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Few procedures have gone through a decade of practice-changing clinical trials as impressive as thrombectomy for stroke. Beginning in 2015 with multiple trials showing a benefit with thrombectomy in early large-vessel occlusion, followed by the extended-window trials in 2018 and then the large core trials in 2023, it seemed that no corner of the cerebrovasculature would not have a substantial benefit from a proper clot removal — until now. The ESCAPE-MeVO (Endovascular Treatment to Improve Outcomes for Medium Vessel Occlusions) trial 1 and DISTAL (Endovascular Therapy plus Best Medical Treatment [BMT] versus BMT Alone for Medium Vessel Occlusion Stroke — A . . .

Rapid diagnosis and treatment of acute neurological illnesses such as stroke, hemorrhage, and hydrocephalus are critical to achieving positive outcomes and preserving neurologic function—‘time is brain’ 1 – 5 . Although these disorders are often recognizable by their symptoms, the critical means of their diagnosis is rapid imaging 6 – 10 . Computer-aided surveillance of acute neurologic events in cranial imaging has the potential to triage radiology workflow, thus decreasing time to treatment and improving outcomes. Substantial clinical work has focused on computer-assisted diagnosis (CAD), whereas technical work in volumetric image analysis has focused primarily on segmentation. 3D convolutional neural networks (3D-CNNs) have primarily been used for supervised classification on 3D modeling and light detection and ranging (LiDAR) data 11 – 15 . Here, we demonstrate a 3D-CNN architecture that performs weakly supervised classification to screen head CT images for acute neurologic events. Features were automatically learned from a clinical radiology dataset comprising 37,236 head CTs and were annotated with a semisupervised natural-language processing (NLP) framework 16 . We demonstrate the effectiveness of our approach to triage radiology workflow and accelerate the time to diagnosis from minutes to seconds through a randomized, double-blinded, prospective trial in a simulated clinical environment. A deep-learning algorithm is developed to provide rapid and accurate diagnosis of clinical 3D head CT-scan images to triage and prioritize urgent neurological events, thus potentially accelerating time to diagnosis and care in clinical settings.

Correspondence to Dr J Mocco, Department of Neurological Surgery, The Mount Sinai Health System, New York, USA; j.mocco@mountsinai.org The first percutaneous coronary angioplasty was performed in September 1977 in Zurich, Switzerland.1 Less than 10 years later, intra-arterial stents were introduced as a viable treatment for coronary artery disease,2 and by 1994 coronary stenting was an established standard of care for percutaneous coronary intervention.3 4 This rapid growth and the resulting lives saved are impressive. While much of neurointervention’s foundation is rooted in the advent and growth of aneurysm coil embolization, we have also been pioneers in developing advanced technologies and techniques to treat other vascular lesions, such as arteriovenous malformations and dural arteriovenous fistula.5–8 And yes, we have opened clogged pipes as well.9–14 In fact, we have identified increasingly expansive patient cohorts that may benefit from thrombectomy,15 16 as well as demonstrating that clogged drains (veins) can be opened like arteries.17 18 Not bad, not bad at all. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. stent restenosis study Investigators.

Trials examining the benefit of thrombectomy in anterior circulation proximal large vessel occlusion stroke have enrolled patients considered to have salvageable brain tissue, who were randomly assigned beyond 6 h and (depending on study protocol) up to 24 h from time last seen well. We aimed to estimate the benefit of thrombectomy overall and in prespecified subgroups through individual patient data meta-analysis. We did a systematic review and individual patient data meta-analysis between Jan 1, 2010, and March 1, 2021, of randomised controlled trials of endovascular stroke therapy. In the Analysis Of Pooled Data From Randomized Studies Of Thrombectomy More Than 6 Hours After Last Known Well (AURORA) collaboration, the primary outcome was disability on the modified Rankin Scale (mRS) at 90 days, analysed by ordinal logistic regression. Key safety outcomes were symptomatic intracerebral haemorrhage and mortality within 90 days. Patient level data from 505 individuals (n=266 intervention, n=239 control; mean age 68·6 years [SD 13·7], 259 [51·3%] women) were included from six trials that met inclusion criteria of 17 screened published randomised trials. Primary outcome analysis showed a benefit of thrombectomy with an unadjusted common odds ratio (OR) of 2·42 (95% CI 1·76–3·33; p<0·0001) and an adjusted common OR (for age, gender, baseline stroke severity, extent of infarction on baseline head CT, and time from onset to random assignment) of 2·54 (1·83–3·54; p<0·0001). Thrombectomy was associated with higher rates of independence in activities of daily living (mRS 0–2) than best medical therapy alone (122 [45·9%] of 266 vs 46 [19·3%] of 238; p<0·0001). No significant difference between intervention and control groups was found when analysing either 90-day mortality (44 [16·5%] of 266 vs 46 [19·3%] of 238) or symptomatic intracerebral haemorrhage (14 [5·3%] of 266 vs eight [3·3%] of 239). No heterogeneity of treatment effect was noted across subgroups defined by age, gender, baseline stroke severity, vessel occlusion site, baseline Alberta Stroke Program Early CT Score, and mode of presentation; treatment effect was stronger in patients randomly assigned within 12–24 h (common OR 5·86 [95% CI 3·14–10·94]) than those randomly assigned within 6–12 h (1·76 [1·18–2·62]; pinteraction=0·0087). These findings strengthen the evidence for benefit of endovascular thrombectomy in patients with evidence of reversible cerebral ischaemia across the 6–24 h time window and are relevant to clinical practice. Our findings suggest that in these patients, thrombectomy should not be withheld on the basis of mode of presentation or of the point in time of presentation within the 6–24 h time window. Stryker Neurovascular.

Stent retriever thrombectomy of large-vessel occlusion results in better outcomes than medical therapy alone. Alternative thrombectomy strategies, particularly a direct aspiration as first pass technique, while promising, have not been rigorously assessed for clinical efficacy in randomised trials. We designed COMPASS to assess whether patients treated with aspiration as first pass have non-inferior functional outcomes to those treated with a stent retriever as first line. We did a multicentre, randomised, open label, blinded outcome, core lab adjudicated non-inferiority trial at 15 sites (ten hospitals and four specialty clinics in the USA and one hospital in Canada). Eligible participants were patients presenting with acute ischaemic stroke from anterior circulation large-vessel occlusion within 6 h of onset and an Alberta Stroke Program Early CT Score of greater than 6. We randomly assigned participants (1:1) via a central web-based system without stratification to either direct aspiration first pass or stent retriever first line thrombectomy. Those assessing primary outcomes via clinical examinations were masked to group assignment as they were not involved in the procedures. Physicians were allowed to use adjunctive technology as was consistent with their standard of care. The null hypothesis for this study was that patients treated with aspiration as first pass achieve inferior outcomes compared with those treated with a stent retriever first line approach. The primary outcome was non-inferiority of clinical functional outcome at 90 days as measured by the percentage of patients achieving a modified Rankin Scale score of 0–2, analysed by intent to treat; non-inferiority was established with a margin of 0·15. All randomly assigned patients were included in the safety analyses. This trial is registered at ClinicalTrials.gov, number: NCT02466893. Between June 1, 2015, and July 5, 2017, we assigned 270 patients to treatment: 134 to aspiration first pass and 136 to stent retriever first line. A modified Rankin score of 0–2 at 90 days was achieved by 69 patients (52%; 95% CI 43·8–60·3) in the aspiration group and 67 patients (50%; 41·6–57·4) in the stent retriever group, showing that aspiration as first pass was non-inferior to stent retriever first line (pnon-inferiority=0·0014). Intracranial haemorrhage occurred in 48 (36%) of 134 in the aspiration first pass group, and 46 (34%) of 135 in the stent retriever first line group. All-cause mortality at 3 months occurred in 30 patients (22%) in both groups. A direct aspiration as first pass thrombectomy conferred non-inferior functional outcome at 90 days compared with stent retriever first line thrombectomy. This study supports the use of direct aspiration as an alternative to stent retriever as first-line therapy for stroke thrombectomy. Penumbra.

[...]he eventually left Massachusetts General Hospital in disgust at its leadership’s lack of commitment to honestly and transparently evaluating patient outcomes.2 Dr Codman spent his life advocating something called the ‘End Results System’ (ERS). The fight to ensure meaningful quality standards, and thereby improve patient outcomes, continues to this day. With multiple vendors, competition should drive down cost, improve the quality of service, and generally advance the quality of patient care. The New York State DoH convened relevant stakeholders (physicians, hospital representation, patient advocacy groups, DoH representatives, etc) and determined state-based DoH standards for what should be required of a PSC, TSC, and CSC. Hospitals then engage any of the four approved COs to perform the site visit and review the process, but if the hospital desires DoH stroke center acknowledgment and a listing on the DoH website (which many emergency department networks rely on for triage guidance), then that CO must certify to the state standards for PSC, TSC, and CSC, not to the COs’ standards (which might be lower).

I am happy most of the country has not gone through what we have here. However, without shared experience, how do we understand? I would like to try to convey some of my thoughts, having experienced, first hand, the SARS-CoV-2 pandemic over the past 2 months in New York City. It is not easy, but I think necessary. I am worried that if we don’t communicate, it will lead to misunderstanding, and if there is misunderstanding, then more lives will be lost.

Atherosclerosis is driven by multifaceted contributions of the immune system within the circulation and at vascular focal sites. However, specific characteristics of dysregulated immune cells within atherosclerotic lesions that lead to clinical events such as ischemic stroke or myocardial infarction are poorly understood. Here, using single-cell proteomic and transcriptomic analyses, we uncovered distinct features of both T cells and macrophages in carotid artery plaques of patients with clinically symptomatic disease (recent stroke or transient ischemic attack) compared to asymptomatic disease (no recent stroke). Plaques from symptomatic patients were characterized by a distinct subset of CD4 + T cells and by T cells that were activated and differentiated. Moreover, some T cell subsets in these plaques presented markers of T cell exhaustion. Additionally, macrophages from these plaques contained alternatively activated phenotypes, including subsets associated with plaque vulnerability. In plaques from asymptomatic patients, T cells and macrophages were activated and displayed evidence of interleukin-1β signaling. The identification of specific features of innate and adaptive immune cells in plaques that are associated with cerebrovascular events may enable the design of more precisely tailored cardiovascular immunotherapies. Single-cell proteomic and transcriptional profiling of atherosclerotic lesions from human carotid arteries reveals specific features of lesional T cells and macrophages associated with symptomatic disease.