Background: Large and giant intracranial aneurysms pose treatment challenges. The benefit–risk balance of flow diverters (FDs) alone versus FDs with coiling remains unclear. This study aimed to compare these two strategies. Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, Embase, Scopus, Cochrane, and Web of Science was performed up to October 2024. Studies comparing FDs with or without adjunctive coiling in large/giant intracranial aneurysms were included. The primary outcome was complete aneurysm occlusion, defined by the Raymond–Roy Occlusion Classification. Additional outcomes included procedural and postprocedural complications. Data were analyzed using a random effects model. Results: 15 studies with 1130 patients were analyzed, with 557 in the FD alone group and 573 in the FD+coiling group. The meta-analysis revealed that FD+coiling significantly improved complete aneurysm occlusion rates (OR 1.59, 95% CI 1.06 to 2.40, P=0.03). While overall ischemic complications were significantly lower in the FD alone group, a sensitivity analysis showed no significant difference (OR 0.49, 95% CI 0.20 to 1.23, P=0.13). Subgroup analysis of fusiform aneurysms showed no significant difference in complete aneurysm occlusion rates (OR 1.10, 95% CI 0.50 to 2.40, P=0.82). Procedural and hemorrhagic complications did not differ significantly, and no publication bias was detected in the results. Conclusions: Combining FDs with coiling improved complete aneurysm occlusion rates in large and giant saccular intracranial aneurysms, although the impact on complications remains controversial. Further investigation into the benefit–risk ratio of this combined approach is warranted.

Background A combination of intravenous (IVT) or intra-arterial (IAT) thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been investigated. However, there is limited data on patients who receive both IVT and IAT compared with IVT alone before MT. Methods STAR data from 2013 to 2023 was utilized. We performed propensity score matching between the two groups. The primary outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day modified Rankin Scale (mRS) score 0–2. Secondary outcomes included successful recanalization (modified treatment in cerebral infarction (mTICI) ≥2B, ≥2C), early neurological improvement, any intracranial hemorrhage (ICH), and 90-day mortality. Results A total of 2454 AIS-LVO patients were included. Propensity matching yielded 190 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio (OR): 0.80, 95% confidence interval (CI) 0.51–1.24, P=0.37; OR: 0.60, 95% CI 0.29 to 1.24, P=0.21, respectively). Rates of successful recanalization and early neurological improvement (ENI) were significantly lower in MT+IVT + IAT. mRS 0–1 and mortality were not significantly different between the two groups. However, the MT+IVT + IAT group demonstrated superior rates of good functional outcomes (90-day mRS 0–1) compared with patients in the MT+IVT group who had mTICI ≤2B, (OR: 2.18, 95% CI 1.05 to 3.99, P=0.04). Conclusion The combined use of IAT and IVT thrombolysis in AIS-LVO patients undergoing MT is safe. Although the MT+IVT+ IAT group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes were favorable in this group suggesting a potential delayed benefit of IAT.

Recent advancements in endovascular treatment (EVT) and different views on optimal management for posterior communicating artery (PComA) aneurysms with oculomotor nerve palsy (ONP) highlight a need to compare recovery timelines between microsurgery and EVT; heterogeneous outcomes and influencing factors may also affect results. A comprehensive systematic review and meta-analysis were conducted by searching PubMed, Embase, Scopus, and Web of Science databases. The extracted data encompassed patient demographics, details on treatment modalities and timing, and characteristics of PComA aneurysms ONP caused by either unruptured or ruptured aneurysms. The primary outcome was ONP favorable recovery, defined as the resolution of admission symptoms, except for subtle ptosis and mild pupillary asymmetry. We used random effect models to calculate odds ratios (OR) and pool prevalence with their corresponding 95% confidence intervals (CI). A total of 40 studies met the inclusion criteria. Overall, microsurgical clipping of PComA aneurysms demonstrated a significantly higher likelihood of ONP recovery compared to EVT at 1,3,6, and 12 months follow-up. However, recovery rates were comparable in long-term follow-up [18 months: (0.87 vs. 0.64, P-value = 0.36); ≥24 months: (0.86 vs. 0.72 P-Value = 0.26)]. The recovery outcomes for early treatment were similar when assessed during the 6-month follow-up (0.75 vs. 0.56, P-value = 0.07). Our findings suggest microsurgery leads to prompt ONP recovery from PComA aneurysms, while EVT shows potential for delayed favorable recovery; both treatments yield short-term recovery when administered early. A case-by-case approach is recommended, emphasizing a comprehensive understanding of patient factors in relation to the immediate and sustained effects of each treatment.

Background Middle meningeal artery embolization (MMAE), whether alone or with surgery, reduces chronic subdural hematoma (cSDH) recurrence. However, the impact of resuming antithrombotic (AT) therapy after MMAE and optimal resumption time remains unclear. Methods A systematic review and meta-analysis were conducted following PRISMA guidelines. Searches of PubMed, Web of Science, Embase, and Scopus through February 28, 2025, identified English-language studies on cSDH treated by MMAE (with or without surgery) reporting AT resumption outcomes. The risk of bias was assessed using the Newcastle–Ottawa Scale (NOS). Primary outcomes included recurrence and radiographic measures. Data were pooled using a random-effects model in R software. Results Of 514 articles, 3 retrospective studies (233 patients) were included. Among these, 78 resumed AT therapy. Random-effects meta-analysis revealed no significant differences in recurrence (OR 1.64, 95% CI 0.45–6.00, P = 0.45), final SDH thickness (MD: 0.27, 95% CI: -0.91, 1.44, P = 0.66), or reduction in SDH thickness (MD: -0.60, 95% CI: -2.15, 0.96, P = 0.45). Subgroup analyses (antiplatelet vs. anticoagulant, MMAE alone vs. MMAE + surgery, early resumption) also revealed no significant differences. Sensitivity analyses confirmed consistent results. All included studies were moderate-to-high quality. Conclusion Resuming AT therapy after cSDH management with MMAE alone or combined with surgery appears not to affect recurrence rates or hematoma resolution. Preliminary findings support the safety of both anticoagulant and antiplatelet agents as well as early resumption. However, larger prospective studies remain essential for confirming these observations and establishing best practices.

Background: Recent trials have furthered uncertainty regarding the endovascular benefit for medium vessel occlusions (MeVO). Stent retrievers (SR) were employed in the first attempt in most interventional arm participants. We sought to compare outcomes in acute MCA M2 occlusions between frontline aspiration and SR, and to delineate procedural and anatomical covariates associated with differential treatment effect. Methods: Retrospective analysis of a multicenter stroke thrombectomy cohort identified cases of MT for M2 occlusions. Unmatched and propensity score-matched (PSM) cohorts were generated comparing frontline aspiration to standalone and combined SR. The primary outcome was functional independence (mRS 0–2) at 90 days. Recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and the effect of M2 laterality, division occlusion and procedure time were assessed. Results: About 1734 patients with M2 occlusions underwent either frontline aspiration (n = 711) or SR/combined (n = 958) thrombectomy between 2013 and 2024. PSM analysis favored aspiration for functional independence (49.9% vs 44.0%, OR 1.27 (1.03–1.57)), complete recanalization (61.2% vs 48.7%, OR 1.66 (1.34–2.05)), complete first pass effect (35.0% vs 27.6%, OR 1.42 (1.13–1.78)), and sICH (3.5% vs 6.2%, OR 0.55 (0.33–0.91)), with no difference in mortality. Frontline aspiration had significantly shorter procedural times (median 28 [IQR 15–49.5] vs 51 [IQR 35–78] minutes; p < 0.001). For every minute increase in procedure time, the probability of functional independence decreased significantly (p < 0.001) less with frontline aspiration (0.35%) compared to SR/combined (1.61%). Conclusion: Frontline aspiration for M2 occlusions resulted in better clinical and angiographic outcomes compared to SRs. Future trials for MeVO with a focus on contact aspiration thrombectomy may succeed where recent trials have failed.