Purpose Large bore catheters are increasingly used in mechanical thrombectomy (MT) for large vessel occlusions (LVOs). Objective To evaluate the efficacy and safety of the super-large bore Cereglide 0.092" (C-92) catheter, featuring the largest inner diameter available. Methods A multicenter observational study was conducted across 12 comprehensive stroke centers in the United States. Efficacy outcomes included the first pass effect (FPE) and successful reperfusion. FPE was defined as a first MT pass achieving a modified Treatment in Cerebral Infarction (mTICI) score of ≥2c. Successful reperfusion was defined as final mTICI score ≥2c. Safety outcomes involved device-related complications, symptomatic intracranial hemorrhage (sICH), and inpatient mortality. Functional outcomes included modified Rankin Scale (mRS) score at discharge and delta National Institutes of Health Stroke Scale (NIHSS) score. Results Fifty patients were included. The most common LVO was the first segment of the middle cerebral artery in 31/50 cases (62%). The C-92 reached the thrombus in 41 patients (82%). Median puncture-to-thrombus and puncture-to-reperfusion times were 15 min (IQR 10–25) and 26 min (IQR 15–49), respectively. FPE was achieved in 25/50 (50%) cases, and in 25/41 (61%) cases when the C-92 reached the thrombus. Successful reperfusion occurred in 36/41 patients (88%). There were no vessel perforations, or sICH. Distal embolization occurred in 4/50 (8%) cases, and 4/50 (8%) died. The mRS score at discharge was 3 (IQR 2–6), and the delta NIHSS score was 8 (IQR 5–12). Conclusion The C-92 catheter demonstrated a safe profile achieving an overall FPE rate of 50%, and favorable functional outcomes in 88% of cases.

Background: Heavily calcified carotid stenosis (HCCS) is considered an exclusion for carotid angioplasty and/or stenting (CAS), amenable only to carotid endarterectomy. This study presents preliminary retrospective dual-center experience utilizing the Shockwave S ⁴ intravascular lithotripsy (IVL) system (Shockwave Medical) as an adjunct to CAS for HCCS. Methods: Patients with symptomatic or asymptomatic HCCS (de novo stenosis or in-stent restenosis (ISR)) undergoing IVL+CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of IVL+CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR postprocedure. Results: Fifteen patients underwent 17 IVL+CAS procedures: de novo HCCS=13, heavily calcified ISR=4; symptomatic disease was addressed in seven cases. Procedures were performed transfemorally under conscious sedation with dual protection; flow reversal through a balloon guide catheter, and distal embolic protection system (EPS) use. Median pre-IVL+CAS stenosis was 73% (IQR 60–80%). Technical success (IVL+CAS+ EPS use) was achieved in all cases. Median post-IVL+CAS residual stenosis was 27% (IQR 12–33%), achieving <50% residual stenosis and procedural success in all. Five patients required dopamine infusion for postprocedural hypotension. No periprocedural ipsilateral strokes occurred. MAE rate was 6.7% (95% CI 0.2% to 32%), including one MI resulting in death. Additionally, one ISR (6.3%; 95% CI 0.2% to 30.2%) identified 160 days after IVL+CAS was retreated with angioplasty. Conclusions: IVL+CAS was safe and effective for treating symptomatic and asymptomatic HCCS, achieving high rates of freedom from MAE. IVL has potential to expand the role of CAS in difficult to treat HCCS.

BACKGROUND: Portable, low-field magnetic resonance imaging (MRI) has the potential to expand access to neuroimaging in environments where conventional MRI is limited. However, diffusion-weighted imaging at low magnetic field is challenged by a low signal-to-noise ratio and gradient strength, which may limit diagnostic confidence in acute ischemic stroke evaluation, particularly for very small strokes. In this study, we evaluated a combination of novel pulse sequences and low-field MRI hardware to enhance lesion detection. METHODS: Patients with a suspected diagnosis of acute ischemic stroke were prospectively enrolled at 3 centers. Diffusion-weighted imaging was performed using a single-direction (SD) or a custom multi-direction (MD) sequence comprising 3 orthogonal directions. Imaging was acquired on 2 0.064 T hardware versions: a first-generation C-arm system (Swoop v1) and a next-generation H-arm system featuring optimized gradient amplifiers, form factor, and cooling system (Swoop v2). Diagnostic accuracy and the lower limit of lesion detection were calculated for both SD and MD images on each system compared with ground-truth MRI (1.5–3 T). RESULTS: A total of 95 patients (n=62 confirmed acute ischemic stroke; n=33 stroke mimics) were included. On SD images, agreement between assessors regarding lesion detection was κ =0.72, and κ =0.84 on MD images. The positive predictive value for differentiating acute ischemic stroke from stroke mimics was 78.2% on SD and 95% on MD images. For SD images, a lesion volume cut point of 0.6 mL yielded a sensitivity of 89% and specificity of 88%. For MD images, the lesion volume cut point was 0.4 mL, with a corresponding sensitivity of 86% and specificity of 83%. MD imaging on the next-generation v2 system improved image uniformity ( P <0.05), reduced scan time by ≈30%, and enabled the detection of lesions as small as 0.15 mL (2.8 mm maximum diameter). CONCLUSIONS: Implementation of diffusion-weighted imaging optimization strategies on low-field MRI improves detection of very small strokes in a clinically feasible time frame.