Ghozy, Sherief

Background The Woven EndoBridge (WEB) device represents an innovative solution for cerebral aneurysm occlusion, particularly for challenging wide-neck bifurcation aneurysms. However, factors affecting sustained occlusion remain poorly understood. We utilized machine learning to attempt to identify predictors of favorable long-term outcomes following WEB treatment. Methods In this multicenter retrospective study, we collected patient demographics, aneurysm characteristics, procedural details, and clinical outcomes. The primary endpoint was improvement in occlusion status, defined as maintained Raymond-Roy Occlusion Classification (RROC) grade 1, or improvement from grade 2 to 1, or from grade 3 to either 2 or 1 on final angiographic follow up. The dataset was split into training (75%) and validation (25%) sets. The CatBoost algorithm was selected based on performance metrics, with Shapley Additive exPlanations (SHAP) values calculated to determine feature importance. Furthermore, a multivariable binomial logistic regression model was performed to validate machine learning findings. Results Among 720 aneurysms from 36 hospitals, 84% showed improvement in occlusion at follow up. Both machine learning and multivariable logistic regression identified aneurysm height as the most consistent correlate of nonimprovement (odds ratio (OR) 0.90 per mm, p = 0.022). In the CatBoost model, the highest-ranking features by SHAP included aneurysm height, patient age, treatment acuity, ACom location, WEB-SLS device, bifurcation anatomy, aneurysm multiplicity, baseline modified Rankin Scale, access route, and partial thrombosis. Conclusions Machine-learning and regression analyses identified consistent predictors of occlusion improvement after WEB treatment, with aneurysm height most strongly linked to nonimprovement. These insights may guide patient selection and follow up. Findings require cautious interpretation and external validation in larger cohorts.

Background For large vessel occlusion (LVO) ischemic strokes, three major techniques of mechanical thrombectomy (MT) have demonstrated efficacy. Here we compare the safety and efficacy of stent retrievers (SR), contact aspiration (Asp), and a combined mechanical thrombectomy (cMT) for LVO ischemic stroke. Methods Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we queried the PubMed, EMBASE, Scopus, and Web of Science databases for studies published prior to December 2024 describing patients with ischemic stroke who underwent MT using SR, Asp, or cMT. Results Twnety-four studies comprising a total of 12 845 patients were included in the analysis. Compared with cMT, Asp was associated with a lower rate of first pass effect (FPE) (risk ratio (RR) 0.67; 95% CI 0.46 to 0.96), shorter procedure duration (mean difference (MD) −13.35 min; 95% CI −20.83 to –5.87), and lower risk of arterial dissection (RR 0.50; 95% CI 0.29 to 0.87). Additionally, SR use was linked to a higher procedure duration compared with Asp (MD 13.39 min; 95% CI 5.55 to 21.22) and a lower symptomatic intracranial hemorrhage rate (RR 0.75; 95% CI 0.59 to 0.96). No significant differences were observed between groups in terms of number of passes, successful recanalization, 90-day functional outcomes, mortality, arterial perforation, or embolization to new territory. Conclusions All three techniques demonstrated similar recanalization rates and functional outcomes. However, Asp was associated with shorter procedure times and fewer arterial dissection complications, while cMT showed a higher FPE. Given the comparable overall efficacy, the choice of technique should be guided by the physician’s preference, expertise, and confidence, tailored to the individual patient’s profile.

High-resolution imaging is critical for the diagnosis, treatment planning, and postoperative monitoring of cerebral aneurysms, which affect up to 5% of the population and pose a significant risk of rupture and subarachnoid hemorrhage. Surgical clipping remains a definitive treatment option, but metallic clips can introduce substantial imaging artifacts, complicating posttreatment assessment. This review synthesizes current knowledge on the impact of aneurysm clip materials and designs on artifact generation and explores strategies for artifact mitigation. Conventional materials like titanium are favored for their biocompatibility and reduced ferromagnetism but still cause beam hardening, streak artifacts, and signal loss in CT and MRI scans. Emerging alternatives, including ceramics, composites, polymers, and bioresorbable clips, show promise in reducing artifacts while maintaining mechanical reliability. Innovations in clip design, such as fenestrated or low-profile models, further aid in minimizing imaging distortion. Advanced imaging methods, including dual-energy CT, iterative reconstruction algorithms, and metal artifact reduction software, demonstrate significant improvements in image quality but may introduce limitations such as increased processing demands or subtle anatomical distortions. Future directions emphasize the development of next-generation clip materials, robotic-assisted surgical approaches, and artificial intelligence-driven reconstruction techniques to further optimize visualization and patient safety. Continued research and multidisciplinary collaboration will be essential to translate these innovations into routine neurosurgical practice.

Background: In younger patients (<60 years) with cryptogenic stroke (CS) presumed to be patent foramen ovale (PFO)-related, the standard approach involves transcatheter PFO closure combined with antithrombotic therapy. However, due to their exclusion from randomized clinical trials (RCTs), no formal recommendations exist for patients ⩾60 years. This study had two objectives (1) to compare the efficacy and safety of PFO closure versus antithrombotic therapy alone (ATA) exclusively in older patients (⩾60 years) and (2) to assess the outcomes of PFO closure in patients ⩾ 60 years versus < 60 years. Methods: We searched PubMed, Embase, Web of Science, and ScienceDirect databases to obtain articles in all languages from January 2004 until July 2025. The primary outcome was risk of recurrent stroke during follow-up. Secondary outcomes were risk of new-onset atrial fibrillation (AF), all-cause mortality, and in-hospital complications. PROSPERO registration ID: CRD420250652870. Results: Only one RCT (post hoc evaluation of the DEFENSE-PFO trial) and 11 observational studies were included. In patients aged ⩾ 60 years, risk of recurrent stroke was lower when PFO was closed compared with ATA (5.48% vs 10.05%, respectively, hazard ratio (HR) = 0.56, 95% confidence interval (CI) = 0.45–0.80, p < 0.001, I 2 = 45.6%). All-cause mortality was also lower for PFO closure versus ATA (1.73% vs 7.59%, respectively, HR = 0.41; 95% CI = 0.19–0.90, p = 0.02; I 2 = 43.8%). There was no difference between PFO closure and ATA in risk of new-onset AF (HR = 1.13, 95% CI = 0.53–2.44, p = 0.74). Compared with patients < 60 years, individuals ⩾ 60 years who underwent PFO closure had a higher risk of recurrent stroke (2.94% vs 1.04%, respectively, HR = 3.47; 95% CI = 1.61–7.48; p = 0.001), new-onset AF (4.86% vs 1.01%, respectively, HR = 4.12; 95% CI = 1.90–8.95; p < 0.001), and all-cause mortality during follow-up (8.32% vs 0.39%, respectively, HR = 8.24; 95% CI = 3.49–19.46; p < 0.0001). In-hospital complications after PFO closure were comparable between two age groups. Due to insufficient data, we were not able to perform a subgroup analysis based on anatomic features of PFO, antithrombotic regimen, or occluder devices. Conclusion: Based on available data, which is predominantly derived from observational studies, PFO closure is associated with a reduced risk of recurrent stroke compared to ATA in patients over 60 years. However, these findings are subjected to limitations, including the potential for selection bias, unmeasured confounding, and insufficient long-term follow-up. Furthermore, long-term randomized trials are essential to definitively confirm efficacy and establish clinical guidelines for PFO closure in this older population.

Background/Objectives: Idiopathic intracranial hypertension (IIH) often features dural venous sinus stenosis; venous sinus stenting (VSS) improves venous outflow and intracranial pressure, but most stents are off-label, and few are engineered for intracranial venous anatomy. The aim was to synthesize animal models relevant to IIH/VSS, catalogue stents used clinically for VSS and summarize corresponding animal data, appraise current preclinical VSS research, and propose a pragmatic preclinical evaluation framework. Methods: We performed a targeted search (PubMed, Web of Science, Scopus; through to May 2025), dual-screened the records in Nested Knowledge, and extracted the model/device characteristics and outcomes as per the predefined criteria. Results: We identified 65 clinical VSS studies; most were retrospective and used off-label carotid/peripheral/biliary stents (Precise, Zilver, and Wallstent were the most frequent). Recent dedicated systems (River, BosStent) have limited animal evidence; VIVA has GLP porcine venous peripheral data demonstrating its patency, structural integrity, and benign healing outcomes. Rodent models reproduce obesity/androgen drivers with modest, sustained ICP elevation; large animal models show the technical feasibility of in sinus implantation, but no chronic focal venous stenosis model fully mirrors the IIH condition. Conclusions: Despite broad clinical uptake, the translational underpinnings of VSS in IIH remain incomplete: most devices lack intracranial venous-specific preclinical validation, and there is no existing animal model that recapitulates both IIH biology and focal sinus stenosis.

Background Guide catheter (GC) placement, whether distal or proximal, may influence the efficacy and safety of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, definitions of placement and procedural strategies vary across studies, limiting clarity. Methods We systematically searched PubMed, Embase, Scopus, and Web of Science from inception to September 1, 2024. Comparative studies of adult patients with anterior circulation AIS-LVO undergoing MT that reported GC placement were included. Both balloon GCs (BGCs) and non-BGCs were eligible. Data were pooled using random-effects models in R. Outcomes included functional independence (modified Rankin Scale 0–2 at 90 days), successful reperfusion (modified thrombolysis in cerebral infarction ≥2b or expanded thrombolysis in cerebral infarction ≥2c), first-pass recanalization (FPR), mortality, puncture-to-recanalization (PTR) time, and complications. Subgroup analyses were performed by thrombectomy technique and catheter type. Results Seven retrospective studies comprising 2148 patients (1042 proximal, 1106 distal) were analyzed. Distal placement was associated with higher rates of functional independence (risk ratio (RR): 1.25, 95% confidence interval (CI): 1.10–1.42), successful reperfusion (RR: 1.13, 95% CI: 1.04–1.22), and FPR (RR: 1.35, 95% CI: 1.15–1.58), as well as lower 90-day mortality (RR: 0.52, 95% CI: 0.28–0.82). PTR time was shorter with distal placement (mean difference: −7.7 min, 95% CI: −10.8 to −4.6). No significant differences were observed for symptomatic intracranial hemorrhage (RR: 0.96, 95% CI: 0.55–1.65) or emboli to new territory (RR: 0.84, 95% CI: 0.28–2.52). Benefits were consistent across both BGCs and non-BGCs. Heterogeneity existed in outcome definitions and techniques, and publication bias could not be excluded. Conclusions Distal GC placement is associated with improved reperfusion, efficiency, and functional outcomes in MT for anterior circulation AIS-LVO, without increased complications. Given the retrospective nature of included studies, anatomic confounding, and inconsistent outcome definitions, findings should be considered preliminary. Multicenter trials are needed to confirm whether catheter position independently predicts MT outcomes.

Background: Patients with acute ischemic stroke secondary to distal and medium vessel occlusion (AIS-DMVO) and minor strokes present a challenge in determining the most appropriate emergent treatment. Factors leading to early neurological deterioration (END) in this patient population are understudied, but END is known to result in poor functional outcomes. Therefore, we aimed to investigate the factors contributing to END in minor AIS-DMVO cases. Methods: We included patients with AIS-DMVO and minor strokes from 37 sites across North America, Asia, and Europe. Minor stroke was defined as a baseline National Institutes of Health Stroke Scale (NIHSS) score of ⩽5. The primary outcome measure, END, was defined as a shift of ⩾4 points in the NIHSS score at day one after treatment compared to baseline. Univariable and multivariable logistic regression analyses were performed to identify factors associated with END. Results: Among 559 consecutive patients with DMVO and minor strokes, END was reported in 68 patients. In multivariable analysis, mechanical thrombectomy (MT) was independently associated with higher odds of END (adjusted odds ratio [aOR] 2.37, 95% CI 1.12–5.02, p = 0.02), while intravenous thrombolysis (IVT) was associated with lower odds of END (aOR 0.46, 95% CI 0.26–0.81, p = 0.008). However, the association between MT and END was no longer statistically significant in the IPTW-adjusted analysis (OR 1.65, 95% CI 0.69–3.98, p = 0.26). Hypertension and antiplatelet use at baseline were also independently associated with END. Among MT-treated patients, successful and excellent recanalization and first-pass effect were protective against END. Conclusion: MT was associated with END in patients with minor AIS-DMVO, although this association was not significant after IPTW adjustment. IVT was independently associated with reduced risk of END. These findings support careful patient selection and further study in randomized trials.

Background: Ischemic stroke remains a leading cause of morbidity and mortality worldwide. Cardioembolic sources account for a significant proportion of these events, necessitating accurate identification of underlying structural heart abnormalities. Traditionally, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have been utilized for this purpose, although both have limitations. Cardiac computed tomography (CCTA) has emerged as a potential alternative, offering non-invasive imaging with high sensitivity and specificity for detecting intracardiac thrombi. Objective: This study aimed to evaluate the diagnostic yield of CCTA compared to TTE and TEE in detecting high-risk cardioaortic sources of embolism, including left ventricular (LV) thrombus, left atrial (LA) thrombus, valvular thrombus, and ulcerated aortic plaques, in patients with ischemic stroke. Methods: We conducted a retrospective, single-center cohort study at Mayo Clinic, Rochester, MN, including 426 ischemic stroke patients who underwent CCTA within 30 days of stroke onset between March 2019 and June 2023. We compared the diagnostic yields of CCTA, TTE, and TEE in detecting structural cardiac sources of embolism. Results: The overall diagnostic yield of CCTA for detecting high-risk cardioaortic sources was 15.5%. Specifically, CCTA identified LV thrombus in 2.3% of patients, LA thrombus in 4.0%, valvular thrombus in 2.8%, and ulcerated aortic plaques in 7.0%. In comparative analysis, CCTA demonstrated a higher yield than TTE (16.0% vs 3.5%, p < 0.001) and a comparable yield to TEE (25.3% vs 20.7%, p = 0.47) in detecting these sources. Conclusions: CCTA proved to be a viable option for identifying high-risk structural sources of cardioembolism in ischemic stroke patients. Its non-invasive nature, coupled with the ability to perform imaging soon after stroke onset, underscores its clinical utility. However, further prospective and blinded studies are required to validate these findings and fully establish the efficacy of CCTA in this context.