eCLIPs bifurcation remodeling system for treatment of wide-neck bifurcation aneurysms: A systematic review and meta-analysis of safety and efficacy.

BACKGROUND: Wide neck bifurcation aneurysms (WNBAs) are a subtype of aneurysms that are especially complex to treat. We aim to conduct a systematic review and meta-analysis to synthesize the available literature on the safety and efficacy of employing endovascular clip system (eCLIPs) in the treatment of WNBAs. METHODS: We report this study in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed, Embase, Web of Science, and Scopus were queried for this review. Screening and extraction were performed by at least two authors to ensure accuracy and completeness, and a senior author arbitrated any discrepancies. All data were analyzed using R software version 4.3.0. and random-effects model. RESULTS: Four studies were finally included, of which three were prospective and one was retrospective. Successful adjunctive coiling occurred in 91.38% (95% CI = 70.71-97.9) of cases and overall technical success was achieved in 88.61% (95 CI = 75.54-95.15) of cases. The pooled complete occlusion (Raymond-Roy Class I) was 50.65% (95% CI = 39.63-61.60) and adequate occlusion (Raymond-Roy Class I/II) was 84.42% (95% CI = 74.53-90.93). Thrombo-embolic complication had a pooled rate of 1.22% (95% CI = 0.17-8.15), retreatment rate was 6.10% (95% CI = 2.56-13.83), and mortality reported in 3.66% (95% CI = 1.18-10.74) of patients. CONCLUSION: The use of eCLIPs may be a safe and efficacious treatment for WNBAs. Future randomized controlled trials are needed for further validation of the findings.

Outcomes of mechanical thrombectomy in patients with acute ischemic stroke and thrombocytopenia: systematic review and meta-analysis.

BACKGROUND: Mechanical Thrombectomy (MT) has improved outcomes in acute ischemic stroke (AIS) due to Large Vessel Obstruction (LVO). However, there is limited data on the safety and outcomes of MT in AIS patients with thrombocytopenia. This study aims to assess the efficacy and safety of MT in this population. METHODS: Following the PRISMA guidelines, a comprehensive systematic review was conducted using PubMed, Embase, Web of Science, and Scopus. Studies meeting inclusion criteria underwent rigorous risk of bias assessment using the ROBINS-I tool. We compared outcomes between patients with and without thrombocytopenia undergoing MT. Using the R software version 4.3.1, meta-analyses were conducted employing random-effect models. RESULTS: This meta-analysis encompassed data from 5 studies. Thrombocytopenic AIS patients who underwent MT (n = 974) exhibited lower rates of functional independence (OR 0.83, 95% CI 0.71-0.98; p = 0.030) compared to patients with normal platelet counts (n = 2036). In addition, the thrombocytopenic group experienced higher mortality as compared to the group with normal platelet counts (OR 1.76, 95% CI 1.26-2.45; p < 0.001). Rates of sICH were found to be similar between groups (OR 1.20, 95% CI 0.74-1.93; p = 0.456), as were rates of successful recanalization (OR 0.94, 95% CI 0.47-1.87; p = 0.863). Lastly, no significant differences were observed in procedure times between thrombocytopenic and non-thrombocytopenic groups. CONCLUSION: As compared to patients without thrombocytopenia, thrombocytopenic AIS patients undergoing MT displayed lower functional independence and higher mortality rates, with no significant differences in sICH or successful recanalization.

Endovascular outcomes for anterior choroidal artery aneurysms: systematic review and meta-analysis.

BACKGROUND: Anterior choroidal artery (AchoA) aneurysms are relatively rare compared to other types of aneurysms. However, the occurrence of transient or permanent occlusion of the choroidal artery during endovascular or surgical treatment is an uncommon but potentially serious complication. In this study, we aim to investigate the safety and efficacy profile of endovascular treatment (EVT) for AchoA aneurysms. METHODS: The primary outcome of interest was angiographic and clinical outcomes. Secondary outcome variables transient and permanent ischemic complications, symptomatic choroidal artery occlusion and retreatment rates. A random-effects model was used to calculate prevalence rates and their corresponding 95 % confidence intervals (CI), and subgroup analyses were performed to assess the complication rates for Type 1(arterial type, directly arising from ICA) and Type 2(neck type, arising from AchoA branch)) AchoA aneurysms, ruptured vs non-ruptured and for flow diverter (FD) treatment versus coiling. RESULTS: Our study included 10 studies with 416 patients with 430 AchoA aneurysms. The overall good clinical outcome rate (mRS score 0-2) is 94.5 % with a retreatment rate of 2.0 %. A subgroup analysis showed no statistical difference between coiling(75.3 %) and flow diverter(80.9 %) treatment in terms of complete occlusion(p-value:0.62). Overall permanent complication rate is 1.4 % (p-value:0.54) and transient ischemic complications rate is 4.2 %(p-value:0.61). Symptomatic choroidal artery occlusion rate is 0.8 %(p-value:0.51)Type 2 AchoA aneurysms had a significantly higher complication rate of 9.8 % (p-value<0.05) compared to Type 1 aneurysms. Unruptured aneurysms have significantly better clinical outcomes than ruptured aneurysms(OR: 0.11; [0.02;0.5], p-value:<0.05) CONCLUSION: Endovascular treatment of AchoA aneurysms demonstrated positive clinical results, with low rates of retreatment and complications. Coiling and flow diverters proved similar outcomes in achieving aneurysm occlusion. Ruptured aneurysms have lower good clinical outcomes comparing to unruptured aneurysms. Type 2 AchoA aneurysms had a higher risk of complications compared to Type 1.

Impact analysis of primary and secondary research in radiology journals.

INTRODUCTION: Primary and secondary studies are considered the two major research categories. In this study, we examined the scientific and social media impact of primary and secondary publication types in papers published radiological journals during 2010-2020. MATERIALS AND METHODS: PubMed publication type tags were used to filter original articles and systematic review and meta-analysis (SR/MA) articles. Clarivate Web of Science was utilized to obtain a list of all radiology journals from the category "Radiology, Nuclear Medicine and Imaging" in Science Citation Index Expanded (SCIE). Automated approach was developed for programmatic extraction of bibliometric and Altmetric yearly citations of each included article using Dimensions API and Altmetric API with Python. Statistical analysis was performed to compare the citation rates between primary and secondary research articles. RESULTS: A total of 96,684 published articles from 2010 to 2020 were identified and their meta-data collected. The mean 2-year citation count following publication year was 5.8 for primary research and 10.2 for SR/MA articles (p < 0.001). Between 2010 and 2020, the mean number of citations per SR/MA article was 51.3 compared to 30.5 per primary research article (p < 0.001). Mean Altmetric score was 8.2 in SR/MA compared to 3.7 for primary research articles (p < 0.001). CONCLUSION: Secondary research studies have been increasing in impact in both academia and social media compared to primary research. Our results highlight the importance and impact of systematic reviews and meta-analysis articles as a scientifically influential study type in radiology.

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study.

BACKGROUND: Mechanical thrombectomy (MT) has revolutionized the treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO), but its efficacy and safety in medium vessel occlusion (MeVO) remain less explored. This multicenter, retrospective study aims to investigate the incidence and clinical outcomes of vessel perforations (confirmed by extravasation during an angiographic series) during MT for AIS caused by MeVO. METHODS: Data were collected from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. A total of 1373 AIS patients with MeVO underwent MT. Baseline characteristics, procedural details, and clinical outcomes were analyzed. RESULTS: The incidence of vessel perforation was 4.8% (66/1373). Notably, our analysis indicates variations in perforation rates across different arterial segments: 8.9% in M3 segments, 4.3% in M2 segments, and 8.3% in A2 segments (p = 0.612). Patients with perforation had significantly worse outcomes, with lower rates of favorable angiographic outcomes (TICI 2c-3: 23% vs 58.9%, p < 0.001; TICI 2b-3: 56.5% vs 88.3%, p < 0.001). Functional outcomes were also worse in the perforation group (mRS 0-1 at 3 months: 22.7% vs 36.6%, p = 0.031; mRS 0-2 at 3 months: 28.8% vs 53.9%, p < 0.001). Mortality was higher in the perforation group (30.3% vs 16.8%, p = 0.008). CONCLUSION: This study reveals that while the occurrence of vessel perforation in MT for AIS due to MeVO is relatively rare, it is associated with poor functional outcomes and higher mortality. The findings highlight the need for increased caution and specialized training in performing MT for MeVO. Further prospective research is required for risk mitigation strategies.

Intensive vs Conventional Blood Pressure Control After Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Importance: Endovascular thrombectomy (EVT) is standard treatment for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO), but optimal post-EVT blood pressure (BP) control remains debated. Objective: To assess the association of different systolic BP targets following EVT with functional outcomes, mortality, and complications in patients with AIS due to LVO. Data Sources: Systematic review and meta-analysis of databases (PubMed, Embase, Web of Science, Scopus, and Cochrane Library) to September 8, 2023. Study Selection: Inclusion criteria consisted of randomized clinical trials examining post-EVT management of systolic BP in patients with AIS and LVO comparing intensive vs conventional targets. Nonrandomized studies, observational studies, noninterventional trials, meeting abstracts, duplicate studies, studies with overlapping data, and non-English language studies were excluded. Two authors independently applied these criteria through a blinded review, with discrepancies resolved through consensus. The risk of bias in the included studies was assessed using the revised tool for assessing risk of bias in randomized trials. Data Extraction and Synthesis: This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Three authors extracted data regarding study characteristics, baseline patient data, and outcomes of interest. The pooled data were analyzed using a random-effects meta-analysis. Main Outcomes and Measures: Rates of functional independence, 90-day mortality, symptomatic intracranial hemorrhage, and hypotensive events. Results: A total of 4 randomized clinical trials with 1571 initially enrolled patients were included in the analysis. Lower functional independence rates were observed in the intensive control group (relative risk [RR], 0.81 [95% CI, 0.67-0.98]). No significant differences were found in 90-day mortality (RR, 1.18 [95% CI, 0.92-1.52]), symptomatic intracranial hemorrhage (RR, 1.12 [95% CI, 0.75-1.67]), or hypotensive events (RR, 1.80 [95% CI, 0.37-8.76]). There was minimal heterogeneity among the studies included in the functional independence outcome (I2 = 13% and τ2 = 0.003), which was absent among other outcomes (I2 = 0 and τ2 = 0). Conclusions and Relevance: These findings suggest that intensive post-EVT BP reduction does not yield benefits and may carry risks. While awaiting the results of additional ongoing trials, a conservative BP management strategy after endovascular recanalization is favored in daily practice.

Mechanical thrombectomy for the treatment of large vessel occlusion due to cancer-related cerebral embolism: A systematic review.

BACKGROUND: Cancer-related cerebral embolism due to direct tumor embolization results in a rare acute ischemic stroke with large vessel occlusion (LVO). Despite the established status of mechanical thrombectomy (MT) in LVO management, its effectiveness and safety remains inadequately explored in this specific patient group. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using the Nested Knowledge AutoLit software, encompassing databases like Embase, PubMed, Scopus, and Web of Science, from their inception up to 9 May 2023. RESULTS: In the review of 35 studies encompassing 37 cases, mean patient age was 52 years, and 30% were female. Cardiac myxoma (29.7%), cardiac papillary fibroelastoma (16.2%), and squamous cell carcinoma of the lung (8.1%) were the most frequent underlying cancers. The left middle cerebral artery was the most commonly affected occlusion site (24.3%). Of the patients, 67.5% underwent MT alone, while 32.5% received MT combined with intravenous thrombolysis. Successful reperfusion (thrombolysis in cerebral infarction (TICI) 2b-3) was achieved in 89.1% of cases, with 59.4% reaching TICI 3. Functional independence was observed in 29.7% of patients. CONCLUSION: While limitations exist, this comprehensive study highlights the potential benefits of MT in a patient group historically excluded from major trials, warranting further investigation.

Endovascular embolization of cerebrospinal fluid-venous fistula: a comprehensive systematic review on its efficacy and safety for the management of spontaneous intracranial hypotension.

Cerebrospinal fluid (CSF)-venous fistula can cause spontaneous intracranial hypotension (SIH) and poses a significant diagnostic and management challenge. This study aims to provide a comprehensive overview of the clinical and radiological outcomes of endovascular embolization as a novel treatment approach for CSF-venous fistula in patients with SIH. This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. The primary outcome was the efficacy of the embolization procedure in occlusion of the CSF-venous fistula, and secondary outcomes included procedural complications and improvement of clinical symptoms and radiological findings. A total of nine studies consisting of 77 patients met the inclusion criteria. Orthostatic and/or Valsalva headache was the most common symptom. The mean age of the patients was 57 ± 8.9 years, and females accounted for 59.7% (46/77) of the cases. Sixty-five (84.4%) patients reported complete resolution or significant improvement in symptoms. The Bern score, Headache Impact Test-6, and the Patient Global Impression of Change scales demonstrated significant improvements in radiological findings and patients' quality of life. Following the procedure, 22 patients (28.6%) experienced rebound intracranial hypertension and 27 patients (35.1%) had transient local pain at the site of the embolization. Our study showed that endovascular embolization is a safe and effective treatment for CSF-venous fistula in patients with SIH, providing complete resolution or significant improvement of clinical symptoms and radiological findings, and positive impacts on patients' quality of life.

Flow diverters in the treatment of intracranial dissecting aneurysms: a systematic review and meta-analysis of safety and efficacy.

BACKGROUND: Intracranial dissecting aneurysms present clinical challenges, demanding immediate intervention due to their high bleeding risk. While traditional treatments have limitations, the potential of flow diverters shows promise but remains a subject of ongoing debate for optimal management. The aim of this study was assess the safety and efficacy of flow diverters in the treatment of intracranial dissecting aneurysms. METHODS: A systematic review and meta-analysis was performed following established guidelines. The search encompassed PubMed, Scopus, Web of Science, and Embase databases up to July 20, 2023. Eligible studies reporting outcomes of interest were included, and relevant data were extracted and analyzed using R software. RESULTS: The analysis, based on data pooled from 20 included studies involving 329 patients, revealed a favorable functional outcome rate of 89.7% at the last follow-up. The mortality rate during the follow-up period was 2.4%, decreasing to 0.9% when excluding the outlier study. In the final angiographic follow-up, a complete occlusion rate of 71.7% and an adequate occlusion rate of 88.3% were observed. Notably, studies with longer angiographic follow-up times exhibited lower rates of complete (P=0.02) and adequate (P<0.01) occlusion. A minimal aneurysm recurrence/rebleeding rate of 0.1% was noted, while in-stent stenosis/thrombosis occurred at a rate of 1.14%. Additionally, ischemic events/infarctions were seen in 3.3% of cases. The need for retreatment was minimal, with a rate of 0.9%, and the technical success rate was impressively high at 99.1%. CONCLUSION: This study highlights the safety and efficacy of flow diverters in treating intracranial dissecting aneurysms. Further research, encompassing larger multicenter studies with extended follow-up periods, is crucial for comprehending occlusion dynamics, refining treatment strategies, improving long-term outcomes, and addressing methodological limitations.

Common design and data elements reported in active mechanical thrombectomy trials focusing on distal medium vessel occlusions and minor strokes: a systematic review.

BACKGROUND: Distal medium vessel occlusions (DMVOs) and minor strokes represent emerging frontiers in mechanical thrombectomy (MT). Although several randomized clinical trials (RCTs) are underway, the design characteristics of these trials and the specific questions they aim to address have not been extensively explored. This current study sought to investigate the design and data elements reported in active prospective DMVO and minor stroke studies. METHODS: The ClinicalTrials.gov database was searched for ongoing prospective studies assessing the role of MT in patients with DMVOs or minor strokes. The Nested Knowledge AutoLit platform was utilized to categorize reported outcomes and inclusion/exclusion criteria. Frequencies of reported data elements were extracted from study protocols. RESULTS: A total of 10 (8 DMVO and 2 minor stroke) studies enrolling 3520 patients were included. All DMVO studies employ different criteria regarding target occlusion locations. Five DMVO studies use stent retrievers as the first-line thrombectomy technique (62.5%, 5/8), while three studies allow any MT techniques, generally at the operator's discretion. Four DMVO studies permit intravenous thrombolysis (IVT) utilization in both intervention and control arms (50%, 4/8). The DISTALS trial excludes patients receiving IVT, while the DUSK trial and Tigertriever registry only enroll patients who are ineligible for IVT or for whom IVT failed to achieve reperfusion. DMVO studies exhibit notable heterogeneity in symptom onset duration thresholds for inclusion (<6 hours: 2 studies; <12 hours: 2 studies; <24 hours: 3 studies). Minor stroke trials employ similar inclusion criteria and outcome measures except for symptom duration thresholds for inclusion (8 hours for ENDOLOW and 23 hours for MOSTE). CONCLUSIONS: There is considerable heterogeneity among active DMVO trials regarding potential target DMVO locations and time thresholds for inclusion based on the last known well time. Furthermore, our review indicates that the utility of aspiration thrombectomy in DMVOs and the advantages of MT without IVT over IVT alone will remain largely unexplored even after completion of active DMVO trials.

Safety and efficacy of the Woven Endo-Bridge-17 device for intracranial aneurysm treatment: A systematic review and meta-analysis.

BACKGROUND: The Woven Endo-Bridge (WEB) device revolutionized the treatment of wide-necked bifurcation aneurysms by intrasaccular flow diversion. The latest advancement is the WEB-17 system, offering greater flexibility with fewer wires, enabling treatment of smaller distal aneurysms using smaller microcatheters than the WEB-21 system. METHODS: We conducted a systematic review following preferred reporting items for systematic reviews and meta-analyses guidelines, analyzing data from seven retrospective cohort studies involving 483 aneurysms treated with the WEB-17 device. Statistical analysis computed pooled prevalence rates and 95% confidence intervals using appropriate models for each outcome and R software version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria). RESULTS: Technical success was achieved in 475 out of 483 aneurysms treated with the WEB-17 device, with a success rate of 98.34% (95% confidence interval (CI) = 96.72-99.17). Among the successful cases, 4.97% (95% CI = 1.60-14.39) required adjunctive devices. Adequate occlusion, defined as complete occlusion or neck remnants, was observed in 94.41% (95% CI = 88.17-97.46) of cases. Periprocedural complications were infrequent, with thromboembolic complications occurring in 4.93% (95% CI = 3.29-7.30) of cases, hemorrhagic complications in 1.28% (95% CI = 0.58-2.83), and postprocedural neurologic complications in 0.99% (95% CI = 0.31-3.14). Procedure-related morbidity was observed in 1.71% (95% CI = 0.86-3.39) of cases, and there was one procedure-related mortality reported at 0.21% (95% CI = .03-1.50). Mortality unrelated to the procedure occurred in 1% (95% CI = 0.23-4.15). CONCLUSION: Our findings suggest that the WEB-17 device is associated with a high rate of technical success, favorable angiographic outcomes, and a low rate of periprocedural complications. Further research, including prospective trials, is needed to confirm these findings and establish its safety and efficacy definitively.

Disability-free outcomes after mechanical thrombectomy: A systematic review and meta-analysis of the randomized controlled trials.

BACKGROUND: The modified Rankin Scale (mRS) score of ≤2 (functional independence) has been the most common primary endpoint of modern mechanical thrombectomy (MT) trials. However, unlike mRS 0-1, mRS score of 2 indicates disability. An important proportion of the mRS 2 patients are home dependent and report a significant decrease in their quality of life. PURPOSE: To investigate excellent outcome (mRS 0-1) rates after MT. METHODS: We systematically searched Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases. Randomized controlled trials (RCTs) investigating the role of modern MT in acute ischemic stroke were screened. Posterior circulation and large-core infarct trials were excluded from the study. The data regarding excellent outcomes (mRS: 0-1), functional independence (mRS: 0-2), and reperfusion were collected. RESULTS: Twenty-two RCTs comprising 5692 patients were included in the meta-analysis. The overall mRS 0-1 rate was 31.24% (95% CI = 26.95-36.2). The rate of successful reperfusion was 81.8% (95% CI = 77.93-85.86). MT achieved significantly higher rates of mRS 0-1 compared to standard care alone (OR = 2.04; 95% CI = 1.64-2.55; P-value < 0.001), with no heterogeneity detected among studies (I2= 0%; P-value = 0.52). The direct MT and MT plus intravenous thrombolytic treatment groups' excellent outcome rates were comparable (OR = 0.98; 95% CI = 0.82-1.18; P-value = 0.863). Also, aspiration and stent retriever thrombectomy techniques provided similar excellent outcome rates (OR = 0.76; 95% CI = 0.55-1.05; P-value = 0.141). CONCLUSIONS: Our results prove the additional benefit of MT over standard care, using a stricter definition for favorable functional outcome. Nearly one-third of patients presenting with large artery occlusion and treated with MT had no disability at 90 days. While this is remarkable, our results also indicate that reperfusion alone is often not enough to prevent disability and underline the need for better neuroprotection strategies.

Endovascular Embolization Techniques for Cerebrospinal Fluid-Venous Fistula in the Treatment of Spontaneous Intracranial Hypotension.

Cerebrospinal fluid-venous fistula (CVF) is an important cause of spontaneous intracranial hypotension (SIH), a condition characterized by low cerebrospinal fluid (CSF) volume and orthostatic headaches. The pathogenesis of CVF is thought to be direct connection of the spinal dura to one or more veins in the epidural space, allowing unregulated flow of CSF into the venous system. Herein, we provide a comprehensive review of the endovascular management of CVF in patients with SIH. We also focus on the various techniques and devices used in endovascular treatment, as well as the pathogenesis, diagnosis, and alternative treatment options of CVF.

Journal selection guide for radiology case reports.

Case reports and interesting images are valuable contributions to the radiology literature as they provide unique insights into uncommon conditions and rare presentations. Additionally, they serve as a rapidly expanding live image atlas and, therefore, can help radiologists to improve their diagnostics skills. However, due to high rejection rates and an increasing number of predatory publishers, publishing radiology case reports remains a daunting task for junior researchers. To overcome these challenges and ensure timely dissemination of their research findings, authors should consider several factors when selecting a target journal for case report publications. In this primer, we have summarized key considerations in journal selection and highlighted reputable journals that welcome radiology case reports.

Safety and efficacy profile of off-label use of the Pipeline Embolization Device: A systematic review and meta-analysis.

OBJECTIVE: The off-label utilization of the Pipeline Embolization Device (PED) is a common practice in numerous medical centers globally. Therefore, we conducted a systematic review and meta-analysis to evaluate the overall outcomes of this off-label usage of PEDs. METHODS: PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to February 2023 using the Nested Knowledge platform to identify studies assessing the off-label use of PEDs. Any use of PED outside of the FDA-approved indication granted in 2018 is considered off-label use. Overall angiographic occlusion rates, ischemic and hemorrhagic complications, mortality, retreatment rates, and favorable clinic outcomes were included. Statistical analyses were performed to compare the overall outcome rates of anterior cerebral artery(ACA) vs. middle cerebral artery(MCA) and anterior vs posterior circulation subgroups. RESULTS: We included 26 studies involving a total of 1,408 patients. The overall rate of complete occlusion was 80.3 % (95 % CI= 76.0-84.1). Subgroup analysis demonstrated a statistically significant difference in the rate of complete occlusion between anterior circulation (78.9 %) and posterior circulation (69.2 %) (p value=0.02). The rate of good clinical outcomes was 92.8 % (95 % CI= 88.8-95.4). The mortality rate was 1.4 % (95 % CI= 0.5-2.7). The overall rate of ischemic complications was 9.5 % (95 % CI= 7.7-11.6), with a comparable difference between anterior circulation (7.7 %) and posterior circulation (12.8 %) (p value=0.07). There was no statistically significant difference in MCA vs ACA subgroups in all parameters. CONCLUSIONS: Off-label use of PEDs can be a safe and effective treatment option for intracranial aneurysms. However, there is a need for more prospective, high-quality, non-industry-funded registry studies and randomized trials to test the efficacy and safety of off-label usage of PEDs and to expand its indications.

National Institutes of Health grant funding for cerebrovascular diseases.

BACKGROUND: Federal research funding is highly sought after but may be challenging to attain. A clear understanding of funding for specific diseases, such as cerebrovascular disorders, might help researchers regarding which National Institutes of Health (NIH) institutes fund research into specific disorders and grant types. OBJECTIVE: To examine the current scope of NIH grant funding for cerebrovascular conditions. METHODS: The NIH-developed RePORTER was used to extract active NIH-funded studies related to cerebrovascular diseases through January 2023. Duplicate studies were removed, and projects were manually screened and labeled in subcategories as clinical and basic science and as research subcategories. Extracted data included total funding, grant types, institutions that received funding, and diseases studied. Python (version 3.9) and SciPy library were used for statistical analyses. RESULTS: We identified 1232 cerebrovascular projects across seven diseases with US$699 952 926 in total funding. The cerebrovascular diseases with the greatest number of grants were ischemic stroke (705, or 57.2% of all funded projects), carotid disease (193, or 15.7%), and hemorrhagic stroke (163, or 13.2%). R01 grants were the most common mechanism of funding (632 grants, or 51.3%). The National Institute of Neurological Disorders and Stroke (NINDS) funded the most projects (504 projects; US$325 536 405), followed by the National Heart, Lung, and Blood Institute (NHLBI) (376 projects; US$216 784 546). CONCLUSION: Cerebrovascular disease receives roughly US$700 million in NIH funding. Ischemic stroke accounts for the majority of NIH-funded cerebrovascular projects, and R01 grants are the most common funding mechanism. Notably, NHLBI provides a large proportion of funding, in addition to NINDS.

Effects of intravenous thrombolysis on stent retriever and aspiration thrombectomy outcomes: a systematic review and meta-analysis of the randomized controlled trials.

BACKGROUND: Risks and benefits of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) have been a topic of interest. However, IVT's specific effects on stent retriever (SR) and aspiration thrombectomy (ASP) outcomes remain largely unexplored. In this meta-analysis, we aimed to investigate the effects of IVT on SR and ASP thrombectomy outcomes. METHODS: In accordance with PRISMA guidelines, a systematic literature review was conducted using Medline, Embase, Scopus, Web of Science, and Cochrane Center of Clinical Trials databases. Outcomes of interest included successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b), modified first pass efficacy (mFPE), functional independence (modified Rankin Scale (mRS) ≤2), symptomatic intracranial hemorrhage (sICH), and embolization to new territories (ENT). RESULTS: Four randomized controlled trials with 1176 patients were included. SR and ASP resulted in similar mTICI ≥2b, mFPE, and mRS 0-2 rates in patients with and without IVT administration. SR without IVT was associated with a significantly lower rate of mFPE compared with the SR+IVT (RR 0.85, 95% CI 0.74 to 0.97). Furthermore, ASP without IVT resulted in a lower rate of mRS 0-2 than the ASP+IVT with a strong trend towards significance (RR 0.78, 95% CI 0.60 to 1.01). Finally, bridging therapy did not increase sICH and ENT rates after ASP or SR thrombectomy. CONCLUSIONS: Our findings suggest that SR and ASP thrombectomy have comparable safety and efficacy profiles, regardless of prior IVT administration. Additionally, our results indicate that the addition of IVT may improve certain efficacy outcomes based on the employed first-line MT technique.

Quantitative image signature and machine learning-based prediction of outcomes in cerebral cavernous malformations.

PURPOSE: There is increasing interest in novel prognostic tools and predictive biomarkers to help identify, with more certainty, cerebral cavernous malformations (CCM) susceptible of bleeding if left untreated. We developed explainable quantitative-based machine learning models from magnetic resonance imaging (MRI) in a large CCM cohort to demonstrate the value of artificial intelligence and radiomics in complementing natural history studies for hemorrhage and functional outcome prediction. MATERIALS AND METHODS: One-hundred-eighty-one patients from a prospectively registered cohort of 366 adults with CCM were included. Fluid attenuated inversion recovery (FLAIR) T2-weighted brain images were preprocessed, and CCM and surrounding edema were segmented before radiomic feature computation. Minority class oversampling, dimensionality reduction and feature selection methods were applied. With prospective hemorrhage as primary outcome, machine learning models were built, cross-validated, and compared using clinico-radiologic, radiomic, and combined features. SHapley Additive exPlanations (SHAP) was used for interpretation to determine the radiomic features with most contribution to hemorrhage prediction. RESULTS: The highest performances in hemorrhage predictions on the test set were combining radiomic and clinico-radiological features with an area under the curve (AUC) of 83% using linear regression and selected features, and an F1 score of 61% and 85% sensitivity using K-nearest neighbors with principal component analysis (PCA). Multilayer perceptron had the best performance predicting modified Rankin Scale ≥ 2 with an AUC of 74% using PCA derived features. For interpretation of the selected radiomic signature XGBoost model, Shapley additive explanations highlighted 6 radiomic features contributing the most to hemorrhage prediction. CONCLUSION: Quantitative image-based modeling using machine learning has the potential to highlight novel imaging biomarkers that predict hemorrhagic and functional outcomes, ensuring more precise and personalized care for CCM patients.

Machine learning prediction of hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the United States.

BACKGROUND AND PURPOSE: Predicting patient recovery and discharge disposition following mechanical thrombectomy remains a challenge in patients with ischemic stroke. Machine learning offers a promising prognostication approach assisting in personalized post-thrombectomy care plans and resource allocation. As a large national database, National Inpatient Sample (NIS), contain valuable insights amenable to data-mining. The study aimed to develop and evaluate ML models predicting hospital discharge disposition with a focus on demographic, socioeconomic and hospital characteristics. MATERIALS AND METHODS: The NIS dataset (2006-2019) was used, including 4956 patients diagnosed with ischemic stroke who underwent thrombectomy. Demographics, hospital characteristics, and Elixhauser comorbidity indices were recorded. Feature extraction, processing, and selection were performed using Python, with Maximum Relevance - Minimum Redundancy (MRMR) applied for dimensionality reduction. ML models were developed and benchmarked prior to interpretation of the best model using Shapley Additive exPlanations (SHAP). RESULTS: The multilayer perceptron model outperformed others and achieved an AUROC of 0.81, accuracy of 77 %, F1-score of 0.48, precision of 0.64, and recall of 0.54. SHAP analysis identified the most important features for predicting discharge disposition as dysphagia and dysarthria, NIHSS, age, primary payer (Medicare), cerebral edema, fluid and electrolyte disorders, complicated hypertension, primary payer (private insurance), intracranial hemorrhage, and thrombectomy alone. CONCLUSION: Machine learning modeling of NIS database shows potential in predicting hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the NIS database. Insights gained from SHAP interpretation can inform targeted interventions and care plans, ultimately enhancing patient outcomes and resource allocation.

Effect of Treatment Choice on Short-Term and Long-Term Outcomes for Carotid Near-Occlusion: A Meta-Analysis.

OBJECTIVE: Current guidelines recommend best medical treatment (BMT) over revascularization for carotid near-occlusion (CNO); however, it remains unclear whether BMT, carotid artery stenting (CAS), or carotid endarterectomy (CEA) is the optimal treatment strategy. The present meta-analysis aimed to compare outcomes among patients with CNO receiving BMT, CAS, or CEA. METHODS: PubMed, Web of Science, Scopus, and Embase were searched. English studies with ≥1 month follow-up, that used established CNO diagnostic guidelines, that provided outcomes by treatment, and in which 95% confidence intervals (CIs) were calculable were included. Studies on acute ischemic stroke (AIS) requiring emergent reperfusion therapy, nonatherosclerotic lesions, nonprimary research articles, non-English, and nonhuman studies were excluded. Outcomes were mortality, AIS, transient ischemic attack, myocardial infarction within and beyond 30 days, and restenosis. A generalized linear mixed model, subgroup analysis, and meta-regression were used to compare outcomes. RESULTS: Thirty-eight studies were included. Pooled rates for AIS beyond 30 days were 9.90% (95% CI, 4.31%-21.16%), 0.79% (95% CI, 0.24%-2.53%), and 0.80% (95% CI, 0.15%-4.07%) for BMT, CAS, and CEA, respectively. Subgroup analysis was statistically significant (P < 0.001). Meta-regression showed lower incidence favoring procedural intervention (CAS vs. BMT, P = 0.001; CEA vs. BMT, P = 0.003). Subgroup analysis for mortality beyond 30 days was also significant (P = 0.016) but meta-regression did not favor one treatment over another. Other outcomes were not statistically significant. CONCLUSIONS: Revascularization for CNO may decrease long-term stroke rates. Given that current guidelines are based on randomized controlled trials from the 1990s, updated randomized trials are warranted to determine the optimal treatment for CNO.