Ghozy, Sherief

Objective Cognitive impairment is increasingly recognized in patients with cerebral venous congestion (CVC), yet the cognitive tools used are largely adapted from stroke and dementia research. This review examines current literature on cognitive function in CVC, including conditions such as cerebral venous sinus thrombosis (CVST), idiopathic intracranial hypertension (IIH), and dural arteriovenous fistulas (dAVFs). Special emphasis is placed on the limitations of common screening tools like the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE). Cognitive dysfunction—primarily affecting executive function, processing speed, and attention—is reported in up to 86% of CVC cases, yet only about 20% of studies use validated cognitive testing tools, most of which may lack sensitivity for CVC-specific deficits. Emerging techniques such as ocular motor testing and physiological markers show promise but require further validation. There is an urgent need for standardized, CVC-specific cognitive assessment protocols that reflect the unique pathophysiology of venous disorders. Future research should prioritize the development of targeted cognitive batteries and integrate objective physiological measures to enhance diagnostic accuracy.

Objective Mechanical thrombectomy (MT) is well-established for the treatment of acute ischemic stroke (AIS) from large vessel occlusion (LVO), with growing data supporting the expansion to distal and medium vessel occlusions (DMVO). Despite successful recanalization in DMVO, certain patients still experience poor long-term clinical outcomes, prompting our study to comprehensively explore pre-MT factors influencing outcome despite excellent recanalization (final modified Thrombolysis in Cerebral Infarction [mTICI] score ≥2c). Methods We retrospectively examined data from patients who consecutively underwent MT for a primary middle cerebral artery (MCA) DMVO across 37 centers in North America, Asia, and Europe. We identified baseline clinical and imaging factors associated with poor clinical outcome (defined as a modified Rankin Scale [mRS] score of 3–6) at 3 months, despite excellent recanalization using a multivariable model. Results Between September 2017 and July 2021, 623 patients achieved mTICI > 2b and they were included in our study. Among them, 198 (32%) experienced a poor clinical outcome (mRS 3–6). Predictors of poor clinical outcome included higher age (OR 1.05 [1.03–1.07], p < 0.001), higher NIHSS at admission (OR 1.12 [1.08–1.15], p < 0.001), higher baseline mRS (OR 1.77 [0.96–3.26], p = 0.067), and diabetes (OR 1.59 [1.01–2.48], p = 0.044). Higher ASPECTS was associated with a decreased risk of poor clinical outcome (OR 0.82 [0.71–0.94], p = 0.006). Conclusion Older age, diabetes, higher baseline mRS, and NIHSS were associated with poor clinical outcome in MCA DMVO despite excellent recanalization. Conversely, a higher ASPECTS decreased the probability of such an outcome.

Background The first-pass effect (FPE) refers to the complete or near-complete revascularization with a single pass of mechanical thrombectomy devices. While previous claims suggest a link between larger catheters and the effectiveness of contact aspiration (CA) thrombectomy, no extensive research has confirmed if larger distal inner diameter (ID) catheters achieve higher FPE rates. Methods We searched PubMed, Scopus, and Web of Science to assess the impact of aspiration catheter distal ID size on FPE. The primary outcome was FPE rate, defined as thrombolysis in cerebral ischemia (TICI) grades 2c-3 at first pass, and the secondary outcome was modified FPE (TICI 2b-3 in a single pass). Aspiration catheters were categorized based on distal ID: 0.060–0.069 (medium bore), 0.070–0.074 (large bore), and greater than 0.074 inches (super-large bore). Rates of FPE were pooled using random effect models and compared using a Chi-square test. Results Our study included 34 articles with 4831 patients. FPE rates were 27.7% (95% CI, 15.1–45.3) for medium bore, 46.6% (95% CI, 33.7–59.9) for large, and 58.3% (95% CI, 44.8–70.7) for super-large catheters. The FPE rate was significantly higher for super-large bore catheters compared with other groups (χ² = 7.26, p = 0.03). A similar trend was observed for modified FPE rates, which were 51.1% (95% CI, 45.3–56.8) for medium bore, 60.0% (95% CI, 52.8–66.8) for large bore, and 80% (95% CI, 56.3–94.2) for super-large bore catheters (χ² = 8.14, p = 0.03). Conclusion Our analysis indicates that larger CA catheters are correlated with higher FPE rates.

Background Accurate and timely prehospital detection of large vessel occlusion (LVO) is critical for optimizing patient triage and initiating appropriate reperfusion therapies. Recent advances in portable stroke detection technologies, such as electroencephalography (EEG) and transcranial Doppler (TCD) ultrasound, offer potential solutions but their diagnostic performance remains unclear. Methods We searched PubMed, Scopus, Embase, and Web of Science, following the PRISMA guidelines. Studies were included if they assessed the diagnostic performance of non-invasive prehospital LVO detection tools compared to CT or MR angiography. Risk of bias was assessed using the QUADAS-2 tool. Results A total of 13 studies were included, examining various portable detection tools including EEG or neurophysiological monitoring, ultrasound-based techniques including TCD or TCCD, portable Openwater optical blood flow monitor and cranial accelerometry. The pooled diagnostic odds ratio (DOR) was 52.7 (95% CI: 28.3–97.8), indicating strong diagnostic performance, with significant heterogeneity among studies (I 2 = 67.3%, P < 0.001). Subgroup analysis revealed that TCD-based methods had the highest DOR (120.4, 95% CI: 76.9–188.7), followed by other tools (26.8, 95% CI: 13.7–52.6), and EEG (18.2, 95% CI: 9.1–36.3). The pooled sensitivity was 87.4% (95% CI: 82.5–91.0) and specificity was 89.39% (95% CI: 83.0–93.5) across all methods. TCD-based methods showed the highest specificity (95.0%, 95% CI: 91.8–97.0). Conclusion Non-invasive prehospital LVO detection tools show promising diagnostic performance, particularly TCD-based methods. Future studies should focus on validating these tools in larger, diverse populations to enhance prehospital stroke triage and improve patient outcomes.

Background Mechanical thrombectomy for ischemic stroke has traditionally been performed via transfemoral access (TFA). However, newer literature on the subject suggests that transradial access (TRA) may be equally efficacious. Methods Online databases (including PubMed, Google Scholar, Embase, and Cochrane) were queried from inception until May 2024. Abstracts and full texts were screened according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Risk of bias assessment was performed using standardized screening tools. All dichotomous outcomes were reported as odds ratio (OR) with 95% confidence interval (CI). RevMan was used to perform the statistical analysis. Results Thirteen observational studies and one randomized clinical trial (RCT) were included in this meta-analysis. The total sample size was 4973, 4074 patients (81.2%) were in the TFA group, and 899 (18.8%) were in the TRA group. No significant differences were observed between the two groups in terms of successful recanalization (OR = 0.92; 95% CI 0.66–1.27; p = 0.60), first-pass recanalization (OR = 0.84; 95% CI 0.69–1.01, p = 0.06), access to reperfusion time (mean difference −2.99 min; 95% CI −8.33 to 2.44, p = 0.27), and favorable functional outcome. Mortality and rates of intracranial hemorrhage were comparable between the two groups, but access site complications were significantly lower in the TRA group (OR = 0.57; 95% CI 0.37–0.88; p = 0.01). Conclusion TRA for thrombectomy in large vessel ischemic strokes is comparable to TFA in terms of efficacy and has a lower incidence of access site complications. RCT data comparison of the two techniques is limited, underscoring the importance of conducting trials.

Background Endovascular therapy (EVT) for stroke due to distal or medium vessel occlusion (DMVO) is safe. Due to the distinct anatomical characteristics of DMVOs, further evaluation of EVT is crucial to determine which devices may yield better outcomes. Methods A retrospective analysis of adults with DMVO treated in 37 centers (11 countries) was queried. The primary outcome of favorable shift in 90-day modified Rankin Scale (mRS) was compared between patients treated with Trevo versus other devices on first pass using 1:1 propensity score matching (PSM) with multivariable adjustment. Secondary outcomes included the number of pass attempts, final thrombolysis in cerebral infarction (TICI) score 2b-3, symptomatic intracranial hemorrhage (sICH), improvement in National Institutes of Health Stroke Scale (NIHSS) at 24h, and 90-day mortality. Results Of the 1115 included patients, 264 (24%) were treated with Trevo (PSM cohort of 261 per group). Trevo use was not associated with a favorable 90-day mRS shift (proportional odds ratio [OR] 1.10, 95% confidence interval [CI] 0.80–1.51). Trevo was associated with fewer passes (adjusted β=-0.25, 95% CI −0.48 - −0.03), higher odds of TICI 2b-3 (adjusted OR 1.97, 95% CI 1.11–3.49), and a greater 24h NIHSS improvement (adjusted β= −1.74, 95% CI −3.11 - −0.36), with no difference in sICH or mortality (p>0.05). Results were similar in sensitivity analyses. Conclusions We observed no safety concerns with Trevo as compared to other EVT devices for DMVO recanalization. There was a signal of better technical efficacy and early clinical improvement.

Background The Woven EndoBridge (WEB) device is a prevalent treatment for intracranial aneurysms. While many studies have assessed the obliteration rate post-WEB embolization, few have focused on long-term outcomes in partially thrombosed aneurysms. Objective To assess whether partially thrombosed aneurysms are at higher risk of recurrence or retreatment following WEB embolization compared with non-thrombosed aneurysms. Methods We evaluated data from 22 academic institutions, focusing on previously untreated cerebral aneurysms treated with the WEB device. Logistic regression was utilized to analyze factors predicting long-term aneurysm obliteration and retreatment necessity. Results Among 1303 patients, 26 presented with a partially thrombosed aneurysm. In the partially thrombosed group, the mean aneurysm maximal diameter was 10.7±4 mm with a neck ratio of 1.99±1.19 mm, larger than in the control group where the mean aneurysm maximal diameter was 6.81±2.37 mm with a neck ratio of 1.64±0.51 mm (P<0.001 for both maximal diameter and neck ratio). At the final follow-up, partially thrombosed aneurysms treated by the WEB device had a 38.5% retreatment rate, compared with 7.0% for non-thrombosed aneurysms (P<0.001). Among partially thrombosed aneurysms, the Raymond-Roy type IIIa/b occlusion rate was higher (38.5% vs 9.9%, P<0.001). On multivariate analysis, partially thrombosed aneurysms compared with non-thrombosed aneurysms had an increased rate of retreatment (OR 3.64, 95% CI 1.28 to 10.1). Conclusion Partially thrombosed aneurysms are associated with a poorer occlusion rate and a higher rate of retreatment following WEB embolization. For partially thrombosed aneurysms, the WEB device appears suboptimal as a first-line treatment, and therefore alternative techniques should be prioritized.

Background Mechanical thrombectomy (MT) is established as an effective treatment for large vessel occlusion strokes, but its efficacy and safety for medium vessel occlusions (MeVOs) remain less clear. This study examines the impact of periprocedural embolization to a new vascular territory (ENT) on clinical outcomes in patients with MeVO stroke treated with MT. Methods A multicenter, retrospective analysis was conducted using the MAD-MT (Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy) registry, including 2122 patients with MeVO stroke w­ho underwent MT between September 2017 and July 2023. ENT was defined as filling defects in previously unaffected territories, excluding embolization near the original occlusion, observed on final angiographic runs after retrieval of the primary thrombus. The associations between ENT, procedural variables, and 90-day clinical outcomes were evaluated, including functional independence (modified Rankin Scale (mRS) scores of 0–2), excellent outcomes (mRS 0–1), mortality, and hemorrhagic complications. Results ENT occurred in 2.9% (63/2122) of patients. Longer onset-to-arterial puncture time (adjusted OR 1.03; 95% CI 1.01 to 1.05; P=0.002) and a greater number of passes (adjusted OR 1.15; 95% CI 1.01 to 1.32; P=0.032) were associated with increased ENT risk, while excellent recanalization (thrombolysis in cerebral infarction (TICI) scale score 2c–3) was associated with reduced ENT risk (adjusted OR 0.41; 95% CI 0.23 to 0.72; P=0.002). ENT was not associated with poorer functional independence, mortality, or hemorrhagic complications. Conclusions ENT during MT for MeVO stroke occurs infrequently and does not significantly affect the clinical outcomes. These findings suggest ENT risk should not deter clinicians from performing MT in patients with MeVO. Further prospective studies are needed to validate these results.

Background The hypoperfusion intensity ratio (HIR) has emerged as a vital measure of tissue-level collateral blood flow, helping to identify patients who are likely to benefit from mechanical thrombectomy (MT). We aimed to assess the HIR’s predictive accuracy for clinical outcomes following MT in patients with acute ischemic stroke. Methods PubMed, Embase, and Scopus were searched to identify studies comparing good versus poor HIR groups based on studies’ reported cut-offs. We pooled binary outcomes to calculate odds ratios (OR) and continuous outcomes to calculate mean differences (MD) with 95% confidence intervals (95% CI) using random-effects models. PROSPERO registration code: CRD42024609185. Results 14 studies with 2987 patients, 1553 with good HIR and 1434 with poor HIR, were included in this meta-analysis. Patients with poor HIR exhibited a significantly higher baseline infarct volume compared with those with good HIR (MD 30.6 mL, 95% CI 20.8 mL to 40.3 mL, P<0.01), though baseline National Institutes of Health Stroke Scale (NIHSS) (P=0.12) and Alberta Stroke Program Early CT Score (ASPECTS) (P=0.35) were comparable between groups. The rates of infarct growth (MD 22.4 mL, 95% CI 6.7 mL to 38.0 mL, P<0.01) and 3-month mortality (OR 2.18, 95% CI 1.04 to 4.58, P=0.04) were higher among the poor HIR group and good functional recovery (modified Rankin Scale 0–2 at 3 months) was lower (OR 0.58, 95% CI 0.42 to 0.80, P<0.01). The rates of symptomatic intracranial hemorrhage (P=0.37) and successful reperfusion (P=0.47) were comparable among groups. Conclusion This meta-analysis highlights the significant negative impact of poor HIR on patient outcomes. These findings emphasize the need for personalized treatment strategies for patients with poor HIR.

Background: Variability in recanalization success during endovascular treatment for acute ischemic stroke (AIS) has led to increased interests in thrombus composition and associated cellular materials. While evidence suggests that bacteria may influence thrombus characteristics, limited data exist on microbiological profiles of thrombi in stroke patients. Objectives: Characterization of bacterial communities present in thrombi of AIS patients undergoing mechanical thrombectomy, providing insights into microbial contributions to stroke pathogenesis and treatment outcomes. Methods: Thrombi were collected from 20 AIS patients. After extracting metagenome, 16S rDNA sequencing was performed. Bioinformatic analysis included taxonomy and diversity assessments. The presence of bacterial DNA and viable bacteria in thrombi was validated using polymerase chain reaction (PCR) and bacterial culturing followed by matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) analysis, respectively. Results: 16S rDNA was amplified in 19/20 thrombi (95%). Analysis identified a diverse microbial community, with Corynebacterium spp. as the most prevalent genus, followed by Staphylococcus spp., Bifidobacterium spp., Methylobacterium spp., and Anaerococcus spp. Alpha diversity analyses (Shannon index: 4.0–6.0 and Simpson index: 0.8–1.0) revealed moderate to high microbial diversity across samples; beta diversity demonstrated distinct clustering, indicating inter-patient variability in microbial profiles. PCR confirmed the presence of DNA specific to dominant bacterial taxa identified through sequencing. Culturing showed the presence of Staphylococcus epidermidis and Enterococcus faecalis in some clots as identified through MALDI analysis. Conclusions: This study shows bacterial communities present in AIS patients’ thrombi, suggesting a potential link between microbial signatures and thrombus characteristics.