The Neurocritical Care Society and the Society of Critical Care Medicine have released a focused guideline update addressing the management of antithrombotic-associated intracranial hemorrhage in adults. Published in September 2026, this open-access guideline provides evidence-based recommendations for clinicians treating patients who develop intracerebral bleeding while on anticoagulant or antiplatelet therapy. The update synthesizes current literature on reversal strategies, hemostatic interventions, and supportive care measures tailored to different antithrombotic agents, including warfarin, direct oral anticoagulants, and antiplatelet medications. These guidelines matter significantly because antithrombotic-associated intracranial hemorrhage represents a serious complication with high morbidity and mortality rates, and optimal management requires rapid, coordinated intervention. By establishing standardized treatment protocols, these recommendations aim to improve patient outcomes, reduce clinical variability, and guide resource allocation in neurocritical care settings. The open-access format ensures broad accessibility for healthcare professionals managing this complex and time-sensitive condition.

Intravenous tissue plasminogen activator (tPA), including alteplase and tenecteplase, represents standard therapeutic intervention for acute ischemic stroke in eligible patients. These fibrinolytic agents dissolve cerebral arterial clots within a critical 4.5-hour treatment window, potentially reversing neurological damage and significantly improving long-term patient outcomes. Before administration, clinicians must rapidly apply exclusion criteria to rule out contraindications including active bleeding, recent surgery, and severe hypertension, with hemorrhage definitively excluded via CT imaging. The treatment approach follows the "time is brain" principle, recognizing that millions of neurons are lost every minute without intervention. Early thrombolysis administration substantially enhances quality of life and functional recovery. Rapid recognition of stroke symptoms and emergency evaluation using the FAST test (Face, Arms, Speech, Time) are essential for identifying candidates for tPA therapy. Prompt medical attention and specialist assessment determine treatment eligibility and optimal management strategies for acute ischemic stroke patients.

Mechanical thrombectomy, or endovascular thrombectomy, is a minimally invasive procedure that removes blood clots from large brain arteries in acute ischemic stroke patients. A specially trained physician advances a catheter through an artery and uses a stent retriever, suction device, or combination of both to capture and restore blood flow. Effectiveness is maximized when performed early, though selected patients may benefit from treatment up to 24 hours after symptom onset, depending on imaging, blockage location, and clinical factors. Recent guidance has expanded eligibility criteria for this life-saving intervention. Treatment decisions should involve a coordinated stroke and neurointerventional team using current national protocols and advanced imaging to identify candidates. Intravenous thrombolytic agents like tenecteplase can be administered concurrently without delaying thrombectomy evaluation. Hospitals without thrombectomy capability must establish clear transfer protocols. Post-procedure care requires intensive neurological monitoring in specialized stroke units. While mechanical thrombectomy significantly improves patient outcomes, it carries procedural risks that should be discussed with patients when feasible.

Researchers have developed a sophisticated contact-resolved finite-element computational framework to model the deployment of the Contour Neurovascular System (CNS), an intrasaccular flow disruptor device used to treat wide-necked intracranial aneurysms. The framework represents the CNS as a dual-layer interwoven Nitinol braid using geometrically exact beam models while modeling the aneurysm wall as a deformable hyperelastic shell. During staged deployment, the model accounts for frictional contact governing wire-wire and wire-wall interactions. Testing across three patient-specific anatomies revealed that seated configuration is highly sensitive to device-wall tangential friction and release depth relative to the aneurysm neck plane. Frictionless contact permits substantial post-contact sliding, whereas finite friction significantly suppresses residual pole motion. Release depth critically influences both wall engagement onset and deployment trajectory. The study demonstrates that conventional geometric placement approaches, which prescribe final device configuration, cannot capture actual contact mechanics or wall-supported states. This mechanics-based framework enables more accurate deployed geometries for subsequent hemodynamic, fluid-structure interaction, and mechanobiological analyses, potentially improving treatment planning for intracranial aneurysm patients.

Baystate Health announced its participation in the PIONEER clinical trial, a national study investigating advanced treatment options for brain aneurysms. The trial represents a significant opportunity to evaluate innovative therapeutic approaches for patients with this serious neurological condition. By enrolling patients in this research initiative, Baystate Health aims to contribute to the broader medical community's understanding of effective aneurysm management strategies. The announcement, made on September 25, 2026, underscores the institution's commitment to offering cutting-edge treatment options and advancing clinical knowledge in neurovascular disease. Participation in such multicenter trials is crucial for developing evidence-based protocols that can improve patient outcomes and expand the therapeutic arsenal available to healthcare providers treating complex brain aneurysms.

During long-term antiplatelet agents (APAs) administration, patients with thrombotic diseases take a fairly high risk of life-threatening bleeding, especially when in need of urgent surgery. Rapid functional reversal of APAs remains an issue yet to be efficiently resolved by far due to the lack of any specific reversal agent in the clinic, which greatly restricts the use of APAs.

Our proposed SAPT regimen, consisting of ticagrelor or prasugrel with peri-interventional bridging using tirofiban, proved effective in preventing thromboembolic events and minimizing rebleeding in the treatment of ruptured BBAs by FDSs with surface modification. Further investigation through larger, randomized, multicenter studies is warranted to more robustly evaluate the safety and efficacy of this approach.

This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.

A case report documents a dural arteriovenous fistula presenting with reversible Parkinsonism and cognitive decline that closely mimicked progressive supranuclear palsy. The patient exhibited parkinsonian features and cognitive impairment characteristic of PSP, a neurodegenerative disorder typically considered irreversible. However, imaging revealed an underlying dural arteriovenous fistula—an abnormal connection between dural arteries and venous sinuses causing venous hypertension and cerebral dysfunction. Following endovascular intervention to treat the fistula, the patient's neurological symptoms, including both parkinsonian features and cognitive decline, demonstrated significant reversibility. This case is clinically significant as it highlights the importance of considering vascular etiologies in the differential diagnosis of atypical parkinsonian syndromes. Dural arteriovenous fistulas can mimic neurodegenerative diseases through hemodynamic compromise and venous congestion affecting motor and cognitive circuits. Recognition of this treatable condition prevents misdiagnosis and unnecessary exposure to disease-modifying therapies for irreversible conditions, while identifying patients who may benefit from vascular intervention and achieve functional recovery.

Cribriform plate dural arteriovenous fistulas (DAVF) represent rare but dangerous neurovascular lesions in the anterior cranial fossa characterized by abnormal shunts between dural arteries and cortical veins. Unlike typical DAVFs, these lesions drain directly into fragile frontal pial veins rather than major dural sinuses, creating substantial hemorrhage risk with patients presenting acute subarachnoid or intraparenchymal bleeding. Diagnosis relies on magnetic resonance angiography and digital subtraction angiography identifying feeder networks from ethmoidal branches of the ophthalmic artery. Historically, transarterial embolization served as the primary treatment, with operators delivering liquid embolic agents through microcatheters via the ophthalmic artery. However, this approach presents significant limitations, including technical difficulty navigating the tiny, tortuous ethmoidal arteries, incomplete obliteration rates of only 53.8%, and serious complications such as central retinal artery occlusion causing permanent blindness. Recent clinical experience has prompted exploration of alternative transvenous approaches to overcome these drawbacks. Given the aggressive natural history of untreated lesions and high rebleeding mortality, improved endovascular techniques are essential for preventing catastrophic outcomes while minimizing procedural morbidity in this challenging patient population.

This systematic review and meta-analysis, conducted according to PRISMA 2020 guidelines, examined the safety of antiplatelet reversal before emergency intracranial surgery in patients with ruptured aneurysms treated with stent-assisted coiling or flow diversion. Analyzing sixty-three records from fifty-nine studies, including four randomized controlled trials and fifty-five comparative cohorts, researchers found that antiplatelet exposure during cerebrospinal fluid diversion significantly increased radiographic catheter-tract hemorrhage fourfold and symptomatic hemorrhage nearly fourfold. Notably, platelet concentrate transfusion provided no clinical benefit and was associated with increased mortality or dependence, whereas desmopressin administration reduced hematoma expansion. Pre-procedural P2Y12 reaction units demonstrated moderate predictive accuracy for complications, while thromboelastography with platelet mapping proved unreliable. These findings challenge current practice by suggesting that reversing antiplatelet therapy with transfusion may be harmful, and that pharmacological approaches like desmopressin offer superior safety profiles for managing emergency neurosurgery in antiplatelet-exposed patients.

Mechanical thrombectomy is an endovascular intervention for acute ischemic stroke caused by large vessel occlusion in the internal carotid artery, middle cerebral artery (M1 or proximal M2 segment), or basilar artery. The procedure uses stent retrievers or aspiration catheters to physically extract blood clots from cerebral arteries and is performed under local or general anesthesia in an interventional neuroradiology suite. Recent clinical trials, including DAWN and DEFUSE-3, have expanded the treatment window to 24 hours in carefully selected patients using CT perfusion or diffusion-weighted MRI mismatch criteria. The procedure is frequently combined with intravenous thrombolysis using alteplase or tenecteplase when patients meet eligibility criteria. Successful reperfusion, defined as TICI 2b-3 (Thrombolysis in Cerebral Infarction score), significantly reduces disability outcomes. This technique represents a critical advancement in acute stroke management, offering patients substantially improved functional recovery when performed within appropriate time windows and anatomical criteria.

Basilar artery occlusion represents a severe stroke subtype with historically poor outcomes. Researchers from multiple comprehensive stroke centers developed the HALF-IT score, a simplified patient selection tool designed to predict functional outcomes following endovascular thrombectomy in these cases. The score dichotomizes patients based on brainstem infarction extent, classifying involvement of 50 percent or greater of any brainstem section as HALF-IT positive. In a multicenter retrospective study of 37 patients treated between 2021 and 2025, researchers evaluated whether the HALF-IT score could predict favorable functional outcomes, defined as a modified Rankin Scale score of 0-3 at 90 days. Results demonstrated that HALF-IT positive patients achieved favorable outcomes significantly less frequently than HALF-IT negative patients, with rates of 14.3 percent versus 68.2 percent respectively. This association remained significant even after adjusting for age, initial stroke severity, reperfusion time, and thrombolysis administration. The HALF-IT score's straightforward, single-parameter approach offers potential value for streamlining patient selection and outcome prediction in basilar artery occlusion cases.

For patients with an acute coronary syndrome event, current guidelines recommend dual antiplatelet therapy for at least 12 months after drug-eluting stent placement. However, several clinical trials have assessed whether continuing dual antiplatelet therapy beyond 12 months is beneficial. We review the pros and cons of extending dual antiplatelet therapy.

Researchers evaluated whether platelet function testing (PFT)-guided antiplatelet therapy reduces complications in patients undergoing stent-assisted coil embolization for unruptured intracranial aneurysms. The retrospective study enrolled 368 patients from two Chinese hospitals between January 2019 and September 2024, divided into a monitored group (n=219) receiving PFT-guided treatment and a non-monitored control group (n=149) receiving standard dual antiplatelet therapy (DAPT). Patients with high on-treatment platelet reactivity to clopidogrel received additional loading doses and tirofiban, while those with aspirin resistance received increased aspirin doses. The monitored strategy significantly reduced seven-day thromboembolic events (3.20% versus 8.05%, p=0.048) and thirty-day thromboembolic events (adjusted HR=0.412, p=0.028) compared to standard DAPT, with no increased bleeding complications. These findings suggest personalized, testing-guided antiplatelet intensification substantially improves safety outcomes in endovascular aneurysm treatment by identifying and managing platelet resistance, which has important clinical implications for optimizing perioperative antiplatelet management in neurovascular procedures.

A 67-year-old patient with a history of cerebellar infarction and multiple dural arteriovenous fistulas (DAVFs) presented with recurrent headache following prior treatments. The anterior cranial fossa DAVF had persisted despite previous transarterial embolization (TAE) via bilateral ophthalmic arteries using Onyx (Medtronic). Given the lesion's location, previous arterial treatment, and the patient's strong refusal of cranial surgery, the treatment team selected transvenous embolization (TVE) as an alternative approach. This technique involved accessing the dilated draining vein directly through the venous system rather than pursuing additional arterial intervention or surgical intervention via craniotomy. The procedure was performed under general anesthesia using standard endovascular techniques, with access gained through the right internal jugular vein. TVE offered a less invasive option compared to surgical vein interruption while addressing the limitations of repeat arterial approaches. This case demonstrates how TVE can serve as a viable alternative for complex anterior cranial fossa DAVFs when conventional arterial embolization fails and patients decline surgical intervention, though the procedure carries specific risks including venous perforation, Onyx reflux, and catheter complications.

# Summary A landmark U.S. clinical evaluation assessed the real-time artificial intelligence system for device tracking during neurointerventional procedures, representing the first formal implementation study of this technology in American clinical practice. The research evaluated an AI-driven tracking system designed to monitor and guide medical devices through neuro-vascular pathways in real-time during interventional procedures. The study measured system performance across multiple clinical metrics, including tracking accuracy, procedural efficiency, and safety parameters during actual patient treatments. Key findings demonstrated the system's capability to enhance real-time visualization and device navigation while maintaining procedural safety standards. This evaluation matters significantly for the neurointerventional field because accurate device tracking can reduce procedure times, minimize radiation exposure, and potentially improve patient outcomes during complex vascular interventions. The successful implementation represents an important validation of AI-assisted technology in clinical neurovascular practice, establishing a framework for broader adoption of real-time tracking systems in interventional radiology. These results advance the integration of artificial intelligence into precision medicine within neurovascular procedures.

# Endovascular Thrombectomy for Mild Vertebrobasilar Artery Occlusion Endovascular thrombectomy, a minimally invasive interventional procedure, has emerged as a treatment approach for patients experiencing mild vertebrobasilar artery occlusion, a serious condition affecting blood flow to the brain stem and cerebellum. The vertebrobasilar system comprises the vertebral and basilar arteries, critical vessels supplying posterior circulation to the brain. While severe basilar artery occlusions typically warrant immediate mechanical thrombectomy, the optimal management strategy for mild occlusions has remained unclear due to limited clinical evidence. This research examines the efficacy and safety of endovascular thrombectomy in mild vertebrobasilar occlusion cases, where symptoms may be less catastrophic but still significant. The procedure involves deploying specialized devices to mechanically retrieve blood clots, restoring vessel patency and cerebral perfusion. Key findings demonstrate that endovascular intervention can achieve substantial recanalization rates while maintaining acceptable safety profiles with minimal complications. This work matters because it addresses a treatment gap for mild vertebrobasilar occlusions, potentially expanding appropriate indications for thrombectomy beyond severe cases and improving clinical outcomes for patients at risk of stroke progression or recurrent cerebrovascular events.

Dual antiplatelet therapy with aspirin and P2Y12 inhibitors remains essential in endovascular neurointervention to prevent thromboembolic complications. However, recent comparative clinical evidence reveals that patient responses vary significantly depending on underlying vascular pathology. Intracranial aneurysms and cerebral artery stenosis represent distinct disease entities requiring differentiated treatment approaches. Aneurysms develop from hemodynamic wall shear stress and structural degradation, while cerebral artery stenosis results from atherosclerotic plaque accumulation and chronic endothelial dysfunction. These pathophysiological differences create unique microenvironments affecting platelet behavior differently. Stenotic lesions with exposed subendothelial collagen exhibit higher baseline platelet reactivity, whereas aneurysmal walls present stasis-prone outpouches where flow dynamics predominate. When neurovascular stents or flow diverters are deployed, they introduce foreign surfaces into non-atherosclerotic vessels, further distinguishing treatment responses. Although both conditions achieve similar thrombotic protection with dual antiplatelet therapy, their bleeding profiles differ substantially. Understanding these distinct safety margins enables interventional teams to refine individualized treatment regimens and optimize post-procedural recovery outcomes.

This multicenter prospective study evaluates a novel flow diverter stent for treating intracranial aneurysms, establishing rigorous inclusion and exclusion criteria to ensure patient safety and data validity. The study excludes patients with recent intracranial implants, prior endovascular interventions within 30 days, significant functional impairment (modified Rankin Scale score ≥3), or contraindications to dual antiplatelet therapy. Additional exclusion criteria encompass pre-existing stents in the parent artery, high neurological event risk, pregnancy status, and allergies to materials including platinum and cobalt-chromium alloys commonly used in flow diverter construction. By carefully controlling for these factors, the research aims to establish the safety and efficacy profile of this new stent technology. Flow diverter stents represent an important therapeutic advancement for complex aneurysm management, offering an alternative to traditional coiling and clipping approaches, making this trial's rigorous methodology essential for validating the device's clinical utility.