BACKGROUND: A minority of patients with stroke qualify for intravenous thrombolysis (IVT) within 4.5-hour window. The safety and efficacy of IVT beyond this period have not been well studied. METHODS: We systematically searched MEDLINE, Embase, Cochrane, and ClinicalTrials.gov for relevant randomized clinical trials. Randomized clinical trials comparing IVT versus standard medical care in patients with ischemic stroke beyond 4.5 hours of symptom onset or last known well without mechanical thrombectomy (MT) were included. Primary outcomes were excellent (modified Rankin Scale score of 0–1) and good (modified Rankin Scale score of 0–2) functional outcomes at 90 days, symptomatic intracerebral hemorrhage (sICH), and death at 90 days. Pooled odds ratios (ORs) with 95% CIs were calculated using a random-effects model. Heterogeneity was assessed by Q test and quantified by I ² values. RESULTS: Eight randomized clinical trials (1742 patients; mean age, 69.8±9 years, 63.5% men) were included. Compared with standard medical care, IVT achieved higher rates of excellent (OR, 1.43 [95% CI, 1.17–1.75]; Q =2.30; P =0.94; I ² =0%) and good functional outcomes (OR, 1.36 [95% CI, 1.12–1.66]; Q =2.07; P =0.96; I ² =0%) at 90 days but also increased sICH rates (OR, 4.25 [95% CI, 1.67–10.84], Q =0.48; P =0.99; I ² =0%). Mortality at 90 days did not significantly differ between treatment groups (OR, 1.28 [95% CI, 0.87–1.89]; Q =4.63; P =0.59; I ² =0%). Subanalyses yielded numerically higher odds of excellent functional outcomes when patients were selected with perfusion imaging (3 studies, OR, 1.45 [95% CI, 1.08–1.94]) compared with diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch (3 studies, OR, 1.34 [95% CI, 0.94–1.91]) and when treated with tenecteplase (3 studies, OR, 1.47 [95% CI, 1.06–2.04]) compared with alteplase (5 studies, OR, 1.38 [95% CI, 1.08–1.78]). CONCLUSIONS: IVT for ischemic stroke beyond 4.5 hours, without MT, led to increased odds of excellent and good functional outcomes compared with standard medical care, despite higher odds of sICH, and a nonsignificant numerical increase in mortality.

Background Flow diverters (FDs) are increasingly used off-label for distal cerebral aneurysms (DCAs), those located at or beyond the anterior cerebral artery (ACA) A2, middle cerebral artery M2, and posterior cerebral artery P2 segments. However, data on their safety and efficacy remain limited. This systematic review and meta-analysis synthesizes current evidence on FD treatment for DCAs. Methods A comprehensive search was performed across PubMed, Scopus, and Web of Science, including studies with ≥5 patients reporting FD treatment of DCAs. Efficacy outcomes included adequate and complete aneurysm occlusion and retreatment rates. Safety outcomes included good functional outcome (modified Rankin Scale (mRS) score 0–2), procedure-related morbidity, mortality, complications, in-stent stenosis, and covered branch occlusion at follow-up. Pooled analyses with 95% confidence intervals (CI) were conducted using a random-effects model. Results Eighteen studies (441 patients, 70% women; mean age: 57.2±13.6 years) with 445 DCAs were included. Most aneurysms were unruptured (93.7%) and located in the ACA territory (78.4%). Adequate and complete occlusion at last follow-up were 90% (95% CI, 86 to 95) and 79% (95% CI, 74 to 85), respectively. The retreatment rate was 1.6% (95% CI, 0.2 to 3). Good functional outcome was achieved in 97% (95% CI, 95 to 99). Procedure-related complications occurred in 9% (95% CI, 5 to 13), with morbidity and mortality of 1.5% and 0.6%, respectively. In-stent stenosis and covered branch occlusion rates were 3% (95% CI, 0 to 8) and 5.5% (95% CI, 2 to 9), respectively. Conclusion FDs appear to be safe and effective for DCAs, with high occlusion rates and low retreatment and complication rates.

Background Selective and superselective intra-arterial cerebral infusion (SIACI/SSIACI) delivers chemotherapy directly to tumor-supplying arteries, achieving high local drug levels with reduced systemic toxicity. Often combined with blood–brain barrier disruption (BBBd) to enhance penetration, these methods have been widely studied, yet a comprehensive evidence synthesis is lacking. This study systematically assesses the safety and efficacy of intra-arterial chemotherapy with BBBd for glioma treatment. Methods We searched PubMed, Embase, and Web of Science for studies on SIACI with BBBd in glioma patients. Safety outcomes included rates of cases with complications, procedure-related complications (major/minor), stroke, intracranial and intratumoral hemorrhage, and mortality. Efficacy was based on tumor response (complete, partial, stable disease, progression). A subanalysis of SSIACI-only cases was also conducted. Results Nine studies with 230 glioma patients were included. The pooled rate of cases with complications was 27.1% (95% CI 19.8% to 35.7%), with procedure-related complications occurring in 15.4% (95% CI 6.1% to 24.6%). Major and minor complication rates were 4.3% (95% CI 0.9% to 7.7%) and 9.7% (95% CI 1.0% to 18.7%), respectively. Stroke, intracranial hemorrhage, and intratumoral hemorrhage occurred in 3.1% (95% CI 0% to 6.1%), 0.5% (95% CI 0% to 3.2%), and 0.04% (95% CI 0% to 3%), respectively, with no procedure-related deaths reported. Pooled response rates were 10.4% complete (95% CI 0% to 21.5%), 24.2% partial (95% CI 14.3% to 34.1%), 38.2% stable disease (95% CI 21.5% to 54.9%), and 39.3% progression (95% CI 14.8% to 63.8%). Subanalysis of superselective infusions yielded comparable outcomes to the overall cohort. Conclusion The findings indicate that SIACI/SSIACI chemotherapy following BBBd is a feasible and safe approach for glioma treatment, demonstrating a favorable procedural risk profile and preliminary signs of efficacy. Further studies are warranted to validate these results and refine procedural protocols.

BACKGROUND AND OBJECTIVES: Endovascular therapy (EVT) has recently become the most widely used treatment method for intracranial aneurysms (IAs). However, the literature on this topic is heterogeneous, with studies assessing and reporting surgical and clinical outcomes in different ways, lacking standardization. We aimed to evaluate the quality of these studies and propose a reporting guideline focusing on essential elements to ensure reproducibility and comparability. METHODS: After Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched Medline, Embase, Cochrane Library, and Web of Science databases. Eligible studies were observational or randomized, reported clinical and/or surgical outcomes of EVTs for IAs, included over 200 patients, and were published in English between January 1, 2022, and January 1, 2024. Studies were assessed focusing on key domains: (1) reporting on the baseline characteristics of the patient sample, (2) assessment and reporting on imaging methods and aneurysm characteristics, (3) reporting on pivotal concepts definitions, (4) reporting on operator(s) and staff characteristics, (5) reporting on anesthetic protocol, (6) reporting on antiaggregant and anticoagulation therapy, (7) reporting on surgical details, (8) assessing and reporting clinical and surgical outcomes, and (9) reporting retreatment details. RESULTS: Thirty-nine studies comprising 79 604 patients were included. Our assessment revealed substantial gaps in the literature on EVTs for IAs, including deficiencies across all domains. An EndoIAs Reporting Guideline was developed, consisting of 74 items distributed across 10 domains, focusing on key surgical and clinical outcomes. CONCLUSION: Substantial deficiencies were identified in data collection and outcomes reporting in the available literature on EVT for IAs, thereby impeding comparability and reproducibility and hindering the building of cumulative evidence. The aim of the proposed EndoIAs Reporting Guideline was to address these fundamental aspects and has the potential to enhance the reproducibility and comparability of future studies, thereby fostering the building of cumulative and reliable evidence of EVT for IAs.