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Abstract Background Data describing the incidence and clinical outcomes of respiratory syncytial virus (RSV) infection among patients with inflammatory bowel disease (IBD) are limited. Methods We conducted a nationwide retrospective cohort study using the Veterans Health Administration (VHA) database. Adults with IBD were identified using a previously validated algorithm and matched 1:2 to non-IBD controls using propensity score matching. Laboratory-confirmed RSV infections that occurred between January 1, 2021, and December 31, 2024, were identified using standardized laboratory codes and confirmed by manual chart adjudication. Primary outcomes included RSV incidence and hospitalizations. Secondary outcomes included intensive care unit (ICU) admission and patient outcomes stratified by IBD medication class. Results After propensity score matching, 52 740 IBD patients and 104 997 non-IBD controls were included. Infection with RSV occurred in 219 patients with IBD and 426 non-IBD patients. Incidence rates of RSV were similar between cohorts across all years in our study period. Hospitalization related to RSV occurred in 18.26% of IBD-RSV patients compared with 13.15% of non-IBD patients (P = .08). ICU admission was rare in both groups (<1%). Among patients with IBD, RSV-related hospitalization did not differ significantly by medication class, when comparing biologic therapy (8.93%) with 5-aminosalicylic acid monotherapy (17.58%) (P = .15). Conclusions In this nationwide cohort, patients with IBD, with predominantly lower exposure to advanced therapies, did not have higher rates of RSV infection or worse clinical outcomes compared with matched non-IBD controls. RSV outcomes were similar across IBD medication classes. These findings support current vaccination recommendations and provide reassurance regarding RSV risk among patients with IBD.

e16300 Background: Transarterial chemoembolization (TACE) remains the standard of care for intermediate stage hepatocellular carcinoma (HCC), yet long term survival is limited by high rates of recurrence and progression. The addition of immune checkpoint inhibitors (ICI) and tyrosine kinase inhibitors (TKI) with TACE has recently emerged as a promising strategy. This meta-analysis evaluates the efficacy and safety of TACE plus systemic combination therapy compared to TACE alone. Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines. Studies evaluating TACE combined with dual systemic therapy (ICI + TKI/VEGF inhibitor) were identified through major databases up to January 2026. Pooled odds ratios (ORs) and Hazards Ratio (HRs) were calculated using fixed effects models as appropriate. Results: Five studies (4 RCTs, 1 cohort) comprising 1964 patients were included. Progression-free survival was significantly longer with TACE combined with dual systemic therapy compared with TACE alone (mean difference 4.12 months, 95% CI 2.86-5.37; p < 0.00001; I² = 73%). The objective response rate was also significantly higher with TACE combination therapy (OR 2.66, 95% CI 2.17-3.26; p < 0.00001), despite substantial heterogeneity (I² = 83%). Grade 3/4 adverse events were significantly more frequent with TACE combination therapy (OR 3.36, 95% CI 2.66-4.25; p < 0.00001; I² = 68%). The most common severe toxicities included Hypertension (16.2%), Immune-mediated Hepatitis (9.6%), and Proteinuria (8.8%). Hypertension occurred significantly more often with TACE combination therapy than with TACE alone (pooled OR 9.52, 95% CI 1.83-49.62; p = 0.007; I² = 51%). Conclusions: The addition of ICI and TKI/VEGF inhibitors to TACE provides consistent, statistically significant and clinically meaningful improvement in disease control for unresectable HCC. This can be explained on the basis of complementary biological mechanisms, including enhanced tumor antigen exposure following TACE, restoration of antitumor T cell activity with ICI, and suppression of TACE induced angiogenesis through VEGF pathway blockade. While the efficacy benefit is robust across trials, safety profiles vary significantly by regimen.The higher rate of grade ¾ adverse effects, especially hypertension and immune-mediated hepatitis, is mainly due to the biological effects of VEGF inhibitors on blood vessels and the increased immune activation caused by immune checkpoint inhibitors. Despite a higher incidence of grade 3/4 toxicities, adverse events were generally manageable with standard supportive care and dose modifications. Overall, these findings support the use of TACE-systemic combinations as a new potential standard of care, with careful patient selection and toxicity monitoring.

e16081 Background: Intratumoral Fusobacterium nucleatum (F. nuc) is a key microbial participant in gastrointestinal malignancy progression. In esophageal squamous cell carcinoma (ESCC), the link between bacterial colonization and metastatic potential requires characterization. This systematic review synthesizes evidence from independent cohorts to define the relationship between bacterial DNA load, molecular pathways driving metastasis, and survival. Methods: PubMed, EMBASE, and Cochrane databases were searched for studies till January 2026 evaluating F. nuc and ESCC prognosis using quantitative DNA-based assays (qPCR or 16S rRNA sequencing). Multivariate-adjusted hazard ratios (HR) for cancer-specific survival (CSS) and disease recurrence were pooled using a Random Effects Model; heterogeneity was assessed by I^2. Synthesis identified technical/geographic consistencies and correlations with pathological markers of tumor invasion and lymph node spread. Results: Eight studies from China and Japan met inclusion criteria. High intratumoral F. nuc load was a significant independent prognostic factor. Elevated DNA load was a robust predictor of poor outcomes, specifically associated with a CSS HR of 1.78 (95% CI 1.06-2.65). Recurrence risk was similarly elevated, yielding a pooled Relapse-Free Survival (RFS) HR of 1.71 (95% CI 1.27-2.30,I^2 = 0).Findings remained stable across multicenter registries in Japan and China, likely due to standardized qPCR targeting nusG or 16S rRNA genes. Qualitatively, high DNA load correlated with advanced pT stage and lymph node metastasis. This phenotype is mediated by TLR4/NF-κB and NOD1/RIPK2 signaling, which drive epithelial-mesenchymal transition (EMT) and foster an immunosuppressive "cold" tumor microenvironment characterized by M2-like macrophage and regulatory T-cell recruitment. Conclusions: Intratumoral F. nuc DNA quantification identifies a high-risk biological subtype of ESCC. Consistency across regional cohorts indicates F. nuc is a universal driver of metastatic progression in squamous cell pathology. Standardized microbial DNA quantification may serve as a high-fidelity biomarker to refine risk stratification and guide microbiota-targeted neoadjuvant strategies to mitigate metastatic spread in ESCC.

e15091 Background: Early identification of patients likely to benefit from immune checkpoint inhibitors (ICIs) remains a major challenge across solid tumors. Circulating tumor DNA (ctDNA) kinetics have emerged as a promising noninvasive biomarker, yet results across studies are heterogeneous. We conducted a systematic review and meta-analysis to evaluate the prognostic and predictive value of early ctDNA reduction in patients receiving ICIs. Methods: A systematic search of PubMed, Embase, Web of Science, and Cochrane Library was conducted from inception through March 2025 following PRISMA guidelines. Studies evaluating early ctDNA dynamics (≤8 weeks after ICI initiation) in adult patients with solid tumors were included. Primary outcomes were progression-free survival (PFS) and overall survival (OS). Secondary outcomes included objective response rate (ORR). Random-effects models were used to pool hazard ratios (HRs) and odds ratios (ORs). Heterogeneity was assessed using I² statistics, and publication bias was evaluated with funnel plots and Egger’s test. Results: A total of 27 studies encompassing 3,842 patients across lung, melanoma, breast, gastrointestinal, and genitourinary malignancies met inclusion criteria. Early ctDNA reduction (defined as ≥50–90% decline or complete clearance, study-specific) was associated with significantly improved PFS (pooled HR 0.45; 95% CI 0.38–0.53; I² = 41%) and OS (pooled HR 0.40; 95% CI 0.32–0.49; I² = 36%). Patients demonstrating early ctDNA reduction had a markedly higher ORR (pooled OR 4.92; 95% CI 3.71–6.53; I² = 29%). Subgroup analyses showed consistent benefit across tumor types and ICI regimens. Early ctDNA dynamics outperformed baseline PD-L1 expression and tumor mutational burden in predicting treatment response. No significant publication bias was detected. Conclusions: Early ctDNA kinetics are a robust, tumor-agnostic biomarker associated with improved survival and treatment response in patients receiving ICIs. These findings support the integration of ctDNA monitoring into early treatment assessment and clinical trial design. Prospective trials are warranted to validate ctDNA-guided immunotherapy strategies.

OBJECTIVE The objective was to evaluate the trajectories of hematoma resolution and functional improvement after middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH), model the temporal pattern of cSDH resolution, and identify factors associated with favorable outcomes. METHODS This real-world multicenter retrospective study included cSDH patients treated with MMAE at 24 centers between 2019 and 2024. Hematoma thickness was measured at baseline and at follow-up intervals (1–4 weeks, 1–3 months, 3–6 months, 6–12 months, and > 12 months after embolization). Resolution patterns were modeled using exponential decay functions. Modified Rankin Scale (mRS) scores assessed functional outcomes. Good functional outcome was defined as mRS score ≤ 2. Resolution patterns were modeled using exponential decay functions to estimate time to 50% and 80% reduction. Patients were categorized as complete resolution (≥ 99%) or by quartile of the remaining distribution (substantial [73%–98%], moderate [53%–73%], partial [27%–53%], minimal [< 27%]). The primary outcome was good functional status (mRS score ≤ 2). RESULTS The authors analyzed a total of 1781 patients with 2295 cSDHs who underwent MMAE. The mean ± SD age was 72.8 ± 12.4 years and 68.1% of patients were male. The initial mean hematoma thickness was 15.31 ± 6.53 mm, decreasing to 5.24 ± 5.91 mm at final follow-up (mean reduction 64.3% ± 42.1%). Resolution followed an exponential decay pattern, with an estimated time to 50% reduction of 1.8 months and to 80% reduction of 8.9 months. Complete resolution occurred in 1031 of 2224 patients (46.4%) with complete follow-up. The median (IQR) mRS score improved from 1 (0–3) at baseline to 0 (0–2) at > 12 months. Good functional outcomes were more common in patients with complete versus minimal resolution (68.9% vs 35.0%, p < 0.001). Achieving ≥ 73% resolution within 90 days was associated with better outcomes (good outcome in 76.9% of those with ≥ 73% resolution vs 67.3% in those without, p < 0.001). Neurological deterioration was the strongest predictor of lack of good outcome (23.7% in patients with neurological deterioration vs 82.4% without, p < 0.001). CONCLUSIONS After MMAE for cSDH, reduction in hematoma thickness follows a predictable exponential decay pattern. Greater extent (≥ 80%) and faster timing (within 90 days) of resolution are valuable prognostic indicators. Functional outcomes improve progressively through 6–12 months after the procedure. The relationship between resolution extent and functional outcomes provides quantitative benchmarks for evaluating treatment response.

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.

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.

OBJECTIVE Mechanical thrombectomy (MT) is well established for large-vessel occlusion (LVO) strokes, but its safety in distal and medium-vessel occlusions (DMVOs) requires further investigation. This study analyzed the relationship between procedural approaches, petechial hemorrhage (PetH), and clinical outcomes in DMVO thrombectomy, with particular attention to technical considerations and the complex interplay between tissue injury and hemorrhagic complications. METHODS A retrospective cohort study was conducted on DMVO stroke patients treated with MT at 37 stroke centers worldwide from 2016 to 2024. Patients were categorized based on follow-up imaging into those with or without PetH. Four logistic regression models analyzed the association of PetH with favorable functional outcomes (modified Rankin Scale score ≤ 2) at 90 days, early neurological improvement (≥ 4-point National Institutes of Health Stroke Scale score decrease at 24 hours), all-cause mortality, and independent determinants of PetH. Adjusted odds ratios (aORs), 95% confidence intervals, and p values were reported. RESULTS Of 1428 patients, 439 (30.7%) developed PetH. Factors independently associated with PetH were multiple thrombectomy passes (aOR 1.58, 95% CI 1.21–2.06; p = 0.001), IV thrombolysis (aOR 1.31, 95% CI 1.01–1.69; p = 0.04), and the combined use of a stent retriever with aspiration as the first-line method compared with aspiration alone (aOR 1.66, 95% CI 1.15–2.38; p = 0.007). Conversely, general anesthesia (aOR 0.55, 95% CI 0.40–0.77; p < 0.001), higher Alberta Stroke Program Early CT Scores (aOR 0.76, 95% CI 0.69–0.83; p < 0.001), and successful recanalization (aOR 0.56, 95% CI 0.39–0.80; p = 0.002) were significantly associated with a lower odds of PetH. PetH was associated with a decreased odds of favorable functional outcomes (aOR 0.51, 95% CI 0.36–0.73; p < 0.001), reduced early neurological improvement (aOR 0.59, 95% CI 0.44–0.79; p < 0.001), and increased all-cause mortality (aOR 1.84, 95% CI 1.23–2.76; p < 0.001). CONCLUSIONS PetH is a frequent sequela following MT in DMVO strokes and is associated with poorer outcomes, likely reflecting underlying ischemic injury rather than direct causation. Procedural factors influence PetH risk, suggesting medical treatment as first-line therapy for DMVOs, with MT reserved for refractory cases using less aggressive approaches.

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 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.