Adnan Mujanovic

BACKGROUND: Contrast-associated acute kidney injury (CA-AKI) after endovascular thrombectomy (EVT) worsens outcomes in acute ischemic stroke, but threshold-based definitions do not capture prognostic information from subthreshold changes. We tested whether early creatinine change within 48 hours of EVT conveys graded prognostic information beyond dichotomous CA-AKI. METHODS: We performed a secondary analysis of the CAN-REST registry (Contrast-Associated Nephropathy After Endovascular Stroke Treatment), a retrospective multicenter observational cohort study of 6638 EVT-treated adults with acute ischemic stroke enrolled at 73 centers in 16 countries between January 1 and December 31, 2023. Early creatinine change was quantified as the natural logarithm ratio of 48-hour creatinine to baseline creatinine (ln[48-hour/baseline creatinine]), with CA-AKI defined per Kidney Disease: Improving Global Outcomes criteria (≥0.3 mg/dL or ≥1.5× baseline rise within 48 hours). Multivariable logistic regression adjusted for prespecified baseline and periprocedural covariates examined associations with 90-day modified Rankin Scale shift and in-hospital mortality; linear versus restricted cubic spline specification was selected by likelihood ratio testing, and contrasts were estimated at ±10%, ±25%, and ±50%. RESULTS: Greater creatinine worsening within 48 hours of EVT was independently associated with an unfavorable 90-day modified Rankin Scale shift (adjusted common odds ratio per 1-unit log-ratio increase, 1.48 [95% CI, 1.07–2.04]; linear) and in-hospital mortality (nonlinear dose-response, of larger magnitude). A 10% increase in creatinine at 48 hours—well below Kidney Disease: Improving Global Outcomes threshold—was associated with worse functional outcome (adjusted common odds ratio, 1.04 [95% CI, 1.01–1.07]) and death (adjusted odds ratio, 1.22 [95% CI, 1.13–1.32]); a 10% decrease in creatinine at 48 hours was associated with lower odds of both outcomes (adjusted common odds ratio, 0.96 [95% CI, 0.93–0.99]; adjusted odds ratio, 0.74 [95% CI, 0.65–0.86]). The functional-outcome association concentrated at upper modified Rankin Scale cut-points (severe disability, death); effect modification by baseline renal function was not significant. CONCLUSIONS: Early creatinine change after EVT conveys graded, outcome-specific prognostic information extending below formal CA-AKI thresholds, with a dose-response detectable at changes as modest as ±10%, complementing binary CA-AKI as a framework for post-EVT renal risk assessment. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06596603.

BACKGROUND: Periprocedural flat-panel computed tomography (FPCT) may complement real-time decision-making during endovascular treatment for stroke. This study aims to summarize current evidence on diagnostic findings, prognostic associations, and clinical applications of periprocedural FPCT in the angiography suite. METHODS: A systematic review and meta-analysis was preregistered (URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD420251142156), conducted and reported according to MOOSE guidelines (Meta-Analysis of Observational Studies in Epidemiology). Medline, Embase, and Scopus were searched for studies published between January 2019 and September 2025 reporting on periprocedural FPCT in endovascular treatment patients (noncontrast FPCT, 3-dimensional–digital subtraction angiography/contrast-enhanced FPCT, or FPCT perfusion). Random-effects models were used to calculate pooled prevalences and odds ratios for associations with outcomes, primarily functional status assessed via the 90-day modified Rankin Scale score. RESULTS: Forty studies comprising 4139 patients were included. For noncontrast FPCT, 3 distinct imaging biomarkers were identified. Intraparenchymal hyperattenuations were frequent (pooled prevalence 49% [95% CI, 42%–56%]) and associated with any intracranial hemorrhage (odds ratio, 10.4 [95% CI, 4.5–24.1]), parenchymal hematoma (odds ratio, 4.3 [95% CI, 2.2–8.7]) and lower rates of good outcomes (eg, 90-day modified Rankin Scale score 0–2; odds ratio, 0.35 [95% CI, 0.24–0.50]). Subarachnoid hyperattenuations occurred in 23% (95% CI, 14%–35%) of patients and were associated with distal occlusions, markers of procedural aggressiveness, and lower rates of good outcome (eg, 90-day modified Rankin Scale score 0–2; odds ratio, 0.69 [95% CI, 0.53–0.91]). Intravascular hyperattenuations (distal occlusion tracker sign; pooled prevalence 35%, [95% CI, 24%–49%]) showed high specificity (93%, 95% CI, 87%–96%) for residual distal occlusions after endovascular treatment. Advanced vessel imaging improved thrombus conspicuity and technical efficacy, while postoperative flat-panel computed tomography perfusion shows added value for the detection of residual hypoperfusion, diagnosis of hemodynamic alterations, and prediction of final infarct. There was evidence for selection bias, suggesting slight overreporting of the above imaging signs. CONCLUSIONS: Periprocedural FPCT may offer real-time neurovascular and parenchymal assessment when conventional 3-dimensional imaging is unavailable. In our cohort, FPCT findings were associated with clinical outcomes and improved recognition of complications. FPCT may hence assist intraprocedural decision-making regarding adjunctive manoeuvres or drug administrations if further prospective validation can be demonstrated.

Background: The operational definition and imaging assessment of the no‐reflow phenomenon, a potential contributor to poor clinical outcome despite successful thrombectomy, remains debated. We aimed to develop expert‐based international consensus on the definition, assessment, and reporting standard of cerebral no‐reflow post‐thrombectomy. Methods: Three‐rounds of a modified Delphi web‐based survey was conducted among corresponding authors of peer‐reviewed clinical studies on cerebral no‐reflow between 2020 and 2025. Responses at each round were used to develop structured questionnaires for subsequent rounds. Consensus was predefined as ≥65% agreement. Results: Among 27 panelists, the response rate was 70%, 74%, and 74% over all rounds. There was broad agreement to conceptualize no‐reflow as macrovascular recanalization with impaired microvascular reperfusion. Consensus was reached that macrovascular recanalization is ideally assessed as (1) digital subtraction angiography with expanded thrombolysis in cerebral infarction (eTICI) grades 2c without clear distal vessel occlusions and/or eTICI 3 only, and (2) absence of a wedge‐shaped time‐to‐maximum (Tmax) or time‐to‐peak (TTP) delay on post‐recanalization perfusion computed tomography (CT) or magnetic resonance imaging (MRI). Regarding impaired microvascular reperfusion assessment, cerebral blood flow, and/or volume were preferred over time‐based perfusion parameters (Tmax/TTP). The panel expressed a preference that no‐reflow should ideally be assessed ≤6 hours post‐recanalization. Pending formal validation, histopathological–radiological correlation in animal models would sufficiently validate the use of imaging‐based definitions in humans. Interpretation: Based on currently available literature and expert opinions, this Delphi study provides a framework for systematically reporting cerebral no‐reflow after endovascular treatment (EVT). The variability in opinions regarding quantitative thresholds highlights priorities for future methodological standardization and validation studies. ANN NEUROL 2026

BACKGROUND: The optimal management of isolated posterior cerebral artery occlusion (iPCAO) remains unclear. We investigated whether baseline perfusion imaging parameters are associated with clinical outcomes and whether they modify the association between endovascular therapy (EVT) and outcomes in iPCAO. METHODS: This prespecified secondary analysis of the international, multicenter, observational PLATO (Posterior Cerebral Artery Occlusion) registry (35 centers, 10 countries, 2015–2025) included consecutive adults with unilateral iPCAO and baseline perfusion imaging (computed tomography or magnetic resonance imaging) with reconstructed parameters. The primary end point was an excellent 90-day outcome (modified Rankin Scale score, 0–1). Perfusion parameters included hypoperfusion volume, infarct core volume, and mismatch ratio. The primary analysis used multivariable mixed-effects regression models (center as random effect) to assess associations between perfusion parameters and outcomes, adjusting for age, sex, treatment year, prestroke modified Rankin Scale score, baseline National Institutes of Health Stroke Scale score, diabetes, stroke cause, posterior circulation Acute Stroke Prognosis Early Computed Tomography Score, occlusion site, intravenous thrombolysis, and onset-to-door time. To test whether the association between EVT and outcomes varies according to baseline perfusion parameters, we evaluated treatment-by-perfusion interactions by including interaction terms (treatment×perfusion parameter) in inverse probability of treatment weighting–adjusted models, with results expressed as ratios of odds ratios (ORs). RESULTS: Of 1811 patients with iPCAO, 443 met inclusion criteria (median age, 74 years; 41.8% female). Larger hypoperfusion volume was associated with lower odds of excellent outcome (adjusted OR, 0.72 [95% CI, 0.58–0.89] per 1-unit increase in natural logarithm–transformed volume). No interaction between perfusion parameters and EVT was observed for the primary outcome. However, increasing core volume was associated with a progressively less favorable modified Rankin Scale score shift (ratio of OR, 0.66 [95% CI, 0.48–0.90]; P _interaction =0.009) and higher mortality (ratio of OR, 1.82 [95% CI, 1.10–3.03]; P _interaction =0.021) with EVT compared with medical management. Increasing hypoperfusion volume was associated with a higher risk of symptomatic intracranial hemorrhage with EVT (ratio of OR, 10.15 [95% CI, 1.06–96.93]; P _interaction =0.044). CONCLUSIONS: In iPCAO, perfusion imaging provides independent prognostic information but does not identify patients with potential benefit from EVT and may instead indicate those at higher procedural risk. REGISTRATION: URL: https://osf.io/62mwt ; Unique identifier: NCT05291637.

Introduction/Objective: Acute intracranial stenting during endovascular thrombectomy (EVT) for ischemic stroke requires intraprocedural antiplatelet therapy (APT) to maintain patency. However, the hemorrhagic risk of combining APT with intravenous thrombolysis (IVT) remains uncertain. We evaluated the safety of IVT combined with conservative versus aggressive intraprocedural APT in patients requiring stenting during EVT. Methods: This multicenter RESISTANT registry subanalysis (2016–2023) included 823 adults. APT was categorized as conservative (aspirin +/− oral P2Y12) or aggressive (including GPIIb/IIIa inhibitors or cangrelor). The primary outcome was a composite of symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma (PH1/PH2). Multivariable logistic regression assessed associations and interactions between IVT and APT. Results: A total of 823 patients were included: 44 (5.3%) received IVT + conservative APT, 130 (15.8%) No IVT + conservative APT, 145 (17.6%) IVT + aggressive APT, and 504 (61.2%) No IVT + aggressive APT. Frequencies of sICH‐PH1‐PH2 were 9.3% with IVT + conservative APT, 10.7% with IVT + aggressive APT, 3.2% with No IVT + conservative APT, and 9.9% with No IVT + aggressive APT. In multivariable analysis without interaction terms, neither IVT (aOR 1.18, 95% CI 0.58–2.27; p = 0.64) nor aggressive APT (aOR 2.10, 95% CI 0.92–5.69; p = 0.10) was independently associated with increased risk of sICH‐PH1‐PH2. However, in the interaction model, IVT within the conservative‐APT stratum (aOR 5.84, 95% CI 1.07–43.92; p = 0.05) and aggressive APT within the no‐IVT stratum (aOR 4.81, 95% CI 1.41–30.22; p = 0.03) were each associated with higher odds of sICH‐PH1‐PH2, while the IVT‐by‐APT interaction term was < 1 (aOR 0.15, 95% CI 0.02–0.94; p = 0.05), indicating attenuation of the joint effect on the multiplicative odds scale. Conclusion: Among patients requiring intracranial stenting during EVT, we found no evidence that IVT and aggressive intraprocedural APT act synergistically to increase hemorrhagic risk. Rather, the negative IVT‐by‐APT interaction suggested attenuation of the joint effect on the multiplicative odds scale, although patients receiving both therapies remained at increased hemorrhagic risk relative to the reference group.

Introduction: Endovascular therapy (EVT) has become an increasingly important part of acute stroke management. However, the lack of trained neurointerventionalists represents a key barrier in expanding availability of EVT in Europe. This project aimed to investigate the association between the number of neurointerventionalists and overall EVT rates. Patients and methods: A cross-sectional analysis was conducted using publicly available data from the Global Burden of Disease Report 2021 and the Stroke Action Plan for Europe (Stroke Service Tracker). Data on the number of neurointerventionalists across 35 European countries were surveyed through a structured survey distributed via the Resident and Research Fellow Section (RRFS) of the European Academy of Neurology (EAN). Correlation analyses were performed to estimate the association between neurointerventionalist density per served population, EVT rates and stroke-related mortality and morbidity. Results: Survey response rate was 71% (25/35 countries). The proportion of acute ischaemic stroke patients treated with EVT ranged from 0.05% to 14.96% of people with ischaemic stroke, and the number of neurointerventionalists ranged from 9 to 137 per country and from 0.3 to 7.5 per million inhabitants. There was a positive correlation between the number of neurointerventionalists per population served and EVT rates (Spearman coefficient ρ = 0.507; 95% CI, 0.209–0.719). Greater availability of trained neurointerventionalists was moderately associated with lower national ischaemic-stroke mortality (ρ = −0.473; 95% CI, −0.746 to −0.065) and lower overall disability-adjusted life years (ρ = −0.444; 95% CI, −0.729 to −0.027). Discussion and conclusion: The number of neurointerventionalists correlates positively with the annual volume of EVT across European countries; higher EVT rates were also associated with lower stroke-related mortality and disability; however, these associations are unadjusted for other important confounders and causality cannot be inferred. These data suggest an urgent need to increase neurointerventional capacity in Europe, for example, by expanding dedicated national training programmes and enhancing support from national and international professional societies.

Objectives: Rescue stenting (RS) has emerged as a bailout strategy after failed reperfusion during endovascular treatment (EVT). Optimal blood pressure (BP) management after RS remains unclear. Our aim is to evaluate the association of BP levels and blood pressure variability (BPV) during the first 24 h after RS with short-term and long-term patient outcomes. Methods: We performed a retrospective analysis of an international registry where data from adult patients who underwent either RS or rescue angioplasty after failed EVT were collected. Patients who received RS with large vessel occlusion and at least 4 BP measurements in the first 24 h were included. Results: RS was performed in 437 patients (40.5% female, mean age 67.1 ± 13 years). Admission median National Institutes of Health Stroke Scale score was 12 (IQR 7–18) and history of hypertension was present in 74.2% of patients. Μean Systolic BP (SBP) in the first 24 h was 137.4 ± 14.6 mmHg. Higher values of BPV (coefficient of variation, standard deviation, average real variability and successive variation) were associated with lower odds for Modified Rankin Scale score 0–2 at 90 days (adjusted odds ratio ranging 0.55 [0.38, 0.79] to 0.99 [0.98, 0.99] per 10 units increase). No associations were found between any SBP measure and death, sICH as well as neurological deterioration at 24 h. Conclusion: In our study, higher BPV was associated with worse clinical outcomes in stroke patients treated with RS as bailout therapy after failed reperfusion. No association was shown between mean, maximum, minimum and delta SBP and clinical outcomes.

BACKGROUND: While rescue stenting (RS) is a recognized bailout strategy following failed endovascular thrombectomy for acute ischemic stroke with large vessel occlusion, first-line stenting (FLS) has emerged as a potential alternative to avoid vascular injury and improve outcomes. However, direct comparisons between these strategies remain limited. We conducted a comparative analysis of FLS versus RS using data from a large, multicenter international registry to evaluate their relative safety and effectiveness. METHODS: We conducted a comparative analysis of FLS versus RS using data from the RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke), a multicenter, international, retrospective cohort of patients with acute ischemic stroke treated with intracranial stenting during endovascular thrombectomy (2016–2023). Patients were categorized by stenting strategy: FLS (stent placed without prior thrombectomy) or RS (stent placed after failed thrombectomy). The primary effectiveness outcome was functional independence (modified Rankin Scale score, 0–2) at 90 days; the primary safety outcome was symptomatic intracranial hemorrhage. Propensity score inverse probability of treatment weighting was used to adjust for baseline differences. RESULTS: Among 827 patients, 723 were in the RS cohort (median age, 67 [interquartile range, 59–77] years; 64.2% male) and 104 in the FLS cohort (median age, 65.5 [interquartile range, 58.8–77] years; 72.1% male). Using FLS as the reference strategy, inverse probability of treatment weighting–adjusted analyses did not detect significant differences in functional independence (odds ratio [OR], 0.64 [95% CI, 0.38–1.07]) or symptomatic intracranial hemorrhage (OR, 0.93 [95% CI, 0.34–2.59]). No significant differences were observed in secondary outcomes, including successful reperfusion, mortality, or procedural complications. In the anterior circulation cohort (n=589), outcomes were likewise comparable (functional independence: OR, 0.62 [95% CI, 0.60–1.25]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). Similarly, in the posterior circulation cohort (n=234), no significant differences were found (functional independence: OR, 0.82 [95% CI, 0.32–2.10]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). CONCLUSIONS: In this study, no significant differences in safety or effectiveness were detected between FLS and RS strategies during endovascular thrombectomy for acute ischemic stroke. Prospective, randomized trials are needed to better define optimal treatment approaches.

Background and aim: Acute intracranial stenting is increasingly used as a rescue strategy during endovascular treatment for large vessel occlusion strokes. Limited data exist regarding the risk, clinical relevance, and optimal management of hemorrhagic transformation (HT) in this context. We aimed to evaluate the incidence, predictors, outcomes, and post-interventional antiplatelet management of HT in an international multicentric registry. Methods: We analyzed data from the RESISTANT registry, including patients who underwent emergent intracranial stenting for acute stroke between 2016 and 2023. Two complementary analyses were performed: (1) characterization of HT subtypes and associated outcomes (NIHSS at discharge, mortality, and mRS at discharge and 90 days) and (2) evaluation of antiplatelet management after Heidelberg class-1 HT detection and its impact on stent occlusion, hemorrhage progression, in-hospital mortality, and 90-day mRS. Results: Among 809 patients included, 177 (22%) experienced HT, of which 63 (8%) were symptomatic intracranial hemorrhage. Parenchymal hematomas (PH-1 and PH-2) and HI-2 were associated with worse functional outcomes and higher mortality. In the post-HT management cohort (n = 117), use of a high-intensity antiplatelet regimen (dual oral antiplatelet or any intravenous agent) was associated with lower risk of stent occlusion (adjusted risk ratio (aOR) = 0.21 [0.05–0.86]) and in-hospital mortality (aOR = 0.08 [0.01–0.50]) without increased hemorrhagic progression (0.52 [0.09–3.07]). Conclusion: HT remains a relevant complication after emergent intracranial stenting, particularly in patients with parenchymal hematoma. High-intensity antiplatelet therapy appears safe in select HT subtypes and was linked to reduced occlusion and mortality.