Piotr Pedowski

Background: Flow diversion is an effective technique for treating intracranial aneurysms (IAs), with a high rate of complete aneurysm occlusion at 1 year. As dual antiplatelet treatment (DAPT) is required, it is restricted to unruptured IA. Surface-modification (SM) flow diverters (FDs), introduced to reduce thrombogenicity, have been poorly evaluated. COATING (Coating to Optimize Aneurysm Treatment In the New Flow Diverter Generation) is the first randomized controlled trial (RCT) evaluating an SM FD (p64-MW-HPC (hydrophilic polymer coating), phenox GmbH) under single antiplatelet treatment (SAPT). Methods: We compared the treatment arm, SM p64-MW-HPC under SAPT (ticagrelor or prasugrel), to the control arm, bare p64-MW under DAPT (ticagrelor or prasugrel+aspirin), for unruptured IA management. The primary endpoint (number of diffusion-weighted imaging (DWI) lesions on MRI 48 hours (±24 hours) after the index procedure) and safety data up to 1 month post-procedure were analyzed. Results: From September 2021 to November 2024, 171 patients (female 84.8%, mean age 55±11 years) were included in 15 centers in Europe and Israel with 83 patients in the treatment arm and 88 in the control arm. The mean (±SD) number of DWI lesions within 48 hours (±24 hours) of the index procedure in the treated aneurysm territory was 6.0 (±13.28) in the HPC and 5.3 (±11.75) in the bare group (P _{non-inferiority testing} <0.0001). 1-month safety data showed no statistically significant difference in thromboembolic events between study arms. Conclusion: COATING is the first RCT to evaluate an SM FD (p64-MW-HPC) under SAPT and shows favorable safety at 1 month.

Objective: Acute ischemic stroke (AIS) remains one of the most common causes of death and disability in the world. Mechanical thrombectomy (MT) is the modality of choice in the treatment of AIS and large vessel occlusion (LVO). The endovascular treatment of medium and distal vessel occlusions (DMVO) is currently under intensive scientific investigation. The aim of our study was to prove the feasibility, effectiveness and safety of MT in patients with a primary, isolated occlusion of the M2 segment of the middle cerebral artery (MCA), with a focus on the recanalization level and the first-pass effect (FPE) as predictors. Methods: We prospectively assessed patients after MT for primary isolated occlusion of the M2 MCA segment that were treated at our center during a three-year period between July 2021 and June 2024. Our final cohort included 137 patients who met the inclusion criteria. Epidemiological, clinical and technical data, as well as the clinical and safety outcomes of MT procedures, were recorded and analyzed. The primary outcome was defined as a modified Rankin scale (mRS) score of 0–2. Secondary outcomes included excellent functional independence (mRS 0–1) and successful recanalization, defined by a modified thrombolysis in cerebral infarction (mTICI) score of 2c–3. Safety outcomes included symptomatic intracerebral hemorrhage (sICH), any intracerebral (IC) hemorrhage and 90-day mortality. Results: The mean age of our cohort was 71.8 ± 12.5 years; 59 were men (43.1%). The primary outcome (mRS 0–2) was achieved in 89 (65%) patients. An excellent functional outcome (mRS 0–1) was reached in 58 (42.3%) and successful recanalization (mTICI 2c–3) in 118 (86.1%) patients. sICH was present in 5 cases (3.7%), any IC hemorrhage in 42 (30.7%) and 90-day mortality in 28 (20.4%). We found a statistically significant correlation between the primary outcome (mRS 0–2) and a successful recanalization mTICI of 2c–3 (p—0.024). This correlation was even stronger between excellent functional outcomes and a recanalization mTICI of 2c-3 (p < 0.001). The study did not confirm the importance of the first-pass effect (FPE) during MT of the M2 segment (p—0.489). We also noticed a significant 31.3% mortality increase in the group of patients in which recanalization of the occluded M2 branch was insufficient. Conclusions: MT is a powerful and effective treatment method for AIS caused by an occlusion of the M2 segment in real-life conditions. Patients have a higher probability of a long-term good functional outcome when complete or near-complete reperfusion is achieved.

Objective: Acute ischemic stroke (AIS) is a leading cause of death, but isolated middle cerebral artery dissection (MCAD) is rarely reported. The aim of this article is to sum up the current information on this pathology and to explore the technical aspects of its endovascular treatment with emphasis on novel coated, antithrombogenic stents and antiplatelet management. Another part of this article offers our experience with the problematics represented by a small sample group of patients with an MCAD diagnosis who were treated in our center. Methods: We conducted literature research and a retrospective review of patients treated for anterior circulation AIS at our comprehensive stroke center from January 2022 to March 2024. The cohort included 16 patients diagnosed with isolated MCAD, 9 received antithrombogenic coated stents, while 7 received bare metal stents. Pharmacological management of coated stents involved the use of Cangrelor for acute antiplatelet therapy, transitioning to oral Ticagrelor. Results: Among the 16 patients treated, those with antithrombogenic coated stents showed no major complications and had a lower incidence of intracranial hemorrhage compared to the bare metal stent group. The average National Institutes of Health Stroke Scale (NIHSS) score at discharge improved in both groups. Functional outcomes and mortality rates were slightly better in the coated stent group, but no statistical significance was proven. Conclusions: Antithrombogenic coated stents, in conjunction with MAPT, demonstrated a safe and effective option for treating isolated MCAD. These stents offer promising potential for improved outcomes and reduced complications compared to traditional treatments. Further multicentric studies with larger cohorts are recommended to validate these findings.