Background Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO. Method This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2–3–4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques. Results A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03). Conclusion Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.

Background Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0–2). Methods Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0–2). A favorable outcome was defined by achieving a modified Rankin scale of 0–3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B. Results We identified 58 patients who presented with ASPECTS 0–2 and underwent MT . Median age was 70.0 (59.0–78.0) years, 45.1% were females, and 202 (36.3%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 268 (54.6%) patients and stent retriever was used in 70 (14.3%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 4.5%, 27.9% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes. Conclusions This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0–2.

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.

Purpose: Techniques for endovascular thrombectomy in acute ischemic stroke due to medium or distal vessel occlusions (MDVO) need to be improved, and first-line aspiration is emerging as a promising technique. The objective was to describe first-pass and final reperfusion rates with a triaxial direct aspiration first pass technique (ADAPT) and a novel, quadriaxial technique (QUATTRO-ADAPT) using RED43 Reperfusion Catheters to target MDVOs. Methods: This retrospective study collected data from 11 stroke centers in Europe and North America between 2023 and 2025. Patients with primary, isolated MDVOs who underwent thrombectomy using first-line aspiration with RED43 Reperfusion Catheters were included. Primary outcome was first-pass successful reperfusion rate (modified Treatment In Cerebral Infarction score ≥ 2b). Additionally, final reperfusion rates, complications and functional outcomes up to 90 days were evaluated. Results: We included 85 cases. Median age was 74 years (IQR 67–81) and median National Institutes of Health Stroke Scale score 9 (IQR 6–15). The majority (69.4%) had an occlusion of the co- or nondominant M2 segment of the middle cerebral artery. First-pass successful reperfusion was 63.5% overall, with 55.6% for the triaxial ADAPT and 69.4% for the quadriaxial QUATTRO-ADAPT. Final successful reperfusion was achieved in 96.5%. Complications included vessel perforations (2.4%), subarachnoid hemorrhage (3.5%), parenchymal hematoma type 2 (2.4%), and symptomatic intracerebral hemorrhage (1.2%). Functional independence (modified Rankin Scale 0–2) at 90 days was observed in 58.7%. Conclusion: This study shows that first-line aspiration, especially in a quadriaxial approach, can be effective and safe. These findings should be evaluated in prospective trials.

Background Endovascular thrombectomy (EVT) has transformed acute ischemic stroke (AIS) care, with onset-to-puncture (OTP) time widely recognized as a critical determinant of outcome. However, emerging evidence suggests that in-hospital procedure time (PT)—from arterial puncture to final recanalization—may have an equally or more significant impact. This study examines the relative contribution of PT versus OTP to functional outcomes in patients with AIS undergoing EVT. Methods A retrospective analysis was conducted of 6644 patients with AIS treated at 44 international stroke centers from the Stroke Thrombectomy and Aneurysm Registry (STAR; 2016–2023). Multivariable regression, time-equivalence analysis, and marginal effects modeling were used to assess associations between PT, OTP, and 90-day modified Rankin Scale (mRS) outcomes. Centers were stratified by procedural efficiency and compared using propensity score matching (PSM). Mediation analysis evaluated whether PT accounted for inter-center differences. Results PT and OTP were independently associated with functional outcomes; however, PT had a significantly stronger effect (adjusted OR for mRS 0–2: PT=0.56 vs OTP=0.96 per hour). Each 5 min increase in PT was equivalent to 78–100 min of additional OTP in outcome impact. Centers with faster average PT had higher rates of functional independence (number needed to treat (NNT)=10), fewer complications, and lower symptomatic intracranial hemorrhage rates. PT significantly mediated the relationship between center tier and outcomes (Sobel’s P<0.001). Conclusion While minimizing OTP remains important, PT exerts a greater influence on outcomes after EVT. Procedural efficiency should be emphasized in stroke systems of care and included in center performance metrics to improve patient outcomes.