamic mechanisms. The most commonly reported complications included hydrocephalus, hemorrhage, and mortality. ROC curve analysis showed that mortality had the highest predictive value (AUC 0.62), followed by hydrocephalus (0.53) and hemorrhage (0.48). A composite risk model (AUC 0.59) suggested that combining clinical variables could improve prognostication. Neurological sequelae such as seizures, developmental delay, and microcephaly were frequent, particularly in hemorrhagic cases. Interestingly, in some patients, AVM treatment led to improvement in cardiac symptoms, suggesting a bidirectional relationship between cerebral and cardiac function. Despite variability in study quality, results were consistent across analyses, even when lower-quality studies were excluded. Most studies were rated moderate to high quality, though classification challenges were noted. Overall, the findings support a meaningful association between specific AVM and CHD subtypes and highlight the importance of early diagnosis and collaborative care involving multidisciplinary approach.
25 May 2026
Read appraisal →Lancet (London, England)
Endovascular thrombectomy for patients with large-core ischaemic stroke presenting up to 24 h after onset (ATLAS): a systematic review and individual patient data meta-analysis with central imaging adjudication
BACKGROUND: Patients with extensive ischaemic change are often excluded from endovascular thrombectomy. We aimed to synthesise the evidence from recent trials in these patients by performing a systematic review and individual patient data meta-analysis to estimate treatment benefit, including within clinical and imaging subgroups. METHODS: In this systematic review and meta-analysis, we searched PubMed and Embase for randomised trials published between March 1, 2018, and March 1, 2025, that evaluated efficacy and safety of endovascular thrombectomy compared with medical management in patients with large-core ischaemic stroke (based on an Alberta Stroke Program Early CT Score [ASPECTS] of ≤5 or estimated ischaemic core ≥50 mL) presenting within 24 h of onset. Individual patient-level data from all eligible trials were obtained. A central imaging core laboratory readjudicated ASPECTS and reanalysed ischaemic core volume. A two-stage meta-analysis with random-effects model was used to evaluate the distribution of 90-day modified Rankin Scale (mRS) scores (the primary outcome) using adjusted pooled generalised odds ratios (aGenORs). Missing data were handled by multiple imputation. Safety outcomes were all-cause mortality within 90-day follow-up and neurological worsening within 24-48 h of randomisation, reported as adjusted pooled relative risk (aRR); and symptomatic intracerebral haemorrhage within 36 h of randomisation (reported as risk difference). Subgroup analyses based on clinical and imaging characteristics were done, including subgroups defined by ischaemic core volume, ASPECTS, and time window from onset to randomisation. The meta-analysis was registered with PROSPERO (CRD420251058584). FINDINGS: We included 1886 patients (944 assigned to endovascular thrombectomy and 942 assigned to medical management) from six trials. Baseline characteristics were similar between treatment groups. At day 90, the distribution of mRS scores was improved in patients in the endovascular thrombectomy group (median score 4 [IQR 3-6]; n=940) versus those in the medical management group (5 [4-6]; n=931; aGenOR 1·63 [95% CI 1·42-1·88], p<0·0001). The endovascular thrombectomy group also had reduced mortality (292 [31·1%]) compared with the medical management group (347 [37·3%]; aRR 0·82 [95% CI 0·70-0·97], p=0·022). No significant differences were observed in symptomatic intracranial haemorrhage (ten [1·1%] of 944 vs nine [1·0%] of 942 patients; pooled unadjusted risk difference -0·17 percentage points [95% CI -1·01 to 0·67], p=0·69) or neurological worsening (197 [22·0%] of 896 patients vs 161 [17·9%] of 899; aRR 1·19 [0·87-1·62], p=0·27). Improved functional outcomes with endovascular thrombectomy were consistent across clinical and imaging subgroups, except for those with an estimated ischaemic core volume of 150 mL or greater, in whom point estimates favoured endovascular thrombectomy, particularly in the early time window (0-6 h), but wide 95% CIs limited interpretation. INTERPRETATION: Endovascular thrombectomy was associated with improved functional outcomes and reduced mortality versus medical management in patients with large-core ischaemic stroke presenting within 24 h of onset. With the exception of very extensive ischaemic changes (core volume ≥150 mL) presenting beyond 6 h, where evidence remains limited, benefit was sustained across ASPECTS and ischaemic core strata for patients presenting up to 24 h after onset. FUNDING: None.
24 May 2026
Read appraisal →Annals of medicine
Endovascular thrombectomy versus best medical therapy for acute vertebrobasilar artery occlusion in patients with low NIHSS scores: a meta-analysis
OBJECTIVE: The efficacy of endovascular thrombectomy (EVT) for acute vertebrobasilar artery occlusion (VBAO) presenting with mild symptoms (National Institutes of Health Stroke Scale [NIHSS] score ≤10) remains uncertain. This meta-analysis aimed to compare the effectiveness and safety of EVT versus best medical therapy (BMT) in this population. METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to September 2025 for comparative studies. The primary outcome was 90-day excellent functional outcome (modified Rankin Scale [mRS] score 0-1). Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS: Seven observational studies involving 3,107 patients were included. In unadjusted analyses, EVT was associated with a higher rate of excellent functional outcome (OR 2.17; 95% CI 1.58-2.96) but not with functional independence (OR 1.58; 95% CI 0.90-2.77). After adjustment for confounders, EVT was associated with higher rate of excellent functional outcome (OR 2.86; 95% CI 1.89-4.31) and functional independence (OR 1.91; 95% CI 1.01-3.62). Safety outcomes including sICH and mortality did not differ significantly between groups. CONCLUSION: In patients with acute VBAO and mild symptoms, EVT may be associated with superior functional outcomes compared to BMT alone, without a significant increase in procedural risks. These findings suggest a potential role for EVT in selected patients with low NIHSS scores and underscore the need for confirmation in randomized trials.
18 May 2026
Read appraisal →Computer methods and programs in biomedicine
Geometry-aware PointNet for rapid prediction of cerebral aneurysm hemodynamics
BACKGROUND AND OBJECTIVE: Cerebral aneurysms affect 2-5% of the global population and pose a significant health risk upon rupture. While computational fluid dynamics provides detailed hemodynamic information for risk assessment, its high computational demands limit routine clinical use. This study aims to develop a deep learning model to rapidly predict three-dimensional velocity fields and wall shear stress at peak systole using aneurysm geometry. METHODS: We synthesized a dataset of 984 idealized middle cerebral artery bifurcation aneurysms. For each case, computational fluid dynamics simulations were conducted with pulsatile boundary conditions to generate ground-truth data, and peak-systolic snapshots were extracted. We developed a single-input point-cloud network augmented with a distance-to-wall feature to predict both velocity fields and wall shear stress. Model performance was evaluated using mean absolute error (MAE), normalized MAE (NMAE), and relative L2 error (rL2). RESULTS: On the test set, the model achieved velocity-field accuracy of NMAE 4.05% and rL2 19.2% over the full geometry domain, and WSS accuracy of NMAE 2.59% and rL2 23.9%. The mean inference time was approximately 1.6 seconds for velocity and 0.3 seconds for wall shear stress per case. Out-of-distribution evaluation on non-idealized geometries showed substantial zero-shot degradation (NMAE 19.1%, rL2 62.4%), while leave-one-out fine-tuning improved performance (NMAE 10.8%, rL2 37.0%). CONCLUSIONS: The proposed geometry-aware point-cloud surrogate provides fast peak-systolic hemodynamic prediction on idealized aneurysm geometries. However, out-of-distribution evaluation indicates that broader patient-specific training, physiological boundary conditions, and reliability assessment are required before routine clinical application.
17 May 2026
Read appraisal →Journal of neurointerventional surgery
Long-term outcomes of the Woven EndoBridge device for intracranial aneurysms: systematic review and meta-analysis
BACKGROUND: The Woven EndoBridge (WEB) device is widely recognized as a safe and effective treatment for intracranial aneurysms (IAs). However, data on the long-term evolution of aneurysm occlusion remain limited. This meta-analysis evaluates the long-term (≥1 year) safety and efficacy outcomes of patients treated with the WEB device. METHODS: A comprehensive literature search was conducted in PubMed, Web of Science, and Scopus for studies published between January 1, 2011 and August 1, 2024 following PRISMA guidelines. Studies reporting outcome for IAs treated with the WEB device and a follow-up period of ≥1 year were included. Data were pooled using a random-effects model to account for variability across studies. RESULTS: A total of 25 studies including 1735 patients and 1768 aneurysms were analyzed (30.1% ruptured). The pooled adequate occlusion rates were 87.3% (95% CI 83.5% to 91.1%) at 1 year, 90.7% (95% CI 86.2% to 95.2%) at 1-2 years, 93.3% (95% CI 87.7% to 99.0%) at 3 years, and 88.4% (95% CI 80.5% to 96.4%) at 5 years. Adequate occlusion was achieved in 89.2% (95% CI 83.0% to 93.2%) of unruptured aneurysms and 85.9% (95% CI 80.2% to 90.1%) of ruptured aneurysms. The overall retreatment rate at the last long-term follow-up was 7.2% (95% CI 4.8% to 9.6%). No procedure- or device-related adverse events were reported beyond 1-year follow-up. Additionally, no cases of delayed rupture or aneurysm rebleeding were observed. CONCLUSION: This systematic review and meta-analysis confirms the high long-term efficacy and safety of the WEB device in treating both ruptured and unruptured aneurysms. The findings support the WEB device as a reliable and effective treatment option for IAs.
16 May 2026
Read appraisal →Journal of neurointerventional surgery
Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial
BACKGROUND: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial. METHODS: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed. RESULTS: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05). CONCLUSION: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.
16 May 2026
Read appraisal →The New England journal of medicine
Endovascular Treatment of Medium-Vessel-Occlusion Strokes
BACKGROUND: Endovascular thrombectomy for acute ischemic stroke due to medium-vessel occlusion has had varying results across trials. Whether thrombectomy improves functional outcomes in patients with medium-vessel occlusion and moderate-to-severe deficits is unclear. METHODS: We conducted an open-label, randomized trial with blinded outcome assessment at 48 centers in China. Eligible patients were adults who presented within 24 hours after the onset of a moderate-to-severe stroke (National Institutes of Health Stroke Scale [NIHSS] score, ≥6; scale, 0 to 42, with higher scores indicating greater neurologic deficits) due to occlusion of a medium vessel. Patients were assigned in a 1:1 ratio to thrombectomy plus medical management (thrombectomy group) or medical management alone (control group). The primary outcome was functional disability as measured by the shift in the modified Rankin scale score (scale, 0 [no disability] to 6 [death]) at 90 days. Violation of the proportional-odds assumption precluded the use of shift in the modified Rankin scale score, so as prespecified, functional independence (modified Rankin scale score of 0, 1, or 2) at 90 days was used as the primary outcome. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: Among 280 patients in the thrombectomy group and 283 in the control group, the median age was 71 years, the median NIHSS score was 10 (range, 3 to 36), and 42.8% were women; 36.6% received intravenous thrombolysis. Functional independence at 90 days was seen in 58.6% of the patients in the thrombectomy group and in 46.6% of those in the control group (adjusted rate ratio, 1.24; 95% confidence interval, 1.07 to 1.44; P = 0.004). The incidence of symptomatic intracranial hemorrhage was 4.7% in the thrombectomy group and 2.2% in the control group; 90-day mortality was 11.1% and 10.2%, respectively. CONCLUSIONS: Among patients with acute ischemic stroke due to medium-vessel occlusion and moderate-to-severe deficits, thrombectomy led to a greater likelihood of functional independence than medical management alone but also to a higher risk of symptomatic intracranial hemorrhage. (Funded by the National Natural Science Foundation of China and the Noncommunicable Chronic Diseases-National Science and Technology Major Project; ORIENTAL-MeVO ClinicalTrials.gov number, NCT06146790.).
15 May 2026
Read appraisal →Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
Thrombolysis in spinal cord infarction: Case report and systematic review
INTRODUCTION: Spinal cord infarction (SCI) is a rare but severe cause of acute myelopathy, and evidence supporting reperfusion therapies remains limited. METHODS: We report a 73-year-old man with spontaneous cervical SCI treated with intravenous alteplase and perform a systematic review (database search from inception to 13 November 2025) of case reports/series describing intravenous (IV) or intra-arterial (IA) thrombolysis for SCI, extracting data about clinical presentation, diagnostic and therapeutic work-up and functional outcomes. RESULTS: Our patient improved after thrombolysis and achieved functional independence at 3 months (modified Rankin Scale [mRS] 2). The review identified 21 studies (19 case reports, 2 case series) totaling 25 patients; including our case, 26 patients were analyzed. Mean age was 57.4 years (range 14-83), and anterior spinal artery (ASA) syndrome was the most common presentation. Most patients received IV thrombolysis; 4 underwent IA therapy (alone or combined). Considering the last available assessment, 14/25 patients (56.0%) had a favorable outcome (mRS 0-2), 8/25 (32.0%) had mRS 3, and 3/25 (12.0%) had mRS 4-5. No symptomatic treatment-related hemorrhagic complications were reported. DISCUSSION AND CONCLUSION: Published experience suggests that thrombolysis in carefully selected patients with suspected SCI may represent a reasonably safe therapeutic option, but evidence is limited and subject to major bias. Prospective registries and multicenter studies are needed to clarify safety, efficacy, and selection criteria.
12 May 2026
Read appraisal →AJNR. American journal of neuroradiology
Predicting Intracranial Aneurysm Rupture Risk and Intervention Outcomes Using Denoising-Enhanced CTA
BACKGROUND AND PURPOSE: Our aim was to develop a comprehensive multimodal framework for assessing the rupture risk of intracranial aneurysms and predicting intervention outcomes. In addition, it seeks to a novel denoising algorithm to enhance the quality of CTA images, thereby improving morphologic profiling. MATERIALS AND METHODS: This retrospective multicenter study included 352 patients with intracranial aneurysms who underwent CTA. A multimodal framework was developed, integrating 3 complementary feature sets: clinical variables, radiomic texture features, and deep learning-derived aneurysm morphologic data. A novel denoising algorithm was applied to improve image quality, thereby enhancing prediction performance. Model validation was performed through cross-validation, using multiple end points, including the Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), and mRS grading systems. RESULTS: The multimodal framework demonstrated robust performance, achieving an area under the curve (AUC) of 0.896 [0.819-0.973] for aneurysm rupture prediction, outperforming conventional single-technique models (radiomics-based model: 0.752 [0.693-0.809]; deep learning-based model: 0.823 [0.789-0.827]). Incorporating the denoising technique further enhanced performance, with the AUC for rupture prediction increasing to 0.908 [0.836-0.981]. In clinical grading tasks, the model showed strong efficacy, achieving an AUC of 0.907 [0.845-0.968] for Hunt-Hess grading, 0.883 [0.662-0.988] for World Federation of Neurosurgical Societies grading, and 0.926 [0.879-0.973] for mRS. CONCLUSIONS: Our system demonstrates promising performance in predicting aneurysm rupture and clinical grading assessments, indicating its potential for comprehensive aneurysm evaluation. Moreover, the proposed denoising method effectively mitigates noise interference, enhances morphologic edge features, and improves the accuracy of existing models.
11 May 2026
Read appraisal →AJNR. American journal of neuroradiology
Neuroimaging Predictors of Futile Recanalization in Anterior Circulation Stroke: A Systematic Review and Meta-Analysis
BACKGROUND: Mechanical thrombectomy (MT) has transformed the management of large vessel occlusion stroke; however, a considerable proportion of patients fail to achieve functional recovery despite successful recanalization. This futile recanalization underscores the need to better understand imaging biomarkers that may predict poor outcomes after endovascular therapy. PURPOSE: To systematically review and synthesize evidence on neuroimaging biomarkers associated with futile recanalization after MT in acute ischemic stroke. DATA SOURCES: PubMed, Scopus, Web of Science, and EMBASE databases were searched up to March 2025, supplemented by manual reference screening. STUDY SELECTION: Eligible studies enrolled adult patients with anterior-circulation stroke who underwent thrombectomy, reported pretreatment neuroimaging findings, and evaluated functional outcomes despite successful reperfusion. Case reports, reviews, abstracts, and nonhuman studies were excluded. DATA ANALYSIS: Two reviewers independently screened, extracted data, and assessed study quality using the Prediction Model Risk of Bias Assessment Tool. Random-effects meta-analysis was performed where appropriate. Heterogeneity, publication bias, and sensitivity analyses were undertaken. DATA SYNTHESIS: Fifty-one studies were included. Lower ASPECTS scores were strongly associated with futile recanalization (OR = 0.81). Core infarct volume showed inconsistent associations, whereas perfusion and collateral markers, including elevated hypoperfusion intensity ratio, delayed venous outflow, and poor collateral scores, demonstrated strong predictive value. Chronic white-matter injury, leukoaraiosis, and cerebral atrophy were also consistently associated with worse outcomes. LIMITATIONS: Limitations included heterogeneity in imaging protocols and thresholds; predominance of retrospective single-center cohorts; limited direct comparison across imaging modalities; and variable adjustment for confounders. CONCLUSIONS: Neuroimaging biomarkers, particularly ASPECTS, perfusion-derived metrics, collateral status, and markers of chronic small vessel disease, provide important prognostic information for identifying patients at risk of futile recanalization despite successful thrombectomy.
11 May 2026
Read appraisal →Journal of medical systems
Prognostic Modeling Based on Post-Endovascular Thrombectomy Systolic Blood Pressure Trajectories Using Explainable Artificial Intelligence: A Secondary Analysis of the OPTIMAL-BP Trial
Blood pressure (BP) management following successful reperfusion after endovascular thrombectomy (EVT) is critical in achieving favorable clinical outcomes. Individualized BP management using predictive modeling by machine learning may further improve prediction of functional outcomes. This study was a retrospective analysis of data from the Outcome in Patients Treated with Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP) trial, a randomized controlled trial comparing between intensive and conventional BP management during the 24 h after successful recanalization by EVT from June 18, 2020, to November 28, 2022. The trial was conducted across 19 centers in South Korea. Machine learning models were developed to predict functional independence (90-day modified Rankin Scale 0 to 2). Model performance was compared between clinical variables only and systolic blood pressure (SBP) metrics in addition to clinical variables. In addition, the Shapley additive explanations (SHAP) analysis was performed to provide model explanation and understand the importance of SBP metrics. A total of 288 patients (61.1% men, median age 75 years [interquartile range, 65-81]) were included. Among the six algorithms, the deep neural network model incorporating SBP metrics performed best on validation, achieving an area under the curve of 0.86 (95% confidence interval, 0.76-0.92) which was significantly better than the model using only clinical variables (area under the curve 0.80 [95% confidence interval, 0.69-0.88], P = .037). Among SBP metrics, SHAP analysis identified time rate of SBP and minimum SBP as important features, with time rate showing greater influence in the intensive group and minimum SBP in the conventional group. Integrating SBP metrics with clinical variables significantly improved machine learning performance in predicting functional outcomes after successful EVT. Explainable artificial intelligence (AI) identified time rate and minimum SBP as key predictors of outcome. Trial Registration Information: ClinicalTrials.gov (NCT04205305; registered December 17, 2019).
9 May 2026
Read appraisal →Journal of Korean medical science
Comparison of Clinical and Radiological Outcomes Between Suction Aspiration and Combination Methods of Mechanical Thrombectomy in Patients With Acute Cerebral Infarction: The COMPETE Trial
BACKGROUND: Recent advances in suction catheter technology suggest that suction aspiration may prevent thrombus fragmentation during mechanical thrombectomy. We therefore hypothesize that the radiological outcomes of suction aspiration as a first-line treatment would not be inferior to those of the combination technique. This study aims to evaluate the radiological and clinical outcomes of first-line suction aspiration compared with those of the first-line combination technique for large artery occlusion amenable to both modalities. METHODS: The COMPETE trial is a prospective, randomized, multicenter, noninferiority, open-label trial. A total of 1,136 patients will be randomized at a 1:1 ratio to either the suction aspiration or combination technique groups. RESULTS: The primary endpoints are successful recanalization (modified Thrombolysis in Cerebral Infarction scale score ≥ 2b) and a good clinical outcome (modified Rankin Scale score of 0-2) at 90 days after thrombectomy. The technical outcome is the switching rate from the combination technique to suction aspiration and from suction aspiration to the combination technique. The safety outcomes include procedural morbidity, nonprocedural morbidity, procedural mortality, and nonprocedural mortality. CONCLUSION: The COMPETE trial is expected to determine whether the use of suction aspiration as a first-line approach in patients with acute ischemic stroke is noninferior to the combination technique in achieving successful radiological and good clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06254755; CRIS (KCT0007726).
23 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Systolic blood pressure within 24 hours after successful reperfusion correlates with outcomes in acute ischemic stroke: a secondary analysis of the EHCHANTED2/MT Trial
BACKGROUND: The optimal threshold or range for systolic blood pressure (SBP) control in patients with successful reperfusion after endovascular thrombectomy for acute ischemic stroke (AIS) remains undefined. This study investigated whether SBP within the first 24 hours after successful reperfusion correlates with functional outcomes in AIS. METHODS: In this secondary analysis of the ENCHANTED2/MT trial, patients were categorized into two groups (120-140 mm Hg and 140-180 mm Hg, respectively) based on achieved SBP within 24 hours after randomization. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included neurological deterioration at 7 days, major disability (mRS score of 3-5 at 90 days), hospitalization duration, and health-related quality of life assessed by the three-level EuroQoL 5-Dimension Self-Report Questionnaire (EQ-5D-3L) at 90 days. Safety outcomes included early neurological decline (END), 90-day mortality, symptomatic intracranial hemorrhage (sICH), and any intracranial hemorrhage (ICH). Treatment effects were expressed as ORs with 95% confidence intervals (CIs). RESULTS: A total of 611 patients (363 in the 120-140 mm Hg group and 248 in the 140-180 mm Hg group) were included. The mean (SD) age was 67 (12) years and 37.8% were female. After adjusting for confounders, the 120-140 mm Hg group was significantly associated with better functional outcomes (mRS: 2 (IQR 1-4) vs 2 (IQR 1-5); adjusted OR 1.54 (95% CI 1.10 to 2.17), P=0.013). Compared with the 140-180 mm Hg group, the 120-140 mm Hg group had lower rates of neurological deterioration at 7 days (adjusted OR 0.68 (95% CI 0.47 to 0.98), P=0.037) and 90-day mortality (47 (13.0%) vs 53 (21.4%); adjusted OR 0.48 (95% CI 0.27 to 0.86), P=0.013). There were no significant differences between groups in END, major disability at 90 days, hospitalization duration, EQ-5D-3L score, sICH, or ICH (all P>0.05). CONCLUSIONS: In patients with successful reperfusion after endovascular thrombectomy, an average SBP within 24 hours of 120-140 mm Hg was associated with a greater likelihood of functional independence compared with 140-180 mm Hg.
18 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Safety and efficacy of selective and superselective intra-arterial cerebral infusion with blood-brain barrier disruption for glioma: a systematic review and meta-analysis
BACKGROUND: Selective and superselective intra-arterial cerebral infusion (SIACI/SSIACI) delivers chemotherapy directly to tumor-supplying arteries, achieving high local drug levels with reduced systemic toxicity. Often combined with blood-brain barrier disruption (BBBd) to enhance penetration, these methods have been widely studied, yet a comprehensive evidence synthesis is lacking. This study systematically assesses the safety and efficacy of intra-arterial chemotherapy with BBBd for glioma treatment. METHODS: We searched PubMed, Embase, and Web of Science for studies on SIACI with BBBd in glioma patients. Safety outcomes included rates of cases with complications, procedure-related complications (major/minor), stroke, intracranial and intratumoral hemorrhage, and mortality. Efficacy was based on tumor response (complete, partial, stable disease, progression). A subanalysis of SSIACI-only cases was also conducted. RESULTS: Nine studies with 230 glioma patients were included. The pooled rate of cases with complications was 27.1% (95% CI 19.8% to 35.7%), with procedure-related complications occurring in 15.4% (95% CI 6.1% to 24.6%). Major and minor complication rates were 4.3% (95% CI 0.9% to 7.7%) and 9.7% (95% CI 1.0% to 18.7%), respectively. Stroke, intracranial hemorrhage, and intratumoral hemorrhage occurred in 3.1% (95% CI 0% to 6.1%), 0.5% (95% CI 0% to 3.2%), and 0.04% (95% CI 0% to 3%), respectively, with no procedure-related deaths reported. Pooled response rates were 10.4% complete (95% CI 0% to 21.5%), 24.2% partial (95% CI 14.3% to 34.1%), 38.2% stable disease (95% CI 21.5% to 54.9%), and 39.3% progression (95% CI 14.8% to 63.8%). Subanalysis of superselective infusions yielded comparable outcomes to the overall cohort. CONCLUSION: The findings indicate that SIACI/SSIACI chemotherapy following BBBd is a feasible and safe approach for glioma treatment, demonstrating a favorable procedural risk profile and preliminary signs of efficacy. Further studies are warranted to validate these results and refine procedural protocols.
18 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Explainable machine learning model for predicting functional outcomes in posterior circulation stroke after thrombectomy
BACKGROUND: The early prediction of functional outcomes in patients with posterior circulation stroke (PCS) is crucial for timely interventions and optimizing treatment plans. We have developed and validated a machine learning (ML) model for predicting 3-month functional outcomes in patients with PCS undergoing endovascular thrombectomy (EVT). METHODS: The derivation cohort, consisting of 202 patients with PCS who underwent EVT at four medical centers from January 2020 to December 2023, was separated for training and internal validation, and an external dataset of 54 patients admitted from January 2020 to July 2023 was used for external validation. The target outcome was a good functional outcome, defined as a modified Rankin Scale score of 0-3 at 3 months. Seven ML models were trained using preoperative features, with the primary evaluation metric being the area under the receiver operating characteristic curve (AUC). The top performing model was further trained using intraoperative and postoperative features. Model interpretations were generated using the Shapley additive explanations (SHAP) method. RESULTS: The Random Forest model demonstrated the best discriminative ability among the models considered. After feature selection, the final preoperative model used seven features, achieving an AUC of 0.83 in the test set and 0.81 in the external validation cohort. The inclusion of intraoperative and postoperative features further enhanced the model's performance, resulting in an AUC of 0.84 and 0.90 in the test set and 0.83 and 0.90 in the external validation cohort, respectively. These models have been incorporated into a publicly accessible web-based calculator (https://zhelvyao-123-60-basilarz.streamlit.app). CONCLUSION: The interpretable ML models provide dynamic accurate predictions of functional outcomes in patients with PCS after EVT, offering valuable insights for personalized risk stratification and optimizing perioperative management, with potential for integration into clinical workflows.
18 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Feasibility and non-inferiority of mobile telementoring for digital subtraction angiography: a single-center observational study
BACKGROUND: Telementoring is an emerging approach in surgical education that offers remote supervision and guidance through digital platforms. This study aimed to evaluate the feasibility and non-inferiority of a mobile-based telementoring system for digital subtraction angiography (DSA) and compare it with traditional face-to-face mentoring. METHODS: This prospective, single-center observational study included 71 patients who underwent DSA between April 2021 and May 2024. Patients were categorized into control (n=48, face-to-face mentoring) and telementoring (n=23) groups. A mobile telementoring system (JOIN, Allm Inc., Tokyo, Japan), which enabled real-time image sharing and voice communication between the examiner and the remote supervisor, was employed. The primary endpoints were contrast volume, procedural time, and radiation dose, with a non-inferiority margin of 20% applied. RESULTS: No significant differences were observed between the two groups in contrast volume (88.3±39.6 mL vs 97.1±36.4 mL, p=0.499), procedural time (44.1±17.7 min vs 50.7±19.0 min, p=0.308), or radiation dose (427.9±262.2 mGy vs 506.6±307.1 mGy, p=0.346). Non-inferiority was confirmed across all primary endpoints. No procedural complications occurred. Qualitative feedback indicated high user satisfaction, with the system facilitating effective remote supervision and decision-making. CONCLUSIONS: This study demonstrates the feasibility and non-inferiority of a mobile telementoring system for DSA, effectively supporting real-time remote guidance and reducing the need for on-site supervision. Its implementation may enhance access to expert mentoring, particularly in regions with limited specialist availability, contributing to equitable and efficient cerebrovascular care.
18 Apr 2026
Read appraisal →Journal of neurointerventional surgery
Stroke thrombectomy with a novel reperfusion system including a 0.088'' aspiration catheter: the Imperative Trial
BACKGROUND: Mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) stroke, yet most device trials focus on individual technologies rather than complete systems. OBJECTIVE: To evaluate the safety and efficacy of the Zoom Reperfusion System compared with performance goals derived from a meta-analysis of trials using established thrombectomy technologies. METHODS: Prospective, multicenter, non-randomized, investigational device exemption trial conducted across 26 United States centers from October 2021 to March 2024. Adults with anterior circulation LVO stroke within 8 hours of onset were treated using the Zoom System, which includes aspiration catheters ranging from 0.035″ to 0.071″, and a novel 0.088″ intracranial guide/aspiration catheter. The primary efficacy endpoint was successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3) within three passes using Zoom-only components, adjudicated by an independent core laboratory. The primary safety endpoint was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included final reperfusion, first-pass success, time to reperfusion, 90-day modified Rankin Scale (mRS), and mortality. RESULTS: Among 260 patients (median age 68 years; median National Institutes of Health Stroke Scale (NIHSS) 15), successful reperfusion within three passes was achieved in 83% (216/259; 95% CI: 78% to 89%), exceeding the performance goal (p<0.001). Final reperfusion was 92%, with 5.5% requiring rescue devices. First-pass mTICI 2b-3 success was 57%. Median puncture-to-reperfusion time was 19 min. At 90 days, 55% achieved mRS 0-2. The sICH rate was 1.9%, and 90-day mortality was 12.7%. CONCLUSIONS: The Zoom Reperfusion System demonstrated a safety and efficacy profile exceeding prespecified contemporary performance metrics with potential to significantly shorten reperfusion times and reduce the need for rescue therapy. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov--Identifier:NCT04129125.
17 Apr 2026
Read appraisal →Journal of the American Heart Association
Effects of Computed Tomography Hyperdense Middle Cerebral Artery Sign on the Efficacy of Endovascular Therapy in Acute Ischemic Stroke With Large Infarcts: A Subgroup Analysis of the ANGEL-ASPECT Trial
BACKGROUND: The hyperdense middle cerebral artery sign (HMCAS) observed on noncontrast computed tomography is associated with thrombus composition and thrombectomy outcomes. The impact of HMCAS on the efficacy of endovascular therapy (EVT) in patients with large core infarcts remains unclear. METHODS: This analysis uses data from the ANGEL-ASPECT (Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core) trial, a multicenter randomized controlled trial conducted in China. Patients with acute ischemic stroke and anterior-circulation large-vessel occlusion were categorized according to whether HMCAS was present on baseline noncontrast computed tomography. The primary outcome was the 90-day modified Rankin Scale score. RESULTS: Of the 432 patients included in this analysis, 33% were HMCAS positive on baseline noncontrast computed tomography. In the EVT-treated patients, patients with HMCAS had worse functional outcomes than those without HMCAS (adjusted relative risk, 0.44 [95% CI, 0.26-0.73]; P=0.002). Patients with HMCAS required a greater number of thrombectomy passes (P<0.001). Among patients without HMCAS, EVT was associated with better functional outcomes than medical management (generalized odds ratio [OR], 2.78 [95% CI, 1.80-4.27]; P<0.001), whereas this benefit was not statistically significant among patients with HMCAS (adjusted OR, 1.69 [95% CI, 0.93-3.08]; P=0.09). There was no significant interaction between HMCAS status and treatment assignment (P=0.19). CONCLUSIONS: In this subgroup analysis comparing EVT with medical management, we found no statistically significant treatment-by-HMCAS status interaction, indicating that the benefits of EVT extend to patients with large core infarcts irrespective of HMCAS status. However, the magnitude of benefit appears greater in patients without HMCAS, whereas those with HMCAS tend to have a poorer overall prognosis. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04551664.
9 Apr 2026
Read appraisal →AJNR. American journal of neuroradiology
Delphi Consensus on Early Neurologic Improvement after Mechanical Thrombectomy
BACKGROUND AND PURPOSE: Early neurologic improvement (ENI) following mechanical thrombectomy (MT) has been a topic of substantial interest. The literature has more than 40 ENI definitions, yet no consensus has been reached. In this Delphi study, we sought to investigate experts' perspectives on the available ENI definitions and determine whether a consensus can be achieved. MATERIALS AND METHODS: The Delphi approach assessed experts' perspectives on available ENI definitions. Following a systematic literature review, the first survey round was prepared and sent to 20 experts using a Web-based anonymous survey platform (qualtrics.com). The first round of questions was publicly shared on the letsgetproof.com platform to gather perspectives of neurointerventionalists worldwide on ENI definitions. Expert and volunteer answers formed the basis of subsequent rounds, in which closed-ended questions were sent only to experts. Consensus was defined as an agreement of ≥70% for binary closed-ended questions and ≥50% for closed-ended questions with >2 response options. RESULTS: Experts completed 3 survey rounds. They recognized that the heterogeneity in ENI definitions is the most critical factor limiting the use of ENI in clinical practice and stroke research. All experts acknowledged that stroke physicians need a standardized universal ENI definition. Consensus was reached on the notion that a unified ENI definition should focus on predicting functional independence at 3 months. They agreed that NIHSS improvement of ≥8 points at 24 hours could serve as the unified ENI definition. They acknowledged that incorporating prestroke comorbidities, occlusion location, baseline NIHSS scores, and procedure-related parameters would complicate the ideal ENI definition and limit its use in clinical settings. The experts could not reach a consensus on the potential utility of ENI as a primary end point in MT trials. CONCLUSIONS: In our Delphi analysis, experts agreed on an ENI definition. They did not endorse using different ENI criteria for patients with comorbidities, posterior circulation occlusions, or high baseline NIHSS scores. Further prospective studies are needed to validate or refine ENI definitions and to address the paucity of data on the prognostic utility of ENI in specific clinical scenarios.
5 Apr 2026
Read appraisal →AJNR. American journal of neuroradiology
Flow Diversion versus Coiling with or without Stenting for Unruptured Wide-Neck Intracranial Aneurysms: A Randomized Comparison
BACKGROUND AND PURPOSE: There are few randomized trials comparing coiling (with or without stent placement) and flow diversion (FD) for the treatment of wide-neck unruptured intracranial aneurysms. MATERIALS AND METHODS: EVIDENCE was an investigator-led randomized (1:1) trial conducted in 7 French university hospitals. Patients with 7 to 20-mm intradural unruptured intracranial aneurysms with a 4- to 10-mm neck and a "dome/neck" ratio of ≥1 were randomly allocated to coiling with or without adjunctive stent placement or FD alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS> 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that FD would decrease treatment failures from 35% to 10%, requiring 90 patients. Primary analyses were intent to treat. RESULTS: Among the 91 enrolled patients, four (two in each group) withdrew consent; 87 patients were included in the analysis: 43 in the FD group and 44 in the control group. Most patients had <10 mm (57/87; 65.5%) asymptomatic ophthalmic aneurysms (75/87, 86.2%). A poor primary outcome, ascertainable in 86 patients, was reached in 8/43 patients with FD (18.6%; 95% CI, 9.7%-32.6%) compared with 10/43 coiling patients (23.3%; 95 CI, 13.1%-37.7%) (RR = 0.80; 95% CI, 0.35-1.83; P = .60). Serious adverse events were similar. CONCLUSIONS: For patients with mostly unruptured, wide-neck ophthalmic aneurysms of <10 mm, FD was not superior to coiling with or without stent placement.
5 Apr 2026
Read appraisal →AJNR. American journal of neuroradiology
Multimodal CT Perfusion-Based Deep Learning for Predicting Stroke Lesion Outcomes in Complete and No Recanalization Scenarios
BACKGROUND AND PURPOSE: Predicting the final location and volume of lesions in acute ischemic stroke is crucial for clinical management. While CTP is routinely used for estimating lesion outcomes, conventional threshold-based methods have limitations. We developed specialized outcome-prediction deep learning models that predict infarct core in successful reperfusion cases and the combined core-penumbra region in unsuccessful reperfusion cases. MATERIALS AND METHODS: We developed single-modal and multimodal deep learning models using CTP parameter maps to predict the final infarct lesion on follow-up DWI. Using a multicenter data set from multiple sites, we developed deep learning models and evaluated them separately for patients with complete recanalization (successful reperfusion [CR], n = 350) and no recanalization (unsuccessful reperfusion [NR], n = 138) after treatment. The CR model was designed to predict the infarct core region, while the NR model predicted the expanded, hypoperfused tissue encompassing both the core and penumbra regions. Five-fold cross-validation was performed for robust evaluation. RESULTS: The multimodal 3D nnU-Net model demonstrated superior performance, achieving mean Dice scores of 35.36% in patients with CR and 50.22% in those with NR. This model substantially outperformed the current clinically used method, providing more accurate outcome estimates than the conventional single-technique threshold-based measures, which yielded Dice scores of 15.73% and 39.71% for CR and NR groups, respectively. CONCLUSIONS: Our approach offered both successful reperfusion and unsuccessful reperfusion estimations for potential treatment outcomes, enabling clinicians to better evaluate treatment eligibility for reperfusion therapies and assess potential treatment benefits. This advancement facilitates more personalized treatment recommendations and has the potential to substantially enhance clinical decision-making in acute ischemic stroke management by providing more accurate tissue outcome predictions than conventional single-technique threshold-based approaches.
4 Apr 2026
Read appraisal →