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Background The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window. Methods We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others. Results Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p  < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection ( p  < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) ( p  < 0.0001). Conclusion Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging.

Mechanical thrombectomy (MT) has revolutionised the treatment of ischaemic stroke, leading to decreased rates of disability and mortality. However, many centres are unable to deliver a 24/7 service. Consequently, many patients who present in the non-operating hours are not considered for this treatment. We conducted a quality improvement project (QIP) to provide patients presenting out of hours with access to MT. To achieve this, we designed a protocol to rescan those patients just before opening of the service to select the candidates based on the favourable perfusion criteria. Twenty-two out of the 39 patients included in the QIP had MT, which was not accessible before initiation of our protocol. In stroke centres where 24/7 MT service is not available, patients with large vessel occlusion (LVO) stroke, who present in the non-operating hours, can get access to this treatment by consideration of early morning rescanning just before opening of the service.

PurposeTo evaluate the safety and the efficacy of percutaneous pharmaco-mechanical thrombectomy (PPMT) of acute superior mesenteric vein (SMV) thrombosis.MethodsA database of patients treated between 2011 and 2018 with acute venous mesenteric ischemia (VMI) was reviewed. VMI was diagnosed in the presence of SMV thrombosis and CT evidence of jejunal thickening. All patients presented with mild to moderate peritonism, which allowed surgery to be postponed. Initial treatment consisted of heparinization. PPMT was indicated in case of worsening abdominal pain despite anticoagulation and was performed via a transjugular or transhepatic approach, using a rotational aspiration thrombectomy catheter, followed by transcatheter thrombolysis. Clinical success was defined as symptoms resolution. Technical success was defined as patency of > 50% of SMV at venography and resolution of jejunal thickening. Patients were discharged on lifelong oral anticoagulation (INR 2.5–3.5). Follow-ups were performed using CT and color Doppler ultrasound.ResultsPopulation consisted of eight males, aged 37–81 (mean 56.5 years). Causes for thrombosis were investigated. Urokinase infusion time ranged from 48 to 72 h (3,840,000–5,760,000 IU). Clinical and technical success was obtained in all cases. One patient experienced bleeding from the superior epigastric artery and was treated with embolization. One patient died of multi-organ failure after 35 days, despite resolution of SMV thrombosis. In no case was surgery required after PPMT; mean hospitalization was 14.1 days (9–24). Mean follow-up of remaining seven patients was 37.7 months (12–84 months).ConclusionPPMT of acute SMV thrombosis seems safe and effective, with an 87.5% long-term survival rate and a 12.5% major complication rate.

Background To compare the quality of free-text reports (FTR) and structured reports (SR) of brain magnetic resonance imaging (MRI) examinations in patients following mechanical thrombectomy for acute stroke treatment. Methods A template for SR of brain MRI examinations based on decision trees was designed and developed in house and applied to twenty patients with acute ischemic stroke in addition to FTR. Two experienced stroke neurologists independently evaluated the quality of FTR and SR regarding clarity, content, presence of key features, information extraction, and overall report quality. The statistical analysis for the differences between FTR and SR was performed using the Mann–Whitney U-test or the Chi-squared test. Results Clarity (p < 0.001), comprehensibility (p < 0.001), inclusion of relevant findings (p = 0.016), structure (p = 0.005), and satisfaction with the content of the report for immediate patient management (p < 0.001) were evaluated significantly superior for the SR by both neurologist raters. One rater additionally found the explanation of the patient’s clinical symptoms (p = 0.003), completeness (p < 0.009) and length (p < 0.001) of SR to be significantly superior compared to FTR and stated that there remained no open questions, requiring further consultation of the radiologist (p < 0.001). Both neurologists preferred SR over FTR. Conclusions The use of SR for brain magnetic resonance imaging may increase the report quality and satisfaction of the referring physicians in acute ischemic stroke patients following mechanical thrombectomy. Trial registration Retrospectively registered.

The unfavorable outcome of acute ischemic stroke (AIS) with large vessel occlusion (LVO) is related to clinical factors at multiple time points. However, predictive models used for dynamically predicting unfavorable outcomes using clinically relevant preoperative and postoperative time point variables have not been developed. Our goal was to develop a machine learning (ML) model for the dynamic prediction of unfavorable outcomes. We retrospectively reviewed patients with AIS who underwent a consecutive mechanical thrombectomy (MT) from three centers in China between January 2014 and December 2018. Based on the eXtreme gradient boosting (XGBoost) algorithm, we used clinical characteristics on admission (“Admission” Model) and additional variables regarding intraoperative management and the postoperative National Institute of Health stroke scale (NIHSS) score (“24-Hour” Model, “3-Day” Model and “Discharge” Model). The outcome was an unfavorable outcome at the three-month mark (modified Rankin scale, mRS 3–6: unfavorable). The area under the receiver operating characteristic curve and Brier scores were the main evaluating indexes. The unfavorable outcome at the three-month mark was observed in 156 (62.0%) of 238 patients. These four models had a high accuracy in the range of 75.0% to 87.5% and had a good discrimination with AUC in the range of 0.824 to 0.945 on the testing set. The Brier scores of the four models ranged from 0.122 to 0.083 and showed a good predictive ability on the testing set. This is the first dynamic, preoperative and postoperative predictive model constructed for AIS patients who underwent MT, which is more accurate than the previous prediction model. The preoperative model could be used to predict the clinical outcome before MT and support the decision to perform MT, and the postoperative models would further improve the predictive accuracy of the clinical outcome after MT and timely adjust therapeutic strategies.

This study aimed to identify independent predictors for the risk of hemorrhagic transformation (HT) in arterial ischemic stroke (AIS) patients. Consecutive patients with AIS due to large artery occlusion in the anterior circulation treated with mechanical thrombectomy (MT) were enrolled in a tertiary stroke center. Demographic and medical history data, admission lab results, and Circle of Willis (CoW) variations were collected from all patients. Altogether, 90 patients were included in this study; among them, 34 (37.8%) had HT after MT. The final pruned decision tree (DT) model consisted of collateral score and platelet to lymphocyte ratios (PLR) as predictors. Confusion matrix analysis showed that 82.2% (74/90) were correctly classified by the model (sensitivity, 79.4%; specificity, 83.9%). The area under the ROC curve (AUC) was 81.7%. The DT model demonstrated that participants with collateral scores of 2-4 had a 75.0% probability of HT. For participants with collateral scores of 0-1, if PLR at admission was <302, participants had a 13.0% probability of HT; otherwise, participants had an 75.0% probability of HT. The final adjusted multivariate logistic regression analysis indicated that collateral score 0-1 (OR, 10.186; 95% CI, 3.029-34.248; p < 0.001), PLR (OR, 1.005; 95% CI, 1.001-1.010; p = 0.040), and NIHSS at admission (OR, 1.106; 95% CI, 1.014-1.205; p = 0.022) could be used to predict HT. The AUC for the model was 0.855, with 83.3% (75/90) were correctly classified (sensitivity, 79.4%; specificity, 87.3%). Less patients with HT achieved independent outcomes (mRS, 0-2) in 90 days (20.6% vs. 64.3%, p < 0.001). Rate of poor outcomes (mRS, 4-6) was significantly higher in patients with HT (73.5% vs. 19.6%; p < 0.001). Both the DT model and multivariate logistic regression model confirmed that the lower collateral status and the higher PLR were significantly associated with an increased risk for HT in AIS patients after MT. PLR may be one of the cost-effective and practical predictors for HT. Further prospective multicenter studies are needed to validate our findings.

We report on the first pulmonary embolism treatment via the large‐bore aspiration mechanical thrombectomy device (Inari FlowTriever®) outside the USA, in a resuscitated patient on veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) suffering from severe and acute right heart failure. In this particular high‐risk patient population, where thrombolysis is mostly not applicable, this new technology could be a promising solution as the combination of large‐bore thrombus aspiration and extraction successfully removes large emboli. In our case, right ventricular function improved rapidly after the procedure, ECMO could be weaned, and the patient was dismissed 2 weeks after. In summary, we provide a new therapeutic option for the often difficult treatment of pulmonary embolism in high‐risk patients on VA‐ECMO.

Background and purposeFlow arrest with balloon guide catheters (BGCs) is becoming increasingly recognized as critical to optimizing patient outcomes for mechanical thrombectomy. We performed a systematic review and meta-analysis of the literature for studies that compared angiographic and clinical outcomes for patients who underwent mechanical thrombectomy with and without BGCs.Materials and methodsIn April 2017 a literature search on BGC and mechanical thrombectomy for stroke was performed. All studies included patients treated with and without BGCs using modern techniques (ie, stent retrievers). Using random effects meta-analysis, we evaluated the following outcomes: first-pass recanalization, Thrombolysis In Cerebral Infarction (TICI) 3 recanalization, TICI 2b/3 recanalization, favorable outcome (modified Rankin Scale (mRS) 0–2), mortality, and mean number of passes and procedure time.ResultsFive non-randomized studies of 2022 patients were included (1083 BGC group and 939 non-BGC group). Compared with the non-BGC group, patients treated with BGCs had higher odds of first-pass recanalization (OR 2.05, 95% CI 1.65 to 2.55), TICI 3 (OR 2.13, 95% CI 1.43 to 3.17), TICI 2b/3 (OR 1.54, 95% CI 1.21 to 1.97), and mRS 0–2 (OR 1.84, 95% CI 1.52 to 2.22). BGC-treated patients also had lower odds of mortality (OR 0.52, 95% CI 0.37 to 0.73) compared with non-BGC patients. The mean number of passes was significantly lower for BGC-treated patients (weighted mean difference −0.34, 95% CI−0.47 to −0.22). Mean procedure time was also significantly shorter for BGC-treated patients (weighted mean difference −7.7 min, 95% CI−9.0to −6.4).ConclusionsNon-randomized studies suggest that BGC use during mechanical thrombectomy for acute ischemic stroke is associated with superior clinical and angiographic outcomes. Further randomized trials are needed to confirm the results of this study.

Shaohuai Xia,1,* Junhong Hu,2,* Jing Wu,1 Yingye Liao,2 Guifeng Liang,3 Jinping Li,4 Xiaoguang Fan,2 Xuewei Xia,2 Xinrong Zhong,2 Li Chen5 1Department of Neuro-Oncology, Beijing Xiaotangshan Hospital, Beijing, 100000, People’s Republic of China; 2Department of Neurosurgery, The First Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, 541001, People’s Republic of China; 3Diecai District Maternal and Child Health Hospital of Guilin City, Guilin, Guangxi, 541001, People’s Republic of China; 4Reproductive Center of The 924th Hospital of The Joint Logistic Support Force of The Chinese People’s Liberation Army, Guilin, Guangxi, 541001, People’s Republic of China; 5Department of Neurosurgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Affiliated Provincial Hospital of Fuzhou University, Fuzhou, 350001, People’s Republic of China*These authors contributed equally to this workCorrespondence: Li Chen, Department of Neurosurgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Affiliated Provincial Hospital of Fuzhou University, Fuzhou, 350001, People’s Republic of China, Email fjmuchenli@163.comPurpose: This study aimed to evaluate the predictive value of inflammatory markers, particularly the neutrophil-to-platelet ratio (NPR), combined with clinical parameters for early mortality following mechanical thrombectomy (MT) in patients with large artery occlusive acute ischemic stroke (LAO-AIS), to guide timely clinical interventions.Patients and methods: This retrospective study analyzed 320 LAO-AIS patients who underwent MT between January 2023 and January 2025. Missing data (< 15%) were imputed. Boruta feature selection identified variables for multiple logistic regression. The dataset was randomly divided into training and test sets (7:3). A nomogram was constructed, and four machine learning algorithms—Decision Tree (DT), Extreme Gradient Boosting (XGBoost), Support Vector Machine (SVM), and Naive Bayes (NB)—were developed and validated.Results: Early mortality occurred in 67 cases. Multivariate analysis identified six independent predictors: standardized NPR (NPR_std; OR = 4.51, P < 0.001), age (OR = 1.10, P < 0.001), decompressive craniectomy (DC; OR = 0.19, P < 0.001), responsible artery location (OR = 0.34, P = 0.006), lymphocyte count (LYM; OR = 2.14, P = 0.008), and prothrombin time (PT; OR = 1.31, P = 0.011). The nomogram showed high reliability. XGBoost achieved superior predictive performance, with SHapley Additive exPlanations (SHAP) analysis confirming NPR_std as the most important predictor.Conclusion: The neutrophil-to-platelet ratio (NPR) is an independent predictor of early mortality after MT in LAO-AIS patients. The predictive model provides valuable guidance for clinicians to adjust treatment strategies early.Keywords: stroke, mechanical thrombectomy, prognosis, early mortality, neutrophil-to-platelet ratio