Rapid Endovascular Treatment Research Articles

Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction

The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations. A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options. The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival. Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial.

Clinical outcomes in acute ischemic stroke due to medium vessel occlusion (MeVO) are often poor when treated with best medical management. Data from non-randomized studies suggest that endovascular treatment (EVT) may improve outcomes in MeVO stroke, but randomized data on potential benefits and risks are hitherto lacking. Thus, there is insufficient evidence to guide EVT decision-making in MeVO stroke. The primary aim of the ESCAPE-MeVO trial is to demonstrate that acute, rapid EVT in patients with acute ischemic stroke due to MeVO results in better clinical outcomes compared to best medical management. Secondary outcomes are to demonstrate the safety of EVT, its impact on self-reported health-related quality of life, and cost-effectiveness. Based on previously published data, we estimate a sample size of 500 subjects to achieve a power of 85% with a two-sided alpha of 0.05. To account for potential loss to follow-up, 530 subjects will be recruited. ESCAPE-MeVO is a multicenter, prospective, randomized, open-label study with blinded endpoint evaluation (PROBE design), clinicaltrials.gov: NCT05151172. Subjects with acute ischemic stroke due to MeVO meeting the trial eligibility criteria will be allocated in a 1:1 ratio to best medical care plus EVT versus best medical care only. Patients will be screened only at comprehensive stroke centers to determine if they are eligible for the trial, regardless of whether they were previously treated at a primary care center. Key eligibility criteria are (1) acute ischemic stroke due to MeVO that is clinically and technically eligible for EVT, (2) last-known well within the last 12 h, (3) National Institutes of Health Stroke Scale > 5 or 3-5 with disabling deficit, (4) high likelihood of salvageable tissue on non-invasive neuroimaging. The primary outcome is the modified Rankin scale 90 days after randomization (shift analysis), whereby modified Rankin Score 5 and 6 will be collapsed into one category. Secondary outcomes include dichotomizations of the modified Rankin Score at 90 days, 24 h National Institutes of Health Stroke Score, difference between 24 h and baseline National Institutes of Health Stroke Score, mortality at 90 days, health-related quality of life (EQ-5D-5 L), Lawton scale of instrumental activities of daily living score, reperfusion quality (MeVO expanded Thrombolysis in Cerebral Infarction Score) and infarct volume at 24 h, and cost-effectiveness of endovascular recanalization. Safety outcomes include symptomatic and asymptomatic intracranial hemorrhage and procedural complications. The ESCAPE-MeVO trial will demonstrate the effect of endovascular thrombectomy in addition to best medical management vis-à-vis best medical management in patients with acute ischemic stroke due to MeVO and provide data for evidence-based treatment decision-making in acute MeVO stroke. The raw data discussed in this mansucript will be made available by the corresponding author upon reasonable request.

Prehospital identification of acute ischaemic stroke with large vessel occlusion: a retrospective study from western Norway

BackgroundIn 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness,...

Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients.

Recent studies have implied that ongoing intravenous thrombolysis (IVT) during endovascular treatment (ET) improves functional outcomes in patients who have undergone stroke caused by a large vessel occlusion (LVO). In this study, we investigated the effect of ongoing IVT until completion of ET on procedure duration, first-pass thrombectomy rate, and periprocedural complications. We analyzed patients from the German Stroke Registry-Endovascular Treatment dataset, collected between June 2015 and December 2021. Primary outcomes were modified Rankin Scale (mRS) score after 3 months and achievement of a Thrombolysis In Cerebral Infarction (TICI) score of 2b-3. Secondary parameters included ET duration, first-pass thrombectomy, and periprocedural complications. Of the 13,082 patients in the dataset, 1,639 met the study inclusion criteria. A total of n = 317 patients (19.3%) underwent ongoing IVT until completion of ET, while IVT was completed prior to ET in 1,322 patients (80.7%). Ongoing IVT was associated with higher rates of achievement of an mRS score of 0-2 (or a back-to-baseline) after 3 months [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.08-2.17]. Furthermore, ongoing IVT was predictive of achievement of a TICI score of 2b-3 (OR 1.37; 95% CI 1.03-1.83) and of first-pass thrombectomy (OR 2.07; 95% CI 1.51-2.84), while reducing the rate of peri-interventional complications (OR 0.64; 95% CI 0.44-0.94) and reducing ET duration by 24 min [β = -24.35; 95% CI -32.92-(-15.79)]. Our findings suggest that ongoing IVT until ET completion has a favorable impact on both clinical and angiographic outcomes, as well as on periprocedural conditions, regardless of the overall time intervals involved. Therefore, rapid ET after IVT should be sought in order to take advantage of the additive effect of ongoing IVT during ET. Future studies should consider IVT timing in the context of ET as a potential confounder and treatment target.

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

A Guide to Femoral Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta

Arterial access is essential in the resuscitation of trauma and hemorrhagic shock patients and can be effectively used for rapid endovascular treatment such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and interventional radiology (IVR), continuous invasive hemodynamic monitoring, and frequent blood tests. In the REBOA procedure, obtaining arterial access is the first and most critical step. Arterial access can be obtained in three ways: (1) blind/landmark technique, (2) ultrasound-guided technique or (3) surgical cutdown technique. Regardless of which technique is chosen, it is crucial to recognize external landmarks before implementing any technique. In ultrasound-guided puncture, there are two types of techniques: short-axis puncture and long-axis puncture. There are two methods for actual puncture: the single-wall puncture method and the double-wall puncture method. In cases of hemorrhagic shock, the double-wall puncture method is advantageous when it is necessary to obtain arterial access quickly and reliably. The cutdown technique is useful when the femoral artery cannot be identified through ultrasound guidance or cannot be punctured for a long time owing to puncture-induced hematoma or obesity. This technique should be used without hesitation if it is evaluated to be more rapid and reliable than an ultrasound-guided puncture.

A Prospective Economic Evaluation of Rapid Endovascular Therapy for Acute Ischemic Stroke.

During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient's lifetime. Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis. The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (-$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care. Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient's lifetime.Clinical Trial Registration: NCT01778335.

Randomized Assessment of Rapid Endovascular Treatment in Basilar Artery Occlusion Stroke in 115 Hospital

Randomized Assessment of Rapid Endovascular Treatment in Basilar Artery Occlusion Stroke in 115 Hospital

Abstract WP54: MR CLEAN-MED - The Effect of Periprocedural Medication in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke: Heparin, Antiplatelet Agents, Both or Neither

Background: Rapid endovascular treatment (EVT) in patients with acute ischemic stroke with confirmed proximal intracranial occlusion has been proven safe and effective. Still, many patients do not recover despite recanalization. Yet, it is unknown whether periprocedural antithrombotic medication in patients treated with EVT can improve clinical outcome. The objective of this study is to assess the effect of acetylsalicylic acid (ASA) and unfractionated heparin, alone, or in combination, in patients who undergo EVT. Methods: MR CLEAN-MED is a multicenter, prospective, randomized, open-label, blinded-endpoint trial using a 2x3 factorial design. We plan to enroll 1500 patients with a clinical diagnosis of acute ischemic stroke and confirmed intracranial anterior circulation occlusion, who will undergo EVT with or without prior intravenous thrombolysis according to standard care. Study interventions: IV treatment with ASA (300 mg), low dose unfractionated heparin (loading dose of 5000 IU followed by 500 IU/hour x 6 hours) and moderate dose unfractionated heparin (loading dose of 5000 IU followed by 1250 IU/hour x 6 hours). Primary outcome is the score on the modified Rankin Scale 90 days after inclusion in the study. Safety endpoints include the occurrence of symptomatic intracerebral hemorrhage. Results: First patient enrolled on January 22nd, 2018. 1 active enrolling site, 17 sites starting up. Conclusion: We hypothesize that despite the potentially increased risk of (symptomatic) intracerebral hemorrhage, periprocedural ASA and unfractionated heparin alone or in combination will improve functional outcome of patients with acute ischemic stroke treated with EVT. Trial Registration Number: ISRCTN 76741621 Funding: Dutch Heart Foundation, Dutch Brain Foundation, Stryker

Abstract WP55: The Successful/Partial Early Reperfusion After IV rt-PA Before Mechanical Thrombectomy

Background and Purpose: Intravenous thrombolysis tissue plasminogen activator (IV rt-PA) is known as effective to improve functional outcome for acute ischemic stroke. Also, it is known that rapid endovascular treatment improve functional outcome of patients after IV rt-PA. However, the rate of early reperfusion in patients with occluded artery just after IV rt-PA remains unclear. Purpose of this study was to evaluate prevalence of the early reperfusion after IV rt-PA, before mechanical thrombectomy. Methods: Between January 2015 and April 2018, 1753 consecutive ischemic stroke patients who were hospitalized were identified using prospective stroke registry. Four dimensional computed tomography (4DCT) were performed to identify an occulted artery before IV rt-PA. After IV rt-PA, vessel recanalization was diagnosed using Digital subtraction angiography or MR Angiography. Results: Among 1753 consecutive patients, 246 (14%) patients were received IV rt-PA. 117 patients were enrolled, with a mean age of 77 years (SD, 11 years), 66 (56.4%) were male (91 patients without occlusive artery, 24 without 4DCTA before IV rt-PAand 14 with insufficient 4DCT were excluded). The locations of occlusive artery were ACA (n=2), MCA (n=75), ICA (n=23), PCA (n=7) and BA (n=10).IV rt-PAto DSA was 26 ± 22 minutes. Successful and partial reperfusions of the occluded territory were achieved in 11 (9.4%) and 18 (15.4%), respectively. Initial NIHSS of successful/partial reperfusionwas lower than no recanalization group (13.4 ± 9 vs 19.3 ± 9; P<0.05). There were no significant in the prevalence of the using antithrombotic agents before IV rt-PA, and modified Rankin scale at discharge between these 2 groups. The location of recanalization/partial recanalization cases were ACA (0/2), MCA (22/75), ICA (1/23), PCA (4/7) and BA (2/10). Seven of 23 ICA occlusions were isolated occlusion. Two of 7 patients (28.6%) with isolated occlusion became into terminus occlusion. Conclusions: Successful reperfusion and partial recanalization rate were 9.4% and 15.4% just after IV rt-PA therapy, respectively. IV rt-PA may promote isolated ICA occlusion worsening.

Intra-Arterial Treatment for Patients with Severe Acute Vertebrobasilar Occlusion: A Single-Center Retrospective Study

Recently, favorable outcomes from several randomized controlled trials of rapid endovascular treatment for acute ischemic stroke has emerged. The aim of this retrospective study is to present our clinical experience in severe acute vertebrobasilar occlusion (AVBO) using intra-arterial treatment (IAT). Twenty patients with ischemic stroke in the vertebrobasilar circulation treated by IAT between March 2011 and December 2014 were included. We retrospectively assessed National Institutes of Health Stroke Scale (NIHSS) score on admission and at discharge, Thrombolysis in Cerebral Infarction (TICI) scale, and clinical outcome using modified Rankin scale (mRs) at 90 days, and causes of stroke were prospectively assessed. The mean NIHSS score on admission was 26.4 ± 7.9 (range 9-33) points. The mean time from symptom onset to revascularization was 349.5 ± 124.0 (range 201-579) minutes. Successful recanalization (TICI ≥2b) was achieved in 19 (95.0%) patients. The mean NIHSS score at discharge was 5.7 ± 9.0 (range 0-30) points. A favorable clinical outcome (mRS ≤2) was observed in 12 (60.0%) patients at 90 days and mortality was 25.0% (n = 5). IAT for AVBO provides high rate of recanalization, favorable clinical outcome, and improved survival.

Abstract TP3: Endovascular Treatment for Acute Stroke and Weekend/off Hour Effect: Does it Really Exist ?

Introduction: Faster door to puncture times has been of the most important variables in recent success of endovascular treatment (EVT) trials. However it’s still unclear whether the door to puncture times would be impacted if patients presents at off hours/ weekends. We conducted retrospective analysis of all stroke patients going for EVT at our institution, to look for effect of weekend/off hour’s on door to puncture times. Methods: We collected demographics and time variables for EVT on sequential patients with AIS from 1/ 2008 to 2/2015. Patients were grouped according to time of presentation: daytime weekday (DT) hours vs. nighttime weekday (NT) hours vs. weekend (WE) hours. The baseline demographics, time of last known well to groin puncture (LKTP), door to groin puncture (DTP), and initial imaging to endovascular suite (ITS) were compared between these groups. Results: We analyzed 237 consecutive AIS patients who underwent EVT at our institution out of which 94/237 (40%) were transfers. Direct Admits: Compared to DT presentations, WE (180 vs. 200 min, p = 0.2801) and NT had longer DTP times (180 vs. 210.5, p= 0.0156). Transfers: Compared to those presenting in DT, those presenting at NT had significantly longer LKTP time (348 vs. 417.5, p= 0.0083), DTP time (107 vs. 128, p= 0.0376), and ITS time (54.5 vs. 76.5, p= 0.0024). Compared with DT presentations, those presenting on WE had significantly longer DTP time (107 vs. 145, p= 0.0029) and ITS time (54.5 vs. 90, p= 0.00118). Conclusions: Our data show that patients presenting directly to our emergency room at NT had longer DTP times. In addition, our data revealed transfer patients had time delays across all time variables when presenting at NT and for DTP and ITS when presenting on WE. This data suggests that NT and WE presentations face unique challenges for rapid EVT.

Abstract 18322: No Short-term Mortality Benefit With Endovascular Therapy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis

Background: The efficacy of endovascular treatment in improving functional outcome in acute ischemic stroke has been established. However, it is unclear if there is any beneficial effect on mortality in stroke patients undergoing prompt endovascular treatment. Methods: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus were searched from inception through June 2015 for randomized controlled trials that compared endovascular treatment to the current standard of care in acute ischemic stroke. Studies were selected if they had short-term (90 day) mortality as a measured outcome. Mortality was pooled and odds ratio (OR) was calculated using the Mantel-Haenszel method using a fixed effect model. Results: There were 10 studies with 2835 participants in our analysis. There were 224/1513 (14.8%) deaths reported in the endovascular treatment arm and 214/1322 (16.2%) deaths in the current standard of care arm. There was no difference in 90 day mortality between endovascular treatment and current standard of care (OR 0.86, 95% CI= 0.70-1.06, p =0.51; I2 = 0%). The Figure shows forest plot comparing 90-day mortality in the endovascular treatment arm and the current standard of care arm in patients with acute ischemic stroke. There was visual estimation of publication bias which was not confirmed by trim and fill method. Conclusions: In this meta-analysis we did not find any short term mortality benefit with rapid endovascular treatment as compared to current standard of care. With the improvement demonstrated in functional outcomes, endovascular intervention represents a paradigm shift in stroke therapy. However, more studies are needed to look at both short and long-term survival and cost effectiveness of the modality.

Cerebral protection during neurosurgery and stroke.

This article reviews the recent evidence on perioperative neuroprotection in patients undergoing brain surgery and in patients with acute stroke. With varying degrees of success, numerous pharmacological and nonpharmacological therapies have been employed to provide neuroprotection for patients during the perioperative period and after acute ischemic stroke (IAS). Recent studies have failed to demonstrate neuroprotective effects of intraoperative remifentanil or propofol use, although hypertonic saline may provide better brain relaxation than mannitol during elective intracranial surgery for tumor. Magnesium sulfate offers no improvement in neurological outcome at 90 days after stroke. Medical management alone may be superior to medical management with interventional therapy for the prevention of death or stroke in unruptured arteriovenous malformations. In patients with IAS with a proximal vessel occlusion, small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment resulted in improved functional outcomes and reduced mortality. For endovascular clot evacuation after IAS, conscious sedation may be safer than general anaesthesia. Recent evidence provides insufficient evidence of neuroprotective strategies to guide clinical management, and more randomized clinical trials are needed to optimize patient care.

Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke: Goyal M, Demchuk AM, Menon BK, et al. N Engl J Med 2015;372:1019−30.

Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke: Goyal M, Demchuk AM, Menon BK, et al. N Engl J Med 2015;372:1019−30.

Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

BackgroundAmong patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation.MethodsWe randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis).ResultsThe trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75).ConclusionsAmong patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.)

The ESCAPE Trial: Rapid Endovascular Treatment Leads to Better Outcomes

ESCAPE was a phase 3, multicenter, prospective, randomized, open-label, controlled trial conducted in patients with acute ischemic stroke. Patients received rapid, modern endovascular treatment plus guideline-based care (intervention) or guideline-based care alone. Patients in the intervention group had greater benefits in mortality, morbidity, and quality of life compared with controls.

Randomized assessment of rapid endovascular treatment of ischemic stroke. The ESCAPE Trial Investigators. N Engl J Med.

Randomized assessment of rapid endovascular treatment of ischemic stroke. The ESCAPE Trial Investigators. N Engl J Med.

Abstract T P4: Impact of Extended IV rt-PA Time Window and Immediate Endovascular Therapy on the Outcome in Patients with Major Artery Occlusion

Background and Purpose: In Japan, indication of intravenous recombinant tissue plasminogen activator (IV rt-PA) therapy for acute ischemic stroke (AIS) has been extended to 4.5 hours after the onset from Aug, 2012. Additionally, we have modified our institutional strategy of endovascular treatment (EVT) to start immediately after IV rt-PA in patients with occlusions of internal carotid artery (ICA), proximal portion of middle cerebral artery (MCA), or basilar artery (BA) from Oct, 2012. This study aimed to clarify the impact of these changes on the outcome in patients with major artery occlusion. Methods: We investigated the AIS patients with ICA, MCA or BA occlusion admitted to our hospital within 24 hours after the onset. They were divided into two phases according to admission date: phase 1 (Oct, 2011 to Sept, 2012) or phase 2 (Oct, 2012 to Apr, 2013). Backgrounds, treatments, and outcomes were compared between two phases. Favorable outcomes were defined as modified Rankin Scale (mRS) ≦2 or equal to premorbid mRS, and poor outcome as mRS 5 or 6 at 90 days after the onset. Results: Among 248 patients (130 men, 76.1±12.4 years old, National Institute of Health Stroke Scale [NIHSS] score on admission: median 18 [IQR 11-24]), 152 patients were admitted in phase 1 and 96 in phase 2. Age, sex, onset to admission time, stroke subtype, and sites of occluded arteries were similar in two phases, while NIHSS score on admission was higher in phase 1 than 2 (median 19 vs 17, P=0.046). Compared to phase 1, IV rt-PA (36.8 vs 44.8%), EVT (12.5 vs 26.0%), and either reperfusion therapy (42.8 vs 54.2%) were more frequently performed, and door to IV rt-PA time (71 vs 61min.) and door to EVT time (148 vs 127min.) were shorter in phase 2. The rate of favorable outcome significantly increased (27.0 vs 40.6%, P=0.027) and that of poor outcome decreased (44.1 vs 30.2%, P=0.033) in phase 2. With multivariate analysis in total period, reperfusion therapy was associated to favorable outcomes (OR 2.24, 95% CI 1.05-4.80) and inversely associated with poor outcome (OR 0.29, 95%CI 0.13-0.64). Conclusions: Increased frequency of reperfusion therapy by extended IV rt-PA time window and rapid EVT may contribute to the improvement of outcome in AIS patients with major artery occlusion.

Management of patients with intracerebral hemorrhage due to arteriovenous malformation

The management of cerebrovascular disease has advanced considerably in 2015. Five randomized control trials have firmly established the role of endovascular thrombectomy for ischemic strokes due to large vessel occlusion. The randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN) (Berkhemer et al. NEJM 2015;372:11-20) was the first of a series on the topic. There was a total of 5 randomized controlled trials published showing benefit in terms of functional outcomes at 90 days for mechanical thrombectomy including the Endovascular Therapy for Ischemic stroke with perfusion-imaging selection (EXTEND IA) (Campbell et al. NEJM 2015;372:1009-18), the Randomized assessment of rapid endovascular treatment of ischemic stroke (ESCAPE) (Goyal et al. NEJM 2015;372:1019-30) trials, the stent-retriever thrombectomy after IV t-PA is t-PA alone in stroke (SWIFT-PRIME) (Saver et al. NEJM 2015;372:2285-95), and the thrombectomy within 8 h after symptom onset in Ischemic stroke (REVASCAT) trial (Jovin et al. NEJM 2015; 372:2296-306). Six-year results from randomized controlled Barrow Ruptured Aneurysm Trial (BRAT) found no significant difference in functional outcomes in patients ruptured aneurysms treated surgically clippings versus endovascular treatment (Spetzler et al. JNS 2015;123:609-17. The 10-year results of the International Subarachnoid Aneurysm trial (ISAT) reported similar mortality rates and good functional outcomes between clipped and coiled patients (Molyneux et al. Lancet 2015;385:691-7). We also discuss the impact of genome wide sequencing studies in familial aneurysms, the largest publication on stent assisted coiling and flow diverter for aneurysms and noteworthy papers relevant to Moyamoya and cavernous malformations (Yang et al. Neurosurgery 2015;77:241-7).