Introduction: Endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is supported by high-quality evidence, but patients with metastatic cancer have histocally been excluded from clinical trials. Thus, the safety and efficacy of EVT compared to best medical management (BMM) for LVO patients with metastatic cancer remains unclear. The objective of this retrospective cohort study is to assess outcomes of EVT for LVO stroke patients with concomitant metastatic cancer compared with BMM. Methods: The study population included adult patients with LVO stroke (internal carotid, middle cerebral, or basilar artery occlusion) and metastatic cancer from the 2016 to 2022 Nationwide Readmissions Database. Patients with brain tumors, lymphoma, leukemia, National Institutes of Health Stroke Scale (NIHSS) less than 6, or missing data were excluded. Propensity score matching was performed using 1-to-1 nearest-neighbor matching. The primary outcome was functional independence at hospital discharge. Secondary outcomes included discharge to home, hospital length of stay, in-hospital mortality, and 180-day mortality. Outcomes were also assessed in subgroups of patients who died during the initial hospitalization or within six months. Results: Of 5629 included patients, 3590 remained after propensity score matching (1833 EVT, 1757 BMM). Median age was 70 years for both groups; 52% were women. Compared to BMM, EVT was associated with higher rates of functional independence (17.8% vs 8.7%; P<.001) and discharge to home (42.3% vs 34.1%; P=0.001), with no significant difference in in-hospital mortality (22.8% vs 24.3%; P=0.49), hospital length of stay (median 7 vs 6 days; P=0.34), or 180-day mortality (28.4% vs 28.5%; P=0.98). Among patients who suffered in-hospital mortality (n=845), there was no significant difference in length of stay (LOS) (median 5 vs 4 days, p=0.52). Among patients who survived the index hospitalization but later died within 180 days (N=134), EVT was associated with higher rates of interim functional independence (33.8% vs 12.3%, p=0.014). Conclusions: Among LVO stroke patients with metastatic cancer, EVT was associated with significantly higher rates of functional independence without change in mortality or LOS.

Introduction: Endovascular therapy (EVT) is the only proven reperfusion strategy for basilar artery occlusion, while outcomes remain suboptimal as compared with anterior circulation stroke. Hypothermia is a well-recognized neuroprotectant but systemic cooling carries significant risks. To date, no targeted hypothermia approach has been systematically tested in posterior circulation acute ischemic stroke (AIS). This study aimed to evaluate the safety, feasibility, and preliminary efficacy of Vertebrobasilar Artery Cooling Infusion (VACI), a novel intra-arterial, selective hypothermia strategy delivered during EV in patients with basilar artery occlusion. Methods: In this prospective randomized controlled study (ID: ChiCTR2200065806), 40 patients with basilar artery occlusion undergoing EVT were randomized 1:1 to receive VACI (300 ml of 4 °C saline at 30 ml/min via vertebral artery immediately post-thrombectomy) or control (same volume of 37 °C saline). All patients enrolled received standard care according to current guidelines for stroke management. The primary outcome is symptomatic intracranial hemorrhage (sICH), whereas the secondary outcomes include functional outcome, infarction volume, mortality, ICH, fatal ICH, cerebral vasospasm, coagulation abnormality, pneumonia and urinary infection. Results: All patients completed follow-up. There was no significant difference in the incidence of symptomatic intracranial hemorrhage (sICH) between VACI and control groups. Rates of neurological deterioration and other complications were also compatible between groups. Notably, several favorable trends were observed in the VACI group. These included improved early neurological recovery (median NIHSS at 24 hours: 6 vs. 12.5, p =0.051) and reduced final infarct volume (9.0 ml vs. 17.5 ml). Furthermore, the hypothermia group exhibited a clinically notable reduction in mortality at both 90 days (10.0% vs. 20.0%;) and, more prominently at 7 days (5.0% vs. 20.0%). While these differences did not reach statistical significance, they consistently favored the hypothermia group. Conclusion: This study represents the first randomized trial of selective intra-arterial hypothermia in posterior circulation stroke, demonstrating both safety and preliminary signals of benefit. By integrating targeted cooling into EVT, VACI introduces a novel paradigm that may enhance outcomes in this high-risk population. Larger multicenter trials are warranted to confirm its therapeutic benefit.

Background and ObjectivesTranscranial Doppler (TCD) ultrasound is recommended for measuring cerebral blood flow velocity to guide therapeutic intervention in patients with cerebrovascular diseases. However, the widespread use of TCD is hampered by a shortage of trained practitioners. This study evaluated the efficacy of a simulator-based curriculum in teaching novices the foundational skill to perform TCD insonation.MethodsWe developed a curriculum on a novel simulator that incorporates interactive practice with real-time feedback. We assessed change in the skill levels of medical and premedical students without previous exposure to TCD from pretraining and posttraining tests. Psychomotor skill was assessed based on accuracy in insonating the middle cerebral, anterior cerebral, ophthalmic, basilar, and vertebral arteries. Cognitive skill (knowledge) was assessed using multiple-choice questions (MCQs).ResultsTraining significantly improved skill: the correct insonation rate increased from 16 ± 24% (95% CI 9%–23%) on the pretest to 61 ± 34% (95% CI 52%–70%) on the posttest (N = 56, p < 0.0001, Cohen d = 1.5). First-attempt accuracy improved from 15 ± 23% (95% CI 9%–21%) to 49 ± 31% (95% CI 41%–57%) (N = 56, p < 0.0001, Cohen d = 0.9). Knowledge increased markedly, with MCQs answered correctly rising from 7 ± 26% (95% CI 0%–14%) to 64 ± 19% (95% CI 59%–69%) (p < 0.0001, Cohen d = 2.5). The course, including pre-test and posttests, was completed in 2.6 ± 1.0 hours.DiscussionSimulator-based training rapidly improved the ability of novices to locate intracranial arteries for measurement of blood flow velocity. The data support the employment of simulator-based training as a foundational step to help alleviate the shortage of trained providers. The simulator's self-directed practice allows for scalable, standardized training.

The cause of perimesencephalic subarachnoid hemorrhage (pmSAH) is unclear but has historically been attributed to a venous source. The authors hypothesized that high-resolution cone-beam CT (CBCT) during angiography could better identify pmSAH etiology. All patients with pmSAH treated at the authors' institution between January 2023 and December 2024 were retrospectively analyzed. Patients were excluded if CBCT was not performed as part of the digital subtraction angiography (DSA), if CBCT source data were not available for review, or if the images were deemed to be low quality. All images were reviewed by 2 neuroangiographers with extensive neurovascular imaging experience and discussed until consensus agreement. Data were recorded as counts and percentages. Among 152 patients who presented with spontaneous SAH in 2023-2024, 22 had a pmSAH defined according to the Rinkel criteria. These 22 patients had a catheter angiogram performed on 1 of 2 biplane machines. Thirteen of those patients had high-quality CBCT data available for review, 8 (61%) of whom were found to harbor a basilar perforator focal outpouching consistent with a site of rupture. All patients with pmSAH, including the 8 found to have a basilar perforator aneurysm, achieved an excellent neurological recovery with resolution of the basilar perforator finding on follow-up DSA with CBCT and without experiencing a re-rupture event or clinically significant vasospasm. In the setting of pmSAH, high-resolution CBCT acquired as part of catheter angiography frequently identifies a basilar perforator pseudoaneurysm. Conservative management was associated with excellent outcomes in this series. The authors propose that in the setting of pmSAH, a high suspicion of an arterial etiology should be considered until proven otherwise.

Due to the complex anatomical structure surrounding the basilar artery trunk, basilar trunk aneurysms (BTAs) can result in severe complications and poor prognosis for patients. The treatments for BTAs still remain challenging and uncertain. We conducted a comprehensive search of Embase, MEDLINE, Cochrane Library databases using medical subject headings and free-text terms, with the last search completed on July 1st, 2024. Both single-arm and two-arm meta-analysis were performed to compare the safety and effectiveness of different treatments for BTAs. Both fixed-effects models and random-effects models were calculated. When the heterogeneity was over 50%, we chose the random-effects model. We identified 21 studies enrolling 593 participants and 599 aneurysms. The summary favorable outcome proportion was 0.46 (95% CI: 0.303 to 0.625) for open surgery and 0.75 (95% CI: 0.671 to 0.819) for endovascular treatments in the random-effects model, as the I2 for heterogeneity was 66% (P < 0.01) for open surgery and 53% for endovascular treatments (P < 0.01). Significant differences were observed between the two subgroups in the single-arm meta-analysis (P < 0.01). In the direct comparisons of good outcomes between open surgery and endovascular treatments in BTAs, no statistically significant difference was observed. The relative risk (RR) was 0.82 (95% CI: 0.549 to 1.224) and the P value was 0.5226. The comparison revealed no statistically significant changes in mortality, complications and complete occlusion (P > 0.05). No statistically significant difference was observed between the open surgery and endovascular treatments. The mortality and complication outcomes revealed no distinctions between the two subgroups, regardless of whether direct or indirect comparisons was conducted. The influence of institutional expertise emerged as a critical factor in treatment outcomes. Furthermore, more effective controls and larger sample size are required to achieve more credible and conclusive results.

Basilar artery pseudoaneurysm (BAPA) is an extremely rare yet life-threatening intracranial vascular lesion, characterized by insidious clinical onset and a remarkably high mortality risk upon rupture. In this case report, we describe a patient who was admitted to our department with spontaneous subarachnoid hemorrhage (SAH). Emergency digital subtraction angiography performed on admission revealed no vascular anomalies. One month after SAH onset, a comprehensive multimodal imaging evaluation ultimately confirmed the diagnosis of BAPA. Given the technical challenges in conventional management for this specific case, Traxcess-14 microguidewire-assisted endovascular electrocoagulation was performed as a last-resort therapy. Finally, follow-up imaging at 6 months demonstrated complete resolution of BAPA. Thus, we propose that Traxcess-14 microguidewire-assisted endovascular electrocoagulation may serve as a potential salvage treatment for highly selective BAPA cases in which conventional therapeutic approaches are unfeasible or have failed.

Clinical scores indicating large vessel occlusion (LVO) in acute stroke patients could streamline triage of patients with suspected LVO to endovascular centers. GFAP (glial fibrillary acidic protein) is a promising blood biomarker for indicating intracerebral hemorrhage in acute stroke. This study evaluates whether positive LVO score results combined with a prehospital negative GFAP test (thereby excluding intracerebral hemorrhage) could improve the accuracy of LVO detection. This retrospective diagnostic accuracy study (DETECT LVO) is based on the prospective DETECT study (2022-2024, tertiary care hospital RKH Klinikum Ludwigsburg, Germany), which evaluated the rapid intracerebral hemorrhage detection in acute stroke, measuring prehospital plasma GFAP levels on a point-of-care platform (i-STAT Alinity Abbott). For DETECT LVO 5, established LVO scores (Rapid Arterial Occlusion Evaluation, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Emergency Medical Stroke Assessment, Cincinnati Prehospital Stroke Scale) were retrospectively calculated from paramedic protocols. LVOs were diagnosed with CT-angiography as follows: occlusion of the internal carotid artery, middle cerebral artery, and basilar artery. Diagnostic accuracy for LVO detection was determined using the area under the curve, sensitivity, specificity, positive predictive values, and negative predictive values. Three hundred fifty-three patients suspected of acute stroke (ischemic stroke, n=258; intracerebral hemorrhage, n=76; stroke mimics, n=19) with a mean age of 74.6 years were included. One hundred one patients with ischemic stroke suffered from LVO (internal carotid artery=23.8%; middle cerebral artery=64.4%; and basilar artery=11.9%). Integrating GFAP to LVO scores significantly increased area under the curve (95% CI) for LVO detection (Field Assessment Stroke Triage for Emergency Destination, 0.859 [0.818-0.893] to 0.899 [0.862-0.928]; Rapid Arterial Occlusion Evaluation, 0.845 [0.802-0.880] to 0.892 [0.855-0.923]; 3-Item Stroke Scale, 0.788, [0.741-0.829] to 0.865 [0.824-0.898]; Emergency Medical Stroke Assessment, 0.840 [0.796-0.875] to 0.870 [0.830-0.910]; Cincinnati Prehospital Stroke Scale, 0.827 [0.784-0.865] to 0.862 [0.821-0.896]; P<0.001). Integrating LVO scores combined with GFAP measurements into the prehospital work-up of patients with acute stroke improves diagnostic accuracy for LVO prediction. In the future, this could enable direct transfers of patients with suspected LVO to endovascular centers with reduced misdiagnosis rates. Independent replication in diverse prehospital cohorts is warranted to confirm these findings.

Abstract Objective Cerebral vasospasm peaks between the fourth and seventh days after hemorrhage and occurs in approximately 70% of patients. Cannabidiol (CBD) has shown potential therapeutic effects, including anti-inflammatory, antioxidant, and vasodilatory properties. We aimed to investigate the effects of CBD on vasospasm in rats with induced SAH. Methods Male Wistar rats were divided into six groups, with ten rats in each group: the non-surgical control group (Group 1), the untreated SAH group (Group 2), and groups receiving intraperitoneal injections of 50 mg CBD (Group 3), 100 mg CBD (Group 4), 200 mg CBD (Group 5), or 0.05 mg Nimodipine (Group 6) after SAH induction. Results In our study, total protein levels increased dose-dependently with CBD treatment, reaching the highest levels in the CBD200 group, indicating neuroprotective effects. IL-1ß and IL-6 levels were significantly lower in the groups treated with CBD, especially in the CBD50 group. Glutamate and myeloperoxidase levels were significantly reduced in the CBD-treated groups. We observed a decrease in Synapsin 1 in all treated groups, with the most significant reduction in the group treated with 50 mg/kg CBD. Histological measurements of the basilar artery for vasospasm showed that vasospasm was present in the untreated group, while the artery diameter was widest in the group treated with 50 mg/kg CBD. Conclusion The potential effect of CBD in reducing the severity of vasospasm and improving outcomes after SAH highlights its importance for future clinical applications.

BackgroundCerebral hypoperfusion can result in cognitive decline and is a risk factor for Alzheimer's disease (AD). A common cerebral anatomical variation (vertebral artery hypoplasia [VAH]) has been linked to reduced cerebral blood flow and elevated cerebral pulsatility. Additionally, increased blood pressure (BP) and arterial stiffness are associated with elevated cerebral pulsatility and may increase risk for neurodegeneration and AD in those with VAH. Therefore, the purpose of this study was to determine the influence of BP and arterial stiffness on cerebral pulsatility and biomarkers for neurodegeneration and AD in adults with and without VAH.MethodsSixty‐five cognitively unimpaired healthy older adults (64±4 years; 52 females) with VAH (n = 17) and without VAH (noVAH; n = 48) were included in the study. Brachial BP, arterial stiffness (carotid‐femoral pulse wave velocity), serum blood samples, and 3T magnetic resonance imaging (MRI) were assessed. Serum samples were analyzed for neurofilament light chain (NfL) and phospho‐tau 217 (pTau 217). Intracranial pulsatility index (PI) was quantified using 4D flow MRI in the internal carotid arteries (ICAs), anterior cerebral arteries (ACAs), middle cerebral arteries (MCAs), vertebral arteries (VAs), and basilar artery (BA).ResultsThere were no group differences in BP, arterial stiffness, or cerebral PI (in the ICAs, MCAs, VAs, and BA) between VAH and noVAH (p >0.05 for all). However, the VAH group had greater ACAs PI (p <0.01) compared with the noVAH group. Systolic BP was positively associated with cerebral PI in the MCAs in the VAH group only (r=0.63, p <0.01), as there was no association in the noVAH group (r=0.08, p = 0.60). There were no differences in serum NfL or pTau 217 biomarkers between VAH and noVAH groups (p >0.05 for both). In addition, systolic BP was inversely associated with pTau 217 (r=‐0.80, p <0.01) in the VAH group only, as there was no association in the noVAH group (r=‐0.04, p >0.83).ConclusionsAdults with VAH had greater cerebral pulsatility in the anterior circulation compared with adults without VAH. In adults with VAH, increased systolic BP resulted in elevated cerebral pulsatility and potentially acting as a compensatory mechanism for decreased perfusion pressure, the increased systolic BP resulted in a reduction in pTau 217 levels.

Superior cerebellar artery (SUCA) aneurysms are rare and anatomically challenging lesions. Surgical and endovascular approaches are complicated by the vessel's small diameter, and proximity to eloquent structures. We describe a technique combining balloon-assisted coiling followed by Half-T or Complete T stenting using a braided stent, aiming to achieve high occlusion rates with low complication risk. This retrospective, single-center study included patients with unruptured aneurysms at the origin of the superior cerebellar artery (SUCA) treated between May 2012 and December 2023. All patients underwent balloon-assisted coiling followed by stenting in either a Half-T or Complete T configuration through the remodeling balloon. Clinical and angiographic outcomes, peri-and post-procedural complications, and 12-month follow-up digital subtraction angiography (DSA) were assessed. A total of 55 patients were treated. All achieved immediate post-procedural complete occlusion (Raymond-Roy Class I). The overall periprocedural complication rate was 5.5% (n = 3), including two minor-ischemic events and one limited arterial dissection without ischemic consequence; none resulted in clinical deterioration or worsening of the modified Rankin Scale (mRS) score at discharge. No hemorrhagic events were observed. At 12-month follow-up, 94% of patients maintained Class I occlusion. Favorable clinical outcomes (mRS 0-1) were observed in 92% of patients, of whom 98% demonstrated no change in mRS compared to their pre-procedural baseline. Subgroup analysis of patients treated with a Complete T configuration showed comparable safety and efficacy outcomes. Balloon-assisted coiling followed by Half-T or Complete T stenting appears to be a safe and effective method for treating unruptured SUCA aneurysms, achieving high and durable occlusion rates. Limitations include retrospective design, lack of control group, and self-adjudicated results. Further multicenter and core-lab validated studies are warranted. SUCA = superior cerebellar artery; BA = basilar artery; PCA = posterior cerebral artery; ACT = activated clotting time; FD = flow diverter.

A persistent trigeminal artery (PTA) is a rare embryonic vascular remnant that can be implicated in stroke. This case involves a woman in her late 70s who presented following a ground-level fall with diplopia. Her National Institutes of Health Stroke Scale (NIHSS) score was initially 0, but she later developed acute neurological symptoms with an NIHSS of 25. She was found to have a large posterior circulation ischaemic penumbra on CT angiography. The terminal basilar artery was supplied primarily by a stenosed left Saltzman type I PTA. Angioplasty and stenting of the stenosed left PTA were performed, resulting in successful revascularisation and improved basilar artery flow. The patient showed substantial neurological recovery within 72 hours and was discharged to a rehabilitation facility with an NIHSS of 14. This case underscores the importance of recognising embryonic vascular variants like PTA in stroke and shows that endovascular treatment can be both safe and effective.

Recent outcomes of intravenous tissue plasminogen activator (t-PA) alone in the era of mechanical thrombectomy: A sub-analysis of the Kanagawa Intravenous and Endovascular Treatment (K-NET) registry.

Diseases affecting the central nervous system of domestic animals account for a substantial proportion of the conditions encountered in clinical and surgical practice involving production animals. While the cerebral vascular anatomy is well characterized in humans; however, detailed information remains limited for many mammalian species, particularly regarding the origin of the basilar artery and the contribution of the vertebral artery. The study of the arteria distribution responsible for cerebral irrigation in domestic animals and species used as experimental models, from a phylogenetic perspective, remains relevant in biomedical research due to the high variability in vascular arrangements among species. This study aimed to describe the typology and formation of the arterial circle at the base of the brain in neonatal Saanen goats. Eleven heads from cadavers approximately one month of age (5 males and 6 females) were dissected, after fixation in 10% formaldehyde, followed by arterial injection with colored Petrolátex S-65. The mean and standard deviation of the basilar artery length was 2.5 ± 0.30 cm in females and 2.6 ± 0.22 cm in males. In all specimens, the basilar artery originated from the anastomosis of the right and left vertebral arteries, giving rise to branches supplying the medulla oblongata, the caudal cerebellar arteries, pontine branches, terminal branches, and rostral cerebellar arteries. The arteries at the base of the brain were supplied by both the carotid and vertebrobasilar systems. The encephalic vascular pattern showed a tendency toward type II. These findings are fundamental for understanding the cerebral vascularization of the species and its clinical-surgical applications.

Diagnostic performance of Angio-Based fractional flow for hemodynamic assessment in intracranial Atherosclerosis.

To investigate cerebral vasorelaxation of total flavonoids of Chuzhou chrysanthemum (TFCC) in rats and its mechanism. Cerebral basilar arteries (CBA) of rats were isolated, and the vasodilation induced by TFCC (10-2,560 mg/L) following pretension with 100 nmol/L U46619 or 30 mmol/L KCl were measured using a pressure myograph system. Addition of H2S synthase cystathionine-γ-lyase (CSE) inhibitor dl-propargylglycine (PPG, 100 µ mol/L), a large-conductance Ca2+-activated potassium (BKCa) channel blocker iberiotoxin (IBTX,100 nmol/L) and L-type Ca2+ channel blocker nifedipine (100 nmol/L) were added to determine the effect of pretreatment with the inhibitors on TFCC-induced vasorelaxation. KCl (30 mmol/L) was used as a contractile agent, TFCC (3.3-270 mg/L)-induced relaxation was detected by measuring the length of the long axis of rat cerebral vascular smooth muscle cells (VSMCs). Determination of the effect of pretreatment of VSMCs by IBTX or nifedipine on TFCC-induced cellular relaxation, and intracellular free Ca2+ concentration ([Ca2+]i) was detected by fluorescent method. Endothelial cells (ECs) were co-cultured with VSMCs to observe the effect of endogenous H2S on TFCC-induced relaxation in VSMCs. TFCC caused a concentration-dependent vasorelaxation in the rat CBA precontracted with KCl or U46619 (P<0.01). Endothelial removal markedly attenuated this vasodilation, but the remaining vasorelaxation was still significant (P<0.01). The TFCC-induced cerebral vasorelaxation was remarkably inhibited by PPG, IBTX and nifedipine (P<0.01). TFCC caused a significant relaxation of rat CBA VSMCs (P<0.01). Co-culture with wild-type cerebral ECs but not with cystathionine-γ-lyase- or 3-mercaptosulfotransferase-knockout ECs markedly enhanced TFCC-induced relaxation of VSMCs (P<0.05) and increased H2S content (P<0.01). TFCC decreased the [Ca2+]i in VSMCs (P<0.01), which was attenuated by PPG and IBTX. TFCC dilated rat CBA in both endothelium-dependent and -independent manner. Its endothelium-dependent dilation was probably involved in the blockade of L-type Ca2+ channels caused by endothelial H2S activating BKCa channels in VSMCs; its endothelium-independent relaxation was primarily from the direct blockade of the L-type Ca2+ channels in VSMCs.

Giant basilar artery aneurysm initially manifesting as hydrocephalus

Background Previous clinical trials have supported the use of endovascular therapy (EVT) for basilar artery occlusion (BAO) stroke within 24 hours of symptom onset. However, the safety and effectiveness of EVT in patients with BAO treated beyond 24 hours remains unclear. Purpose To compare clinical outcomes and safety following EVT combined with standard medical care versus medical care alone in patients with acute ischemic stroke due to BAO treated beyond 24 hours from symptom onset. Materials and Methods This multicenter retrospective study enrolled patients between March 2017 and April 2024 across China. Eligible patients had BAO and were treated with EVT or standard medical care beyond 24 hours from symptom onset. The primary outcome was the proportion of patients achieving good functional status (modified Rankin Scale score, 0-3). Primary safety outcomes included 90-day mortality and symptomatic intracranial hemorrhage. Inverse probability-weighted regression was performed to adjust for prespecified clinical characteristics, and instrumental variable analysis was repeated as sensitivity analysis. Results Among 217 patients (median age, 66 years [IQR, 58-73 years]; 160 men), good functional status at 90 days was achieved in 35.7% (46 of 129) of patients who underwent EVT and 26.1% (23 of 88) of controls (inverse probability of treatment weighting [IPTW]-adjusted risk ratio [RR], 1.67; P = .008), which was confirmed by instrument variable analysis (adjusted RR, 2.18; P = .04). There was no evidence of a difference in mortality at 90 days between EVT and control groups (48.1% [62 of 129 patients] vs 54.6% [48 of 88 patients]; IPTW-adjusted RR, 0.80; P = .10). Risk of symptomatic intracranial hemorrhage was higher in EVT compared with control groups (11.9% [15 of 126 patients] vs 1.3% [one of 80 patients]; IPTW-adjusted RR, 11.01; P = .02). Conclusion In this study of patients with BAO treated beyond 24 hours from symptom onset, EVT was associated with higher odds of good functional status at 90 days compared with standard medical care, albeit with increased odds of symptomatic intracranial hemorrhage. Chinese Clinical Trial Registry no. ChiCTR2000041117 © RSNA, 2026 Supplemental material is available for this article.

Clinical predictors of 90-day mortality after endovascular treatment for acute basilar artery occlusion

The conventional transcranial approach for treating lower basilar artery aneurysms is challenging because the deep and narrow surgical field limits surgical maneuvering for clipping. We report a case of a 77-year-old female who presented with right hemiparesis caused by a partially thrombosed giant aneurysm in her lower basilar artery. We performed neck clipping and thrombus debulking using a combined transcranial and endonasal approach. This approach enabled us to secure the parent artery from the endonasal side, which is difficult to achieve with the transcranial approach alone. It also allowed for early thrombus removal, thereby widening the surgical field on the transcranial side. Additionally it compensated for the transcranial blind spot by observing the clip tip from the endonasal side. After surgery, the patient required 3 months of rehabilitation for residual right hemiparesis before being discharged. Follow-up imaging revealed a reduction in the size of the partially thrombosed aneurysm. To our knowledge, this is the first report of a combined transcranial and endonasal approach for the treatment of a basilar artery aneurysm. For lower basilar artery aneurysms, this combined approach may offer advantages in achieving safe parent artery control, thrombus debulking, and neck clipping.

While endovascular therapy (EVT) is established for acute basilar artery occlusion (BAO), the clinical value of remedial angioplasty or stenting (RAS) is debated. This study investigated the efficacy and safety of RAS in patients with BAO undergoing EVT, the etiology dependent outcomes (atherosclerotic vs non-atherosclerotic outcomes), and the comparative effectiveness of balloon angioplasty versus stent based strategies. In this post hoc analysis of the prospective ATTENTION (Trial of Endovascular Treatment of Acute Basilar Artery Occlusion) multicenter trial, 221 patients with BAO receiving EVT were grouped into RAS (n=104) versus non-RAS groups (n=117). RAS included balloon angioplasty, stenting, or combined approaches. The primary outcome was 90 day favorable outcome (modified Rankin Scale score 0-3). Safety outcomes included any intracranial hemorrhage (ICH) and symptomatic ICH (sICH) at 24-72 hours, and 90 day mortality. Inverse probability of treatment weighting balanced baseline covariates, followed by multivariate logistic or ordinal regression for outcomes. Prespecified subgroup analyses by stroke etiology included interaction tests using stratified regression. RAS showed no significant benefit for 90 day favorable outcomes (adjusted OR 0.81, 95% CI 0.55 to 1.19, P=0.282) despite lower ICH rates (OR 0.52, 0.28 to 0.92, P=0.027). RAS was associated with worse outcomes in non-atherosclerotic patients (P=0.003 for stroke etiology × RAS interaction), with no such effect in atherosclerotic cases. Balloon angioplasty alone showed comparable efficacy to stent based interventions (P=0.373). RAS did not improve functional outcomes in BAO overall and was associated with worse outcomes in non-atherosclerotic patients. Atherosclerotic subgroups may derive nuanced benefit, although further research is needed. Etiology tailored EVT strategies are warranted, with balloon angioplasty as a viable initial remedial option. ClinicalTrials.gov NCT04751708.