Mohammed Maan Al-Salihi

Background: Successful endovascular thrombectomy does not always result in optimal neurological recovery in patients with acute ischemic stroke, likely because macrovascular recanalization may not fully restore distal or microvascular perfusion. Adjunctive intra-arterial thrombolysis (IAT) has emerged as a potential strategy to enhance reperfusion after thrombectomy, but its efficacy and safety remain uncertain. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials comparing adjunctive intra-arterial thrombolysis after successful endovascular reperfusion versus standard care or placebo in acute ischemic stroke. We searched PubMed, Scopus, Web of Science, and Embase from inception to August 2026. Meta-analysis was performed using Review Manager (RevMan 5.4). Outcomes included excellent functional outcome (modified Rankin Scale [mRS] 0–1), functional independence (mRS 0–2), mortality, Barthel Index, EuroQol five-dimension (EQ-5D) scores, intracranial hemorrhage (ICH), symptomatic ICH, and systemic bleeding. Subgroup analyses were conducted according to thrombolytic agent and circulation territory. Exploratory trial sequential analysis (TSA) assessed the accumulating evidence for selected outcomes under specified assumptions. Results: Nine trials contributed data on 2810 patients. Adjunctive intra-arterial thrombolysis increased the likelihood of excellent functional outcome at 90 days compared with control (risk ratio [RR] 1.23, 95% confidence interval [CI] 1.13–1.35; p < 0.00001), with low statistical heterogeneity (I² = 17%). TSA supported this finding under the specified assumptions, with the required information size of 1321 patients exceeded. Functional independence did not differ significantly (RR 1.03, 95% CI 0.96–1.10); its TSA remained inconclusive, with 2805 patients representing 8.2% of the required information size of 34,407. Mortality (RR 1.05, 95% CI 0.90–1.23), symptomatic ICH (RR 1.19, 95% CI 0.83–1.71), and systemic bleeding did not differ significantly; these findings do not exclude clinically important harm. Any ICH was more frequent with IAT (RR 1.17, 95% CI 1.03–1.32; p = 0.02), but TSA was inconclusive. EQ-5D scores did not differ significantly. Subgroup findings were exploratory. Conclusions: Adjunctive IAT after successful thrombectomy was associated with a higher likelihood of excellent functional recovery at 90 days. TSA supported this benefit under the stated assumptions but did not establish that future evidence cannot change the estimate. IAT was associated with a modest increase in any ICH that was not confirmed by TSA. Evidence for functional independence and symptomatic hemorrhage remains inconclusive, and nonsignificant safety comparisons should not be interpreted as equivalence. Further trials should evaluate efficacy, patient selection, agent and dose, circulation territory, and adequately powered safety outcomes.

Background and Objectives: Minimally invasive surgery (MIS) has emerged as a less invasive alternative to medical management (MM) in intracerebral hemorrhage (ICH), but its comparative effectiveness remains uncertain. Materials and Methods: We searched PubMed, Web of Science, Scopus, and Cochrane Library for RCTs and prospective matched studies comparing MIS with MM in supratentorial spontaneous ICH. Primary outcomes were functional recovery and mortality; secondary outcomes were adverse events, rebleeding, and ICU stay. Meta-analysis was performed using RevMan 5.4 with 95% confidence intervals (CI). Results: Thirteen studies (11 RCTs, 2 cohorts; 1503 MIS, 1401 MM) were included. MIS significantly improved functional outcomes (Risk Ratio, RR 1.18, 95% CI 1.01 to 1.38), driven mainly by studies including both deep and lobar hematomas, whereas deep-only studies showed inconsistent effects. The benefit was largely attributable to stereotactic aspiration with local thrombolytics (RR 1.23, 95% CI 1.07 to 1.41), while other MIS techniques showed no significant advantage. Early intervention (Conclusions: MIS may reduce mortality and improve functional outcomes in supratentorial ICH, particularly using stereotactic aspiration with thrombolytics. The benefit in deep hematomas remains uncertain. Early intervention and careful patient selection are essential. Further high-quality RCTs are warranted.

The benefits of rehabilitation in acute ischemic stroke patients following thrombectomy remain underexplored. We assessed which activities of daily living (ADLs) show the greatest improvement after goal-directed therapy in an inpatient rehabilitation setting. We retrospectively analyzed pre- and post-rehabilitation functional assessments in 40 acute ischemic stroke patients treated with mechanical thrombectomy. All patients received goal-directed therapy at a rehabilitation facility. Activities were grouped into two domains: (1) self-care (eating, oral hygiene, toileting hygiene, showering/bathing, dressing) and (2) functional mobility (footwear management, rolling, sit-to-lying, lying-to-sitting, sit-to-stand). Mean percent changes were calculated for each activity. Patients had a mean rehabilitation stay of 18 ± 9 days. In the self-care domain, the greatest relative improvements were observed in showering/bathing (44% ± 17%), upper body dressing (39% ± 19%), and toileting hygiene (39% ± 29%). In the mobility domain, the sit-to-lying activity showed the highest improvement (44% ± 20%). All measured activities demonstrated functional gains post-rehabilitation. Goal-directed inpatient rehabilitation was associated with substantial improvements in both self-care and functional mobility following thrombectomy. The most notable gains were in showering/bathing and sit-to-lying transitions. These findings demonstrate that structured inpatient rehabilitation is associated with measurable improvements in functional recovery in stroke patients post-thrombectomy.

Loeys-Dietz syndrome (LDS) is a rare genetic disorder characterized by profound systemic vascular vulnerability, with complex neurovascular manifestations that remain incompletely understood. This systematic review aimed to comprehensively map the spectrum of neurovascular complications in LDS, synthesize existing literature, identify potential genetic and phenotypic correlations contributing to disease severity, and present our case report to illustrate real-world clinical challenges and management complexities. Following PRISMA guidelines, a comprehensive literature search was conducted across PubMed, Scopus, Web of Science, and Cochrane Library from database inception to March 2025. Studies were systematically screened using predefined inclusion/exclusion criteria. The Joanna Briggs Institute Critical Appraisal Checklists were employed for quality assessment. Twenty-five studies, including 13 retrospective cohort studies and 12 case reports, were ultimately included. The review revealed a significant neurovascular disease burden in LDS. Intracranial aneurysm prevalence ranged from 19.4 to 30%, with an average size of 3.6 mm. Genetic mutations in TGFBR1, TGFBR2, and SMAD3 genes were strongly associated with vascular complications. Arterial dissections were documented in 22.2% of patients, with neurovascular events spanning pediatric to adult populations. Our case report illustrated the syndrome's complex multisystemic manifestations, demonstrating bilateral embolic infarcts with hemorrhagic components. This systematic review provides a comprehensive characterization of neurovascular complications in LDS, emphasizing the critical need for specialized, genetic-specific risk stratification and longitudinal monitoring. The findings underscore the complex relationship between genetic mutations and vascular pathophysiology, highlighting potential molecular intervention strategies.

Background and purpose: Despite significant advances in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), approximately 30%–40% of patients experience futile recanalization. This meta‐analysis aimed to assess the effectiveness and safety of adjunctive intra‐arterial thrombolysis (IAT) following EVT in individuals with AIS.Methods: We performed a systematic review and meta‐analysis of randomized controlled trials (RCTs) that compared IAT after EVT with standard care. A literature search was conducted across multiple databases up to March 2025. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0–1) at 90 days, functional independence (mRS 0–2), and mortality rate. Risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous variables were calculated with 95% confidence intervals.Results: Six RCTs comprising 1971 patients were included. Adjunctive IAT significantly increased excellent functional outcomes at 90 days (RR = 1.24 [1.12–1.39], p < 0.0001), without significant improvement in functional independence (RR = 1.04 [0.96–1.13], p = 0.34). The IAT group exhibited significantly higher EuroQol 5 dimensions scores (MD = 0.08 [0.03–0.13], p = 0.001). Mortality rates were comparable (RR = 1.01 [0.84–1.23], p = 0.89). No significant differences were observed in any intracerebral hemorrhage (RR = 1.15 [1.00–1.33], p = 0.08), symptomatic intracerebral hemorrhage (RR = 1.13 [0.76–1.68], p = 0.53), or systemic bleeding complications.Conclusions: Adjunctive IAT following EVT significantly enhances excellent functional recovery and health‐related quality of life after AIS, without significantly increasing hemorrhagic complications. These findings support the consideration of IAT as a complementary strategy following mechanical thrombectomy in AIS patients who present within 24 h of symptom onset.

Background/Objectives: Rivaroxaban is widely used to prevent thrombotic events in cardiovascular diseases (CVD). While various doses and combinations with aspirin have been evaluated across CVD subtypes, the optimal regimen remains unclear. This network meta-analysis aims to identify the most effective and safe rivaroxaban regimens, with or without aspirin, for patients with CVD. Methods: A systematic search of PubMed, Scopus, Cochrane Library, and Web of Science identified randomized-controlled trials (RCTs) assessing rivaroxaban, with or without aspirin, in CVD. Key outcomes included thromboembolic, hemorrhagic, and mortality events. A frequentist network meta-analysis (MetaInsight tool) was performed, using aspirin monotherapy as the reference. Subgroup analyses for coronary artery disease (CAD) were conducted. Results: Seven RCTs were included. Rivaroxaban 2.5 mg twice daily (“bis in die” (BID)) with aspirin showed the most significant venous thromboembolism (VTE) prevention (RR = 0.61, 95% CI [0.43–0.86]) but had the highest major bleeding risk (RR = 1.58, 95% CI [1.26–2]). Rivaroxaban 5 mg BID with aspirin showed the lowest myocardial infarction risk (RR = 0.78). Higher doses (20 mg BID) with aspirin were associated with an increased fatal bleeding risk (RR = 7.14, 95% CI [2.83–17.98]). Rivaroxaban 5 mg BID monotherapy had the highest hemorrhagic stroke risk (RR = 2.7, 95% CI [1.31–5.58]). In CAD, rivaroxaban 2.5 mg BID plus aspirin offered the lowest all-cause mortality (RR = 0.76, 95% CI [0.63–0.93]). Conclusions: Rivaroxaban 2.5 mg BID plus aspirin reduces VTE and lowers mortality in CAD but carries higher bleeding risks. Optimal regimen selection requires a careful risk–benefit balance.

Background: Stent-assisted coil embolization (SACE) is a common endovascular technique for managing intracranial aneurysms. The permanent presence of a stent inside the cerebral artery necessitates the postoperative use of antiplatelets. However, a consensus about how long to continue on it remains debated. This systematic review aims to discuss and quantify the risk of ischemic complications after antiplatelet discontinuation following SACE. Methods: PubMed, Cochrane Library, Scopus, and Web of Science (WOS) were systematically searched for studies assessing the outcomes after antiplatelet discontinuation following SACE for cerebral aneurysms. The primary outcome was the odds of ischemic complications after antiplatelet discontinuation. Using a random-effects model, the pooled event rate, along with a 95% confidence interval (CI), was calculated. The Comprehensive Meta-Analysis software (CMA) software was used for the analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment. Results: A total of five observational cohort studies were included in this systematic review. The studies recruited cases from 2009 and 2020, predominantly in Korea and Japan. Data from 18,425 cases obtained from four studies were analyzed. The duration of antiplatelet therapy varied widely across the included studies. Additionally, most studies reported a median follow-up of 24 months or more after antiplatelet discontinuation. We extracted and analyzed the odds of thromboembolic complications occurring within 6 to 24 months after the discontinuation of antiplatelets. The pooled rate of thromboembolism after antiplatelet discontinuation in this meta-analysis was 0.01 (95% CI: 0.006 to 0.018). Conclusion: This review demonstrates that the risk of thromboembolic complications after discontinuing antiplatelet therapy post-SACE is low. However, no strong consensus exists on the ideal duration for maintaining dual- or single-antiplatelet therapy. Further prospective studies with longer follow-ups are warranted to clarify the optimal durations needed to balance thromboembolic risk with hemorrhagic complications.