Mechanical thrombectomy (MT) is the standard treatment for acute posterior circulation artery occlusion (PCAO), but predicting outcomes remains challenging. Existing prognostic models combine clinical, imaging, and procedural variables but show inconsistent performance. Our objective is to evaluate the diagnostic accuracy of Machine Learning (ML) models in predicting favorable functional outcomes of thrombectomy for acute PCAO. We conducted asystematic review and bivariate diagnostic meta-analysis of PubMed, Embase, and Web of Science. Eligible studies evaluated ML predicting favorable outcomes (Modified Rankin Scale of 0to3 at hospital discharge or at 90days) after MT for PCAO. Pooled sensitivity, specificity, and area under the summary receiver operating characteristic curve (AUC) were calculated with abivariate random-effects model. Five studies including 1739 patients met inclusion criteria. Pooled sensitivity was 78% (95% CI: 59-89%; I2 = 89.29%) and specificity was 80% (95% CI: 74-85%; I2 = 46.06%) for afavorable outcome. The Summary Receiver Operating Characteristic (SROC) curve yielded an AUC of 83% (95% CI: 80-86%). Subgroup analyses revealed that studies including patients with successful reperfusion (mTICI ≥ 2b) had significantly lower sensitivity and specificity. Random forest-based models achieved greater specificity, and multicenter studies demonstrated inferior specificity compared to single-center designs. ML models demonstrate good diagnostic accuracy in predicting functional outcomes after thrombectomy for acute PCAO. Integration of these models into clinical practice may support individualized decision-making and resource allocation, although prospective validation and improved reporting are needed before routine implementation.

Large-core acute ischemic stroke caused by large-vessel occlusion (LVO) is associated with high rates of disability despite mechanical thrombectomy. Prolonged venous transit (PVT), a marker of impaired venous drainage on CTP, has emerged as a potential prognostic indicator, but its role in large-core acute ischemic stroke (AIS)-LVO remains unclear. We aimed to test the hypothesis that PVT is independently associated with unfavorable functional outcomes in patients with large-core AIS-LVO. We conducted a retrospective cohort study using data from consecutive patients with AIS-LVO and large ischemic core volumes (ASPECTS <6 or relative CBF (rCBF)<30% volume ≥50 mL; per the SELECT-2 trial definition) between September 1, 2016, and September 2, 2024. PVT was assessed on pretreatment CTP based on qualitative time-to-maximum maps and was defined as time-to-maximum ≥10 seconds in the superior sagittal sinus or torcula. The primary outcome was unfavorable functional recovery at 90 days, defined as an mRS score of 4-6. One hundred patients met the inclusion criteria, and 41 (41%) had PVT. Unfavorable functional outcomes were more frequent in the PVT+ group (59% versus 37%; P = .036). Multivariable analysis confirmed that PVT was independently associated with unfavorable outcomes (adjusted OR, 4.07; 95% CI, 1.15-14.4; P = .03), even after accounting for penumbra size (time-to-maximum = >6s) and large-core volumes (rCBF <30%). Other predictors included older age (adjusted OR, 1.07; 95% CI, 1.02-1.11; P = .003), higher admission NIHSS (adjusted OR, 1.16; 95% CI, 1.05-1.29; P = .005), and larger rCBF <30% volume (adjusted OR, 1.02; 95% CI, 1.00-1.04; P = .032). PVT is independently associated with unfavorable outcomes in patients with large core AIS-LVO. These findings suggest that PVT may serve as a prognostic marker, warranting further investigation and validation in larger prospective studies to guide treatment decisions in this high-risk population.

Prolonged venous transit (PVT), derived from perfusion imaging, serves as a surrogate for venous outflow (VO) impairment and has been associated with worse outcomes in acute ischemic stroke due to large-vessel occlusion (AIS-LVO). However, the differential impact of superficial-versus-deep venous drainage impairment on functional outcomes remains unclear. PVT1 and PVT2 were used as surrogates for superficial and deep VO impairment, respectively. We retrospectively analyzed 128 patients with AIS-LVO from a prospective registry who underwent successful mechanical thrombectomy (modified TICI 2b/2c/3) with available baseline CTP and 90-day mRS scores. PVT- was defined as the absence of time-to-maximum (Tmax) ≥10 seconds in the posterior superior sagittal sinus (SSS) or torcula (no VO impairment). PVT1 was defined as the presence of Tmax ≥10 seconds in the posterior SSS only (superficial VO impairment); and PVT2, as the presence of Tmax ≥10 seconds at the torcula with or without posterior SSS involvement (deep VO impairment). Multivariable logistic regression assessed the association between PVT gradation and the 90-day mRS score. The proportion of patients achieving favorable outcomes (mRS ≤2) declined stepwise across the PVT gradation: 60.9% in PVT-, 42.1% in PVT1, and 22.7% in PVT2. After we adjusted for age, admission NIHSS score, hypertension, hemorrhagic transformation, IV thrombolysis, and the modified TICI score, PVT gradation remained independently associated with reduced odds of favorable outcome. This association was primarily driven by the PVT2 group, with an adjusted OTR of 0.230 (95% CI, 0.068-0.780) compared with PVT- group. PVT gradation based on Tmax ≥10 seconds timing in distinct venous territories provides prognostic insight into the differential contributions of superficial-versus-deep venous drainage dysfunction, supporting the use of PVT as a meaningful VO imaging biomarker. Deep VO impairment, as reflected by PVT2, is the primary driver of worse functional outcomes despite successful reperfusion in AIS-LVO, indicating its stronger negative prognostic impact compared with superficial VO impairment. These findings can help inform prognosis and postacute management strategies.

Futile recanalisation in patients with anterior large vessel occlusion stroke randomised to mechanical thrombectomy.

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.

BACKGROUND: Collateral blood flow is a critical determinant of successful recanalization in acute ischemic stroke caused by large vessel occlusion. Head down tilt −15° (HDT15), similar to Trendelenburg positioning, is a simple, low-cost positional therapy that may augment cerebral collateral blood flow and penumbral survival. The aim of the study is to assess the safety, feasibility, and efficacy of HDT15 in improving cerebral collateral circulation and clinical outcomes in patients with large vessel occlusion–acute ischemic stroke treated with mechanical thrombectomy (MT). METHODS: The DOWN-SUITE trial (Head Down Tilt 15° to Increase Collateral Flow in Acute Ischemic Stroke) is a multicenter, randomized, open-label, phase 2a/b clinical trial with blinded outcome assessment, conducted across 7 Italian stroke centers. A total of 118 patients with acute ischemic stroke due to M1 segment middle cerebral artery occlusion will be randomized 1:1 in the emergency department to receive HDT15 or standard positioning (head-of-bed 0° to +30°) before and during MT. RESULTS: The primary end point is good collateral status (American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grade 3–4), assessed on the first angiographic sequence during MT by a blinded imaging core laboratory. Secondary end points include feasibility (proportion maintaining HDT15, admission-to-MT time), safety (symptomatic intracranial hemorrhage, pneumonia, vomiting, neurological deterioration, vital signs), and efficacy (neurological improvement before MT, at 24 hours, and at 7 days or discharge, modified Rankin Scale score at 90 days). CONCLUSIONS: The DOWN-SUITE trial will provide evidence on the acute cerebrovascular effect of HDT15 in large vessel occlusion–acute ischemic stroke, potentially establishing a cost-effective, practice-changing intervention to improve collaterals for global stroke care. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06297863.

Establishing updated diagnostic reference levels for interventional radiology: a national Italian survey incorporating procedure complexity indices - Part II: interventional neuroradiology.

STRIDE study post hoc analysis shows first-line mechanical aspiration thrombectomy for either in-stent or in-graft versus native vessel thrombosis in lower extremity acute limb ischemia yields similar outcomes.

Toxic metal Burden in Intracranial Thrombi Retrieved During Mechanical Thrombectomy: An Observational Study.

Use of a Funneled Sheath for Embolic Protection during Deep Venous Thrombectomy.

The use of mechanical thrombectomy in patients with STEMI and large thrombus burden: design and rationale of the NATURE trial

Mechanical Thrombectomy for All Large Core Infarcts: Would Hippocrates Agree?

Stroke is characterized by a sudden onset of neurological deficit attributed to a focal brain injury. The main treatments for patients with an acute ischemic stroke are intravenous thrombolysis and mechanical thrombectomy. Recanalization therapies have significantly improved patient outcomes; however, their effectiveness depends on a range of pathophysiological factors. This prospective observational study included 60 patients with acute ischemic stroke. The control group consisted of 20 healthy blood donors. Patients were divided into three groups based on whether they received intravenous thrombolysis, mechanical thrombectomy, or combination therapy. We investigated differences between recanalization therapies in patients with ischemic stroke with respect to peripheral blood concentrations of the proinflammatory cytokine interleukin (IL)-18 and endothelial glycocalyx degradation products: syndecan-1, heparan sulphate, and hyaluronic acid, measured by enzyme-linked immunosorbent assay. The blood samples were collected before, 24, and 48 h after recanalization therapy. The concentration of IL-18, syndecan-1, and heparan sulphate increased statistically significantly in patients treated with mechanical thrombectomy. The concentration of hyaluronic acid increased statistically significantly in patients treated with intravenous thrombolysis. The findings primarily reflect between-group differences. Our findings indicate that IL-18 has a significant role in the early inflammatory response. IL-18 and EG degradation products represent potential biomarkers for identifying high-risk patients. Their measurement could help improve the treatment, recovery, and outcomes in patients with acute ischemic stroke. The aforementioned observations underscore their potential value as biomarkers for future research.

Rescue stenting (RS) can achieve durable recanalization in cases of acute large vessel occlusion due to underlying intracranial artery stenosis (ICAS), but its clinical effects may be influenced by procedural factors. This study aimed to evaluate whether the severity of stenosis affects the outcomes after RS. In this multicenter retrospective study, patients with acute middle cerebral artery occlusion and underlying ICAS were divided into two groups based on the treatment they received: mechanical thrombectomy (MT) + RS (n = 172) or MT-only (n = 131). Inverse probability of treatment weighting was used to balance baseline characteristics. We systematically evaluated stenosis thresholds from 40% to 90% to identify the optimal cutoff that best differentiated treatment effects on the 90-day modified Rankin Scale (mRS) score and safety outcomes, including symptomatic intracranial hemorrhage (sICH). Astenosis severity of 75% was identified as the optimal cutoff for effect modification. While RS improved recanalization rates overall, its effect on the 90-day mRS score was beneficial only in patients with > 75% stenosis compared to MT-only (Average Treatment Effect (ATE) -0.98, 95% CI -1.73 to -0.22; p = 0.01). In contrast, it showed adetrimental effect in those with < 75% stenosis (ATE 1.08, 95% CI 0.32 to 1.83; p = 0.005). Furthermore, RS increased the rate of sICH regardless of ICAS severity. The clinical benefit of RS is contingent on the underlying stenosis severity, providing favorable outcomes in patients with high-grade stenoses only. ICAS severity should also be considered for treatment decisions, though these findings require validation in prospective controlled studies.

Objective Despite high recanalization rates with mechanical thrombectomy (MT) for acute ischemic stroke (AIS), functional outcomes remain variable. Systemic inflammation is a key driver of secondary brain injury post-reperfusion. The systemic immune-inflammation index (SII), calculated as (platelet count × neutrophil count)/lymphocyte count, integrates multiple inflammatory pathways and has shown prognostic value in cardiovascular diseases and stroke treated with intravenous thrombolysis. However, its role in predicting outcomes specifically for AIS patients undergoing MT remains underexplored. This study aimed to develop and validate an SII-based model for predicting 90-day functional outcomes after MT and to compare its performance with traditional inflammatory biomarkers, namely neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Methods We retrospectively analyzed data from 387 AIS patients treated with MT. The cohort had a median age of 68 years [interquartile range (IQR): 59–75], 67.2% were male, and the median time from stroke onset to thrombectomy was 340 min (IQR: 242.5–465.5). Inflammatory markers were measured at admission, such as SII, platelet lymphocyte ratio (PLR), neutrophil lymphocyte ratio (NLR) and 90-day modified Rankin Scale (mRS) scores. Patients were divided into good (90-day mRS ≤ 2; n = 151) and poor (mRS &amp;gt; 2; n = 236) outcome groups. We constructed and compared four logistic regression models: clinical baseline, baseline + SII, baseline + PLR, and baseline + NLR. Model performance was assessed using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration, and decision curve analysis (DCA). Results SII alone showed higher predictive accuracy (AUC: 0.834) than PLR or NLR. The optimal model (baseline + SII) achieved an AUC of 0.863, significantly improving outcome prediction over the baseline model (AUC: 0.655). Shapley Additive exPlanations (SHAP) analysis confirmed SII as the most influential variable (74.2% contribution). The model demonstrated good calibration and clinical utility across a range of probability thresholds. Conclusion A model incorporating the SII provides superior accuracy for predicting 90-day functional outcome after MT compared to models using NLR or PLR. As an easily obtainable composite biomarker, SII enhances risk stratification and could aid early clinical decision-making for AIS patients undergoing endovascular therapy.

Background: Reperfusion therapies for acute ischemic stroke (AIS)—intravenous thrombolysis and mechanical thrombectomy—have expanded in Brazil’s Unified Health System (SUS) after key regulatory milestones, but system performance varies across regions. Objective: To describe utilization, in-hospital mortality, length of stay, and hospital costs of reperfusion admissions for AIS in the SUS (2018–2025), and examine regional distribution and temporal trends. Methods: Ecological, retrospective time series using SIH/SUS (DATASUS/TabNet). We included admissions with primary ICD-10 I63* and identified reperfusion procedures recorded on the same authorization (thrombolysis; thrombectomy). Outcomes were in-hospital death, mean length of stay, and reimbursed costs. Indicators included counts, proportions, and rates per 100,000 inhabitants (IBGE denominators). Year 2025 covers January–August. Results: We identified 37,543 reperfusion admissions (2018–2025): 36,183 thrombolysis (96.4%) and 1,360 thrombectomy (3.6%). Thrombectomy first appeared in 2023 (n=37), expanded in 2024 (n=769), and remained high in 2025 (n=554, Jan–Aug). Overall in-hospital mortality was 10.6% (thrombolysis 10.4%; thrombectomy 16.3%). Mean length of stay was 8.1 days overall; for thrombectomy it decreased from 11.8 (2023) to 9.4 (2024) and 8.1 days (2025). Aggregate expenditure reached BRL 141.6 million (thrombolysis BRL 110.5m; thrombectomy BRL 31.1m). National reperfusion rates rose to 3.22/100,000 in 2024; thrombectomy reached 0.36/100,000. Conclusions: Reperfusion for AIS expanded in the SUS, with rapid thrombectomy uptake from 2023 while thrombolysis remained predominant. Higher mortality with thrombectomy is consistent with indication/severity bias; length of stay decreased over time. Persistent regional disparities highlight the need to strengthen stroke networks, streamline inter-hospital transfers, and monitor process and cost-consequence indicators to support equitable scale-up.

Intracoronary Vasoactive Therapy for No-Reflow During Primary PCI: A Network Meta-Analysis of Randomized Trials.

Mechanical thrombectomy is the standard of care for acute ischemic stroke due to large vessel occlusion. Whether the mothership model or the drip-and-ship model provides superior outcomes remains unclear. This systematic review and meta-analysis aimed to compare functional and safety outcomes between these 2 models and assess the impact of onset-to-groin puncture delay on outcomes. We conducted a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD420251034209). We searched PubMed, EMBASE, and Cochrane CENTRAL up to March 9, 2025. We included randomized trials, cohort studies enrolling patients with anterior circulation large vessel occlusion treated with mechanical thrombectomy. The primary outcome was 90-day functional independence (modified Rankin Scale score, 0-2). Secondary outcomes included excellent outcome (modified Rankin Scale score 0-1), successful recanalization, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and 90-day mortality. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of Interventions and Risk of Bias 2.0 tools. Meta-regression was performed to evaluate the effect of onset-to-groin puncture time differences on outcomes. Nineteen studies (16 485 patients) were included. The mothership model and drip-and-ship model showed no significant difference in achieving 90-day functional independence (odds ratio, 1.12 [95% CI, 0.94-1.32]). Meta-regression showed that longer delays to thrombectomy in the drip-and-ship model significantly reduced the odds of functional independence (P<0.001). A onset-to-groin time delay of approximately 43 minutes between the two models of care was identified as the threshold beyond which the mothership model conferred superior outcomes. Direct transport to a thrombectomy-capable center should be prioritized when secondary transfer is expected to delay treatment, as functional outcomes worsen significantly beyond this threshold.

To compare the ALGO Smart Pump (ALGO), operating in Adaptive Pulsatile Aspiration (APA™) and Static modes, with the Penumbra ENGINE during in-vitro mechanical thrombectomy, and to determine whether adaptive pulsatile aspiration improves complete clot ingestion (CCI) and reduces aspiration time across catheters sizes and catheter-to-artery (C/A) ratios. Apre-specified integrative analysis of two previously completed in-vitro thrombectomy studies was conducted using astandardized middle cerebral artery occlusion model. Atotal of 720 thrombectomy procedures were performed by two experienced operators using twelve commercial catheters (six small-bore, six large-bore). Three aspiration modalities were tested: ALGO APA™, ALGO Static, and Penumbra ENGINE continuous aspiration (n = 30 per catheter-pump pairing). The primary endpoint was CCI; secondary endpoint was aspiration time. Outcome analysis included two-way ANOVA and Chi-squared tests, with catheter, operator, and C/A ratio terms. The ALGO demonstrated ahigher median CCI rate than Penumbra (81.4% vs. 56.1%, χ2(1) = 52.364, p < 0.001). Aspiration times were significantly shorter with ALGO, particularly in APA™ mode (43.8 s vs. 60.6 s, p < 0.001). Two-way ANOVA demonstrated significant interaction between catheter size and pump type (p < 0.001), with ALGO notably improving small-bore catheter performance. CCI correlated positively with catheter-to-artery (C/A) ratio across both systems, with ALGO maintaining higher success across all ratios. Adaptive pulsatile aspiration enhances clot ingestion efficiency and reduces aspiration time in an in-vitro thrombectomy model, particularly for smaller catheters. These findings support further translational studies on optimizing aspiration dynamics to enhance first-pass success in endovascular stroke therapy.

Acute ischemic stroke (AIS) affects over 795,000 individuals annually in the U.S. and remains a leading cause of death. Alteplase has long been the standard thrombolytic therapy for AIS, though tenecteplase has recently gained attention due to its favorable pharmacokinetics and simplified administration. Despite its increasing clinical use and recent FDA approval for AIS, safety data, particularly regarding bleeding outcomes, remain limited. The objective was to compare the incidence of symptomatic intracranial hemorrhage (sICH), major bleeding events, and in-hospital mortality between alteplase and tenecteplase in AIS. This retrospective, real-world, multi-center chart review compared 832 patients with AIS treated with alteplase or tenecteplase. The primary outcome was the incidence of sICH. Secondary outcome measures assessed were major bleeding and all-cause in-hospital mortality. There were no statistically significant differences in sICH (alteplase 8.8% vs tenecteplase 7.3%, P = 0.5), major bleeding (alteplase 10.9% vs tenecteplase 10.5%, P = 0.9), or in-hospital mortality (alteplase 5.1% vs tenecteplase 5.5%, P = 0.9). Higher NIHSS scores and mechanical thrombectomy were associated with increased risk of bleeding and mortality, regardless of the thrombolytic agent administered. Tenecteplase demonstrated a comparable safety profile to alteplase in the treatment of AIS, with no significant differences in sICH, major bleeding, or in-hospital mortality. Stroke severity and mechanical thrombectomy were stronger predictors of selected adverse outcomes than the choice of thrombolytic agent. These findings support tenecteplase as an alternative to alteplase for AIS thrombolysis.