BACKGROUND AND PURPOSE: The endovascular treatment of aneurysms located at or distal to the circle of Willis and not amenable to coiling remains a challenge. We report our experience with flow-diversion treatment using low-profile braided stents as a stent monotherapy procedure for treating distally located very small or uncoilable aneurysms. MATERIALS AND METHODS: We retrospectively reviewed our data bases to identify patients with aneurysms located at or distal to the circle of Willis who were treated with stent monotherapy using low-profile braided stents. The immediate and follow-up angiographic findings and clinical status of the patients were assessed. RESULTS: Twenty aneurysms in 19 patients were included in the study. The mean size of the aneurysms was 4.7 ± 2.4 mm. Patients were treated via telescopic implantation of 2 stents for 11 aneurysms; single-stent placement was used for the remaining aneurysms. The technical success rate was 95%. We observed a technical complication in 1 case (5.3%) and a late ischemic event in another (5.3%). The final angiographies during a mean follow-up of 14.7 months showed complete aneurysm occlusion in 73.7%. The complete occlusion rate of the aneurysms treated with telescopic stent placement was 81.8%. The modified Rankin scale scores of all patients at the last follow-up were between 0 and 2. CONCLUSIONS: Flow diversion with low-profile braided stents as a stent monotherapy procedure for very small or uncoilable intracranial aneurysms located at or beyond the circle of Willis is a promising, relatively safe, and durable endovascular procedure.

Background: Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability worldwide, with upper-middle-income countries (UMICs) facing a disproportionate burden due to systemic inefficiencies in healthcare delivery. Kazakhstan reports the highest global age-standardized mortality rate from ischemic stroke, underscoring the need to evaluate current stroke care practices and identify areas for improvement. Objective: This study aimed to assess the current state of acute ischemic stroke care in Kazakhstan by examining key time metrics, protocol adherence, and the utilization of advanced technologies such as artificial intelligence (AI) and telemedicine. Additionally, this study sought to identify regional disparities in care and propose actionable recommendations to improve patient outcomes. Methods: A multi-center cross-sectional survey was conducted across 79 stroke centers in Kazakhstan. Data were collected from 145 healthcare professionals, including neurologists, neurosurgeons, and interventional radiologists, through a validated 23-question online questionnaire. Statistical analysis was performed to identify significant associations between variables. Results: Significant regional disparities were observed in stroke care timelines and technology adoption. Remote and rural areas experienced prolonged prehospital delays, with transport times ranging from 120 to 180 min, contributing to door-to-needle times exceeding the recommended benchmark. Urban centers with higher adoption of AI and telemedicine demonstrated faster treatment initiation and better protocol compliance. Staff training was significantly associated with improved treatment outcomes, with trained centers more likely to implement direct-to-angiography suite protocols, reducing in-hospital delays. Conclusions: Addressing acute ischemic stroke care disparities in Kazakhstan requires a multifaceted approach, including expanding AI and telemedicine, implementing targeted staff training programs, and establishing standardized national stroke protocols. These strategies can help reduce treatment delays, bridge the urban–rural healthcare divide, and improve patient outcomes. The findings have implications for other UMICs facing similar challenges in delivering equitable stroke care.

BACKGROUND AND PURPOSE: Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms. MATERIALS AND METHODS: A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed. RESULTS: Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8) months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization. CONCLUSIONS: The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.

Background/Objectives: Intracranial atherosclerosis (ICAS) is a major cause of ischemic stroke, disproportionately affecting populations with significant vascular risk factors. Although ICAS imposes a considerable health burden, research on this condition in Central Asia remains scarce, especially among the Kazakh population. This study analyzes demographic characteristics, treatment outcomes, and procedural challenges associated with ICAS in 216 patients treated at a single institution. Methods: This retrospective study included patients with ≥70% intracranial artery stenosis confirmed by imaging and presenting with ischemic symptoms. All patients underwent angioplasty and stenting with dual antiplatelet therapy (DAPT). Data collected included demographics, comorbidities, stenosis characteristics, procedural details, and outcomes assessed by the modified Rankin Scale (mRS). Results: The median age was 63.5 years (IQR: 57–68.6), and 73.7% were male. Hypertension was the most common comorbidity (98%), followed by ischemic heart disease (58%) and diabetes mellitus (40.9%). Multi-location ICAS was significantly associated with patients over 75 years of age (p = 0.025). Additionally, obesity and stenosis severity greater than 70% showed trends toward significance, with p-values of 0.064 and 0.079, respectively. Stenosis predominantly affected the internal carotid artery (54.5%) and vertebrobasilar system (31.6%). The average hospital stay was longer for posterior circulation stenosis (7.1 days) compared to anterior circulation (4.7 days). The periprocedural complication rate was 0.7%, with two deaths attributed to ischemic complications. At follow-up, four patients experienced worsening mRS scores (>2), particularly those with severe stenosis in the basilar artery and M1 segment. Conclusions: ICAS in the Kazakh population is strongly associated with hypertension and aging, with posterior circulation stenosis contributing disproportionately to worse outcomes. The low complication rates highlight the safety of modern endovascular techniques. However, further research is needed to optimize treatment strategies for severe and multi-location ICAS, particularly in Central Asian populations.

The Woven EndoBridge (WEB) device has emerged as a promising alternative to endovascular coiling. This case report demonstrates the use of stent-assisted WEB deployment for the embolization of multiple wide-neck posterior cerebral artery (PCA) aneurysms. A middle-aged patient was diagnosed with 3 unruptured aneurysms in the P3 and P4 segments of the right PCA, with sizes ranging from 2.5 mm to 6.6 mm. Given the small vessel diameter and distal location of the aneurysms, a combined approach was adopted. Coil embolization was performed for the most distal aneurysm, while stent-assisted WEB deployment was used for the proximal and middle aneurysms. The “flower bud” technique facilitated the safe positioning of the WEB device in challenging anatomical conditions. The procedure was successfully completed without complications, and the patient was discharged on postoperative day 7 with no neurological deficits. Follow-up at 3 months confirmed adequate embolization of all aneurysms, with in-stent stenosis managed conservatively.

Background: The coexistence of extracranial arterial stenoses and intracranial aneurysms presents a unique clinical dilemma. While staged interventions are traditionally preferred to reduce procedural risks, recent advances have enabled single-stage endovascular treatment. This study evaluates the clinical outcomes, procedural strategies, and predictive factors associated with such combined interventions. Methods: This retrospective study included 47 patients treated with single-stage endovascular procedures for concurrent extracranial stenosis and intracranial aneurysm between 2016 and 2024. Clinical, angiographic, and procedural data were collected. Outcomes were assessed using the mmodified Rankin Scale (mRS), and statistical analyses were performed to identify associations between clinical variables and functional outcomes. Results: Of the 47 patients, 85.1% achieved favorable outcomes (mRS 0–2) at ≥6-month follow-up. The most commonly treated arteries were the internal carotid artery (70.2%) and the middle cerebral artery (34%). Stent-assisted coiling or flow diversion was performed in 93.6% of aneurysm cases, while 91.5% underwent carotid or vertebral stenting. Lesion laterality (left-sided aneurysms, p = 0.019) and stenosis length (p = 0.0469) were significantly associated with outcomes. Smoking was linked to multiple stenoses (p = 0.0191). Two patients experienced major complications: one aneurysmal rebleed after stenting, and one intraoperative rupture. Conclusions: Single-stage endovascular treatment for patients with concurrent extracranial stenosis and intracranial aneurysm is technically feasible and clinically effective in selected cases. Lesion configuration, anatomical considerations, and individualized planning are critical in optimizing outcomes.