Ghozy, Sherief

Background Carotid artery tortuosity (CAT) may complicate mechanical thrombectomy (MT), potentially causing delays or preventing recanalization. However, the relationship between CAT and MT outcomes remains largely unexplored. This systematic review aims to evaluate the existing evidence regarding the impact of CAT on MT outcomes. Methods Following PRISMA guidelines, a systematic literature search was conducted using MEDLINE, EMBASE, Web of Science, Cochrane, and Scopus databases. Studies providing data for MT outcomes based on CAT status were included. Outcomes of interest included successful recanalization, first-pass efficacy (FPE), procedure time, functional independence, and procedure-related complications. Results Our search identified nine studies with 2737 patients. Three studies employed DSA to assess tortuosity, whereas the remaining six studies preferred CTA. In seven studies, CAT was associated with prolonged procedure times. In five studies, successful recanalization rates were significantly lower in CAT patients as compared to patients with non-tortuous arteries. Two studies showed that CAT could alter FPE or successful recanalization rates of first-line MT techniques. No study found statistically significant relationships between CAT and functional independence. Three studies examined the association between CAT and safety outcomes, and only one study found increased intracranial hemorrhage rates in patients with CAT. All nine studies employed different CAT criteria. Conclusions Despite the vast MT literature, the number of studies reporting CAT status remains low. CAT may affect procedure time and technical outcomes of MT. Therefore, employing a uniform CAT definition and reporting CAT more frequently can provide insights into management of patients with acute large vessel occlusions.

Background Left ventricular assist devices (LVADs) are used as definitive therapy or as a bridge to heart transplant in patients with advanced heart failure. Thromboembolic complications such as acute ischemic stroke (AIS) are common among patients with LVAD support. This study aims to evaluate the current evidence on the efficacy and safety of mechanical thrombectomy (MT) in patients with AIS due to large vessel occlusions (LVO) and LVAD-support. Methods A comprehensive systematic review was conducted in PubMed, Embase, and Scopus to find observational studies with reports of ≥5 MTs in adult patients with LVAD support (PROSPERO registration code CRD42024597541). Rates of successful and complete reperfusion, favorable functional outcomes at 90 days (modified Rankin Scale (mRS) 0–2 or equal to pre-stroke mRS), mortality at 90 days, any intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) were pooled using generalized linear mixed models. Results Eight studies were included with data from 51 patients and 62 MTs. The rate of successful reperfusion was 87.4% (95% CI 62.5% to 96.6%) and complete reperfusion rate was 57.3% (95% CI 35.1% to 76.9%). Rate of favorable functional recovery was 62.5% (95% CI 42.2% to 79.2%). Rate of sICH was 6.4% (95% CI 0.9% to 34.0%). Mortality rate was 16.7% (95% CI 7.1% to 34.7%). Between 25–40% of patients who were waiting for a heart transplant before their stroke received a heart transplant after MT. Conclusions MT for the emergent treatment of AIS in the setting of LVAD is relatively safe and efficacious for achieving successful reperfusion and good functional recovery.

Background Current randomized controlled trials are investigating the efficacy and safety of mechanical thrombectomy (MT) in patients with medium vessel occlusion (MeVO) stroke. Whether best medical management (MM) is more efficient than unsuccessful vessel recanalization during MT remains unknown. Methods This was a retrospective cohort study using data from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. Only patients with occlusion of the distal branches (M2 and M3) of the middle cerebral artery territory were included. Unsuccessful MT was defined as a modified Thrombolysis in Cerebral Infarction score of 0–2a. Propensity score matching was used to control for confounders. The primary outcome was functional independence, defined as a modified Rankin Scale (mRS) score of 0–2 at 90 days after treatment. Multivariable regression analysis was used to assess factors associated with the primary outcome. Results Of 2903 patients screened for eligibility, 532 patients were analyzed (266 per group) after propensity score matching. The MM group had superior functional outcomes, with 32% achieving mRS 0–1 at 90 days compared with 21% in the MT group (P=0.011). Patients in the MM group also had significantly lower rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 16%, P<0.001) and any hemorrhage (18% vs 48%, P<0.001). On multivariable regression, unsuccessful MT was associated with reduced odds of functional independence (OR 0.50, 95% CI 0.29 to 0.85, P=0.011) and increased odds of sICH (OR 4.32, 95% CI 1.84 to 10.10, P<0.001). Mortality rates were similar between groups (27% in MM vs 29% in MT, P=0.73). Conclusion Unsuccessful MT for MeVO was linked to worse outcomes than best MM. These findings highlight the risks of prolonged attempts and emphasize the importance of efficient procedural decision-making to reduce complications and improve patient outcomes.

Background The impact of certain comorbidities on mechanical thrombectomy (MT) outcomes remains largely unexplored. Diabetes mellitus (DM) and admission hyperglycemia have been associated with poor clinical outcomes for patients treated with MT. In this study, we sought to investigate the effects of DM and admission hyperglycemia on MT outcomes. Methods Following PRISMA guidelines, a systematic literature search was conducted in Medline, Embase, Scopus, and Web of Science databases. Data regarding successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b), functional independence (modified Rankin Scale [mRS] 0–2), excellent outcomes (mRS 0–1), symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. The pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were calculated using random effects model. Results Twenty-one studies comprising 9708 patients were included. A total of 2311 patients (24%) had a history of DM, and 2026 patients (21%) had admission hyperglycemia. Admission hyperglycemia was associated with significantly lower odds of mTICI ≥2b (OR = 0.7, 95% CI = 0.55–0.89), mRS 0–2 (OR = 0.47, 95% CI = 0.41–0.53), and mRS 0–1 (OR = 0.43, 95% CI = 0.34–0.55) as compared to normoglycemic state. Patients with hyperglycemia had significantly higher rates of sICH (OR = 2.05, 95% CI = 1.66–2.54) and mortality (OR = 1.99, 95% CI = 1.58–2.52) than normoglycemic patients. Diabetes mellitus was associated with significantly high rates of mortality (OR = 1.74, 95% CI = 1.31–2.3) and lower rates of mRS 0–2 (OR = 0.60, 95% CI = 0.48–0.76) in sensitivity analyses. Conclusion Our results indicate that admission blood glucose levels and DM can negatively affect MT outcomes. Further research should focus on optimizing MT outcomes for these patients.

Background As the use of flow diverters has expanded in recent years, predicting successful outcomes has become more challenging for certain aneurysms. Objective To provide neurointerventionalists with an understanding of the available machine learning algorithms for predicting the success of flow diverters in occluding aneurysms. Methods This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the four major medical databases (PubMed, Embase, Scopus, Web of Science) were screened. The study included original research articles that evaluated the predictive abilities of various machine learning algorithms for determining the success of flow diverters in achieving aneurysm occlusion. Results Five studies out of 217 were included based on our criteria. The included studies used various variables (patient demographics, aneurysm and parent artery characteristics, flow diverter and hemodynamic-related features, and angiographic parametric imaging) to predict flow diverter treatment outcomes. The machine learning algorithms used, along with their respective accuracy rates, were as follows: logistic regression (61% and 85%), support vector machine (88%), Gaussian support vector machine (90%), linear support vector machine (85%), decision tree (80%), random forest (87%), k-nearest neighbors (83% and 85%), XGBoost (87%), CatBoost (86%), deep neural networks (77.9%), and recurrent neural networks (74%).Two studies trained the machine learning models with both all features and the most significant features. Both studies observed that the accuracy of machine learning models decreased by removing the insignificant features. Conclusion The current literature indicates that machine learning algorithms can be trained to predict the success of flow diverters with an accuracy of up to 90%.

Introduction: In recent years, artificial intelligence (AI) has emerged as a transformative tool for enhancing stroke diagnosis, aiding treatment decision making, and improving overall patient care. Leading AI-driven platforms such as RapidAI, Brainomix®, and Viz.ai have been developed to assist healthcare professionals in the swift and accurate assessment of stroke patients. Methods: Following the PRISMA guidelines, a comprehensive systematic review was conducted using PubMed, Embase, Web of Science, and Scopus. Characteristic descriptive measures were gathered as appropriate from all included studies, including the sensitivity, specificity, accuracy, and comparison of the available tools. Results: A total of 31 studies were included, of which 29 studies focused on detecting acute ischemic stroke (AIS) or large vessel occlusions (LVOs), and 2 studies focused on hemorrhagic strokes. The four main tools used were Viz.ai, RapidAI, Brainomix®, and deep learning modules. Conclusions: AI tools in the treatment of stroke have demonstrated usefulness for diagnosing different stroke types, providing high levels of accuracy and helping to make quicker and more precise clinical judgments.

Bevacizumab (BCZ), commercially known as Avastin, is a monoclonal antibody that targets vascular endothelial growth factor (VEGF). Initially recognized as a breakthrough in oncology, it has since gained FDA approval for various ocular conditions and more recently, for the treatment of glioblastoma multiforme (GBM). Bevacizumab's ability to inhibit excessive neovascularization suggests it may have a potential role in treating chronic subdural hematomas (cSDH). Recent studies have shown that the pathophysiology of cSDH is more complex than previously understood, with VEGF concentrations in subdural fluid significantly exceeding those in serum, contributing to the high recurrence rates. Intra-arterial administration of bevacizumab has shown promising results in recent case series against chronic subdural hematoma, and may be a viable alternative to middle meningeal artery embolization. If successful, this treatment could significantly decrease the rate of recurrence and result in lower rates of severe neurological complications such as visual loss. This literature review explores the connection between bevacizumab and cSDH, focusing on the pharmacological, safety, and delivery aspects of this approach while summarizing the current evidence supporting its use.

Background Aneurysm treatments are crucial to minimize the rupture risk. The underlying molecular processes mediating cellular remodeling, endothelialization, and aneurysm healing following endovascular treatment are poorly understood. The current study aims to explore circulating miRNA as a treatment and outcome-associated biomarkers in patients undergoing endovascular treatment. Methods Patients undergoing endovascular interventions for unruptured intracranial aneurysms, using either flow diverter placement or coil embolization, were enrolled. Blood samples were collected before the intervention and during a follow-up period between 6 and 18 months. Total mRNA/miRNA was isolated from plasma, followed by RNA-seq analysis. Gene Ontology analysis was used to identify pathways linked to altered miRNA expression. Results Twenty-three patients participated, with 13 (56.5%) undergoing flow diversion and 10 (43.5%) coil embolization. The median follow-up sample collection time was 10.70 months (SEM ± 1.32). No significant differences in angiographic occlusion were noted between intervention groups. Differentially expressed miRNAs were not identified between groups at baseline. However, at follow-up, 39 miRNAs were upregulated and 41 were downregulated, independent of intervention. Notably, three miRNAs (miR-4746-5p, miR-4685-3p, and miR-490-3p) were downregulated in the flow diversion group compared to the coil embolization group. Bioinformatics analysis revealed associations with upregulated fluid shear stress, p53, adherens junction pathways, along with downregulated apoptosis pathways. Conclusions This study suggests that fluid shear stress and apoptosis may influence aneurysm healing or thromboembolic events in flow diverter-treated patients. Further research is warranted to elucidate the functional significance of these findings in treatment outcomes, providing valuable insights for improved patient care in intracranial aneurysm management.

Background: Acute ischemic stroke (AIS) imposes a major healthcare burden. It is hypothesized that bacterial infection could influence atherosclerosis and thrombus formation, potentially contributing to AIS. Objectives: We aim to systematically review all studies that have investigated the presence of bacterial signatures within thrombi retrieved following mechanical thrombectomy (MT) procedures in patients with AIS. Design: This systematic review is designed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 checklist. Data sources and methods: A comprehensive search was conducted in the Web of Sciences, PubMed, Scopus, and Embase databases to identify relevant studies. Results: The literature search and screening included 11 studies involving 674 patients, with 414 (61.4%) being male and 260 (38.6%) females. Among all the patients, 393 (58.3%) were positive for bacterial presence in their retrieved thrombi. The most utilized technique for bacterial signature detection was bacterial DNA extraction followed by polymerase chain reaction amplification of the 16S rRNA gene sequence. Staphylococcus aureus was the most studied bacteria among the studies analyzed. Conclusion: Bacterial infections and the presence of bacteria within thrombi may significantly contribute to AIS by initiating or exacerbating atherosclerosis or thrombosis. Understanding the mechanisms by which bacteria affect vascular health is crucial for developing effective preventive and therapeutic strategies for stroke patients.