Samantha Miller

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: Endovascular thrombectomy is increasingly performed for acute ischemic stroke due to medium vessel occlusion (MeVO); however, recent randomized trials—primarily using stent retriever (SR) techniques—have not demonstrated a clear benefit over medical management. This study aimed to compare the direct aspiration first-pass technique (ADAPT) and SR in MeVO using a multicenter endovascular thrombectomy consortium. METHODS: The Society of Vascular and Interventional Neurology registry was queried for all primary MeVO cases treated with ADAPT or SR as the first-pass technique. MeVO was defined as an occlusion of A1, P1, M2, or beyond. Outcomes included time to recanalization, recanalization rates, first-pass effect (defined as Treatment in Cerebral Infarction-3 after first pass), intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes. RESULTS: A total of 1391 patients with MeVO were identified; 415 (29.8%) in the ADAPT group and 976 (70.2%) in the SR group. The most common location of occlusion was the middle cerebral artery-M2 (75.9%), followed by the middle cerebral artery-M3 (11.4%). The median age was 70, and 698 (50.4%) patients were men. Time from angio-suite arrival to expanded Treatment in Cerebral Infarction (eTICI) ≥2b (54 versus 60, P =0.002), time from endovascular access to final recanalization (42 versus 52, P P P P =0.002) and first-pass effect (31.7% versus 23.4%, P =0.002). Rates of good outcome, excellent outcome, intracranial hemorrhage, and sICH were not significantly different between groups. CONCLUSIONS: Although ADAPT yielded faster recanalization, SR achieved a higher first-pass effect and slightly higher recanalization rates. Intracranial hemorrhage, symptomatic intracranial hemorrhage, and clinical outcomes were comparable between groups. This study suggests that both techniques may offer distinct advantages. Prospective randomized controlled studies are warranted to further understand the safety and efficacy of ADAPT versus the SR technique in patients with MeVO.

Introduction: Endovascular thrombectomy (EVT) is an established treatment for large vessel occlusion acute ischaemic stroke, and indications have expanded to include broader patient groups. Whether this expansion has occurred equitably across racial and ethnic populations remains unclear. Materials/methods: We analysed the SVIN (Society of Vascular and Interventional Neurology) Registry+ (2014–2021) to assess disparities in EVT use. Patients were categorised by race/ethnicity (non-Hispanic white (NH-white), NH-black, Hispanic, Asian, other). Off-guideline EVT was defined as treatment in patients with age >85, pre-stroke disability (modified Rankin Scale >1), distal occlusion, large core (Alberta Stroke Program Early CT Score 85 years old and with NIHSS 2 =0.82, p=0.005) and Hispanic (R ² =0.89, p=0.005) patients. Conclusion: NH-black patients were less likely to receive EVT in specific off-guideline scenarios, while Hispanic patients were more likely in mild stroke presentations. Off-guideline EVT use has risen over time, particularly among NH-white and Hispanic patients, underscoring the need for equity-focused stroke care strategies.

BACKGROUND: Symptomatic intracranial atherosclerotic disease can be managed with medical therapy, risk factor control, angioplasty, and stenting. The Wingspan stent demonstrated limited efficacy and higher adverse outcomes than medical management in the SAMMPRIS trial (Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis). Drug-eluting stents, including the Resolute Onyx Zotarolimus-eluting stent, have demonstrated superior outcomes beyond 1 year. This study assessed outcomes at ≥24 months after stenting. METHODS: This retrospective multicenter study compared patients diagnosed with severe symptomatic intracranial atherosclerotic disease who underwent Resolute Onyx Zotarolimus-eluting stent stenting between March 2018 and May 2021 with patients from the percutaneous angioplasty and stenting and the aggressive medical management arms of the SAMMPRIS trial. Individuals who remained alive, stroke-free, and under follow-up at 24 months were included. Propensity score matching was used to align the 3 arms, and landmark analysis using inverse probability weighting, accounting for differential survival to 24 months, was used as complementary sensitivity analysis. The primary outcomes measured were postlandmark (ie, 24 months) stroke recurrence, intracranial hemorrhage, and all-cause mortality. RESULTS: After applying the 24-month landmark and propensity score matching, 204 patients (68 per arm) were eligible (median follow-up, 36 months). Unweighted rates of stroke ( P =0.147), intracranial hemorrhage ( P =0.362), and mortality ( P =0.168) did not differ significantly among groups. Weighted multivariable logistic and Cox regression analyses, adjusting for residual postmatch differences, similarly showed no significant differences in stroke recurrence. Kaplan-Meier analysis did not demonstrate a significant difference in overall survival across the 3 arms (log-rank P =0.139). CONCLUSIONS: Although previous studies have demonstrated the superiority of the Resolute Onyx Zotarolimus-eluting stent compared with the Wingspan system and aggressive medical management for the treatment of severe symptomatic intracranial atherosclerotic disease, the present landmark analysis suggests that these benefits may not consistently extend beyond 24 months. One speculative explanation is that the drug elution–related benefit of the Resolute Onyx Zotarolimus-eluting stent may attenuate over time, but this was not directly assessed in the present study. Prospective, controlled trials are necessary to confirm the implications of our long-term findings.

Introduction Delivering large-bore aspiration catheters through tortuous anatomy remains challenging during mechanical thrombectomy (MT). The Carrier delivery-assist catheter (DAC) was designed to facilitate aspiration catheter navigation, but multicenter data remain limited. We evaluated the efficiency and safety of the Carrier DAC. Methods We performed a multicenter retrospective study of prospectively collected data from patients undergoing MT at 15 U.S. Comprehensive Stroke Centers (September 2024?September 2025). Co-primary endpoints were puncture-to-clot engagement time and first-pass effect (FPE; eTICI 2c?3). A pre-specified single-center analysis compared upfront contact aspiration using the Carrier DAC versus standard 0.021? microcatheter techniques with identical aspiration catheter sizes. Results The multicenter cohort included 211 Carrier-assisted MTs. Median aspiration catheter inner diameter was 0.071?, with super-bore catheters used in 5.7%. Median puncture-to-clot time was 12 minutes, and FPE was achieved in 50.7%. Median puncture-to-reperfusion time was 20 minutes, and mFPE occurred in 74.4%. Parenchymal hematoma and subarachnoid hemorrhage occurred in 11.8% and 6.6%, respectively. Cavernous tortuosity did not affect primary endpoints. The single-center analysis included 242 patients. Carrier use was associated with shorter puncture-to-clot times and numerically higher FPE rates without increased hemorrhagic complications. Conclusions The Carrier DAC enables efficient navigation of large-bore aspiration catheters and may reduce procedural time while maintaining procedural safety. Prospective studies are warranted.

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: The CASONI study (Carotid Artery Stenting Outcomes by Neurointerventional Surgeons) showed that proceduralist experience significantly reduces complications in carotid artery stenting. The CASSH study (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) prospectively evaluates real-world carotid artery stenting outcomes by fellowship-trained neurointerventionalists at comprehensive stroke centers across the United States to validate and expand on CASONI’s findings. METHODS: CASSH is a multicenter, prospective observational study conducted across 15 US comprehensive stroke centers from January 2023 to December 2024. Adults with symptomatic ≥50% or asymptomatic ≥70% carotid stenosis undergoing carotid artery stenting by fellowship-trained neurointerventionalists were included. The primary outcome was a 30-day composite of procedure-related death, stroke, or myocardial infarction. Secondary outcomes included nonprocedural mortality, access site complications, stent thrombosis, and other adverse events. Logistic regression identified predictors of adverse outcomes. RESULTS: Among 889 patients (mean age 70.3±9.9 years; 61.4% male), 87.1% had hypertension and 63.1% were symptomatic. The 30-day composite primary outcome occurred in 1.2% (mortality 0.8%, ischemic stroke 0.3%, hemorrhagic stroke 0.2%, myocardial infarction 0.2%). Composite secondary outcome occurred in 5.4%, most commonly access site complications (1.7%) and nonprocedural mortality (1.5%). Higher preprocedural modified Rankin Scale (odds ratio [OR], 1.42), National Institutes of Health Stroke Scale score (OR, 1.09), and longer fluoroscopy times (OR, 1.02) were associated with increased complication risk. Mortality was independently predicted by elevated modified Rankin Scale (OR, 1.72), higher National Institutes of Health Stroke Scale score (OR, 1.15), older age (OR, 1.05 per year), and lower ejection fraction (OR, 0.96). Postprocedural antiplatelet therapy was protective, reducing both complications (OR, 0.03) and mortality (OR, 0.07). CONCLUSIONS: Carotid artery stenting performed by fellowship-trained neurointerventionalists at comprehensive stroke centers is associated with low rates of periprocedural stroke, myocardial infarction, and death. These outcomes align with the landmark CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), particularly in asymptomatic patients, and are strongly influenced by preprocedural disability, stroke severity, age, and cardiac function, underscoring the importance of patient selection and optimized perioperative care.

Purpose: The optimal anesthetic approach for intracranial stenting in acute stroke remains unclear. We compared outcomes of patients under general anesthesia (GA) versus local anesthesia or conscious sedation. Methods: The RESISTANT registry is a multicenter observational study on acute intracranial stenting during thrombectomy. Patients treated between January 2016 and June 2023 were included and stratified into GA and local anestesia/conscious sedation groups. The primary outcome was an adjusted shift analysis of the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0–2 at 90 days and final modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 scores. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. Adjusted ordinal and logistic regression with mixed-effects models were performed. Results: Of 876 patients, 445 (50.8%) received GA. Median age was 67 years [59–77]; 567 (64.8%) were men. No differences were found in 90-day mRS (adjusted common OR = 1.256 [0.887–1.780], p = 0.199). Rates of functional independence (39.0% vs 44.5%; aOR = 0.956 [0.606–1.507], p = 0.846), mTICI 2c/3 (68.9% vs 68.7%; aOR = 0.941 [0.602–1.471], p = 0.790), and sICH (8.0% vs 8.6%; aOR = 0.769 [0.374–1.584], p = 0.477) were comparable. In-hospital (23.0% vs 12.0%; aOR = 2.39 [1.35–4.22], p = 0.003) and 90-day mortality (33.3% vs 21.1%; aOR = 2.017 [1.227–3.315], p = 0.006) were higher in the GA group. Conclusion: In patients undergoing intracranial stenting during thrombectomy, anesthesia modality was not associated with better outcomes. GA was linked to higher mortality, likely due to indication bias.

BACKGROUND: In the case of failed reperfusion or severe stenosis during endovascular treatment of acute stroke, intracranial stenting is a growing practice. We aimed to study clinical and radiological outcomes in a large multicenter cohort. METHODS: The RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke; 2016–2023) is a multicenter single-arm retrospective registry of patients with acute stroke who underwent intracranial stenting during endovascular treatment across 36 international centers. The primary end point was functional outcome at 90 days. Secondary end points were final successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and stent patency at 24 hours. Safety outcomes included procedural complications, symptomatic intracranial hemorrhage, and in-hospital mortality. Logistic regression models including those variables that achieved statistical significance, along with age, baseline National Institutes of Health Stroke Scale, and baseline modified Rankin Scale, were used to define independent predictors. RESULTS: Among 904 patients enrolled, 876 fulfilled inclusion criteria. Median age was 67.0 (interquartile range, 59.0–77.0) years, 567 (64.8%) were men, and the median National Institutes of Health Stroke Scale score was 12.0 (interquartile range, 7.0–19.0). Anterior circulation was involved in 624 (71.6%), and the rate of tandem extracranial/intracranial occlusion was 4.9%. Stenting was performed in 469 patients (53.5%), owing to failed reperfusion (expanded Thrombolysis in Cerebral Infarction, 0-2a), and in 320 patients (36.5%) because of residual severe stenosis. After stenting, immediate successful recanalization was achieved in 777 (89.5%). At 90 days, the rate of modified Rankin Scale score of 0 to 2 was 41.2%. The number of thrombectomy attempts (adjusted odds ratio, 0.810 [95% CI, 0.707–0.929]; P =0.003) and the final successful recanalization (adjusted odds ratio, 19.394 [95% CI, 5.486–68.560]; P <0.001) were associated with good functional outcome. During admission, the reocclusion rate was 12.2%, most of them within 48 hours. Symptomatic intracranial hemorrhage was diagnosed in 8.4% of patients; no variables were independently associated with a higher probability. CONCLUSIONS: Acute intracranial stenting was a feasible therapy for patients with failed reperfusion or severe stenosis. Successful reperfusion and a lower number of thrombectomy attempts predicted functional outcome. Prospective studies are warranted to confirm efficacy and safety.

Background: Advanced neuroendovascular procedures require trackable and supportive guide catheters, which facilitate safe device delivery. Echo intracranial base catheter was engineered as a large lumen (0.100″ ID) access catheter that is super trackable, supportive, and kink resistance, all while fitting within the puncture of a typical 8F sheath when its used with the thin-walled, Dash short sheath (9F). This case series evaluates its performance as a guide catheter in various neurointerventional procedures. Methods: Consecutive cases using an Echo access catheter were identified from a prospectively maintained patient database at a comprehensive stroke center between April and July 2025. Demographic, clinical, procedural, and angiographic characteristics were collected. Outcomes of interest included procedural success and periprocedural complications, including flow-limiting vasospasm, vessel dissection, and thrombus formation. Results: Echo access catheter was used in a total of eleven cases, including six thrombectomies, two venous sinus stents, one intracranial stent, one intracranial angioplasty, and one aneurysm flow diversion. Average patient age was 61 years old, 6 (54.5%) were female, and all had femoral access. Echo catheter tip was placed in the petrous segment of ICA in three cases (27.2%), the lacerum segment in three cases (27.2%), the cervical segment in two cases (18.1%), the cavernous segment in one case (9.1%), the vertical petrous segment in one case (9.1%), and the transverse sinus in one case (9.1%). Intracranial stenting and flow diversion were completed with use of a distal access catheter, and intracranial angioplasty was successfully performed with an Echo access catheter alone. Echo access catheter was able to easily navigate to the transverse venous sinus over a ledge-reducing delivery microcatheter and deliver devices for venous sinus stenting and angioplasty. There was a 100% procedural success rate. No significant catheter-related complications were observed. Conclusions: This series highlights Echo access catheter's safe and effective use in a diverse representation of neuroendovascular procedures.