In this exploratory study, no statistically significant difference was observed between the safety profiles of clopidogrel-based SAPT and DAPT for patients treated with the Pipeline Shield, despite the higher-risk baseline characteristics in the SAPT cohort. These preliminary findings suggest that clopidogrel monotherapy might be a feasible alternative in select patients, potentially simplifying treatment and reducing DAPT-associated hemorrhagic complications.

In real-world practice, ticagrelor and clopidogrel for patients undergoing FD were equivalent in terms of ischemic stroke and hemorrhage risks, though ticagrelor was associated with a significantly higher risk of all-cause mortality.

Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.

Flow-diverters with antithrombogenic coatings have been developed to reduce thrombogenicity and support endothelialization. This study is the first to compare in vivo DERIVO® 2heal® with its uncoated counterpart, the DERIVO®2 with early HF-OCT and histology under single antiplatelet therapy. DERIVO® 2heal® reduces thrombi formation immediately post- implantation in our rabbit model.

# Professional Summary This article addresses a rare and clinically challenging case of a giant cervical internal carotid artery aneurysm and its associated complications. Giant aneurysms of the internal carotid artery represent less than five percent of all intracranial aneurysms and pose significant treatment difficulties due to their size, location, and potential for devastating neurological outcomes. The case presented examines the clinical presentation, diagnostic findings, and management considerations for patients presenting with this pathology. The article emphasizes the importance of advanced imaging techniques and comprehensive vascular assessment in evaluating such complex lesions. Understanding the natural history and treatment options for giant cervical internal carotid artery aneurysms is critical for clinicians, as these lesions carry substantial risks for rupture, thromboembolism, and mass effect on adjacent structures. The findings contribute valuable clinical insights to the neuroendovascular and neurosurgical literature, highlighting the multidisciplinary approach necessary for optimal patient management and outcome prediction in cases of giant vascular pathology.

Mechanical thrombectomy, also known as endovascular thrombectomy, is a minimally invasive procedure designed to remove blood clots from large brain arteries in patients experiencing acute ischemic stroke. During the procedure, a specially trained physician uses a catheter to navigate through arteries to the blocked vessel, where a stent retriever or suction device captures and removes the clot to restore blood flow. While most effective when performed early, expanded clinical guidance now permits treatment up to 24 hours after symptom onset in selected patients, depending on brain imaging findings, blockage location, and stroke severity. Treatment decisions should be made collaboratively by stroke and neurointerventional teams using current national protocols and advanced imaging evaluations. Intravenous thrombolytic agents like tenecteplase may be administered concurrently while patients are evaluated for thrombectomy, as these treatments are complementary rather than competing. Post-procedure care requires close neurological monitoring in specialized stroke units. Hospitals lacking thrombectomy capabilities must establish clear transfer protocols for eligible candidates. While mechanical thrombectomy significantly improves outcomes for appropriate patients, risks including hemorrhage and vessel perforation require careful discussion with patients or authorized decision-makers when clinically feasible.

Acute ischemic stroke caused by intracranial atherosclerosis-related large vessel occlusion presents significant treatment challenges, with conventional mechanical thrombectomy achieving suboptimal first-pass reperfusion rates and complication risks. Researchers from ORDOS Central Hospital in China developed the RESCUE technique, a novel stepwise endovascular strategy combining retrievable stent placement, tirofiban administration, and microguidewire-assisted extraction with rescue angioplasty. In a prospective randomized trial involving 85 patients, the RESCUE approach was compared against the standard Solumbra technique. The RESCUE group demonstrated significantly superior first-pass reperfusion rates, achieving modified Thrombolysis in Cerebral Infarction grade 2c-3 in 86.0 percent of patients versus 61.9 percent in the Solumbra group. Procedural time was substantially reduced in the RESCUE cohort, with a median duration of 40 minutes compared to 60 minutes. Safety profiles remained comparable between groups, with no significant differences in symptomatic intracranial hemorrhage or mortality rates. These findings suggest RESCUE represents an effective, lesion-specific approach for managing this challenging stroke subset, warranting larger multicenter investigations to confirm broader applicability and clinical benefits.

Flow diverter technology has emerged as a significant advancement in treating complex intracranial aneurysms, offering promising alternatives to traditional surgical approaches. This editorial by Wang and Wan examines the latest developments in flow diverter interventions, focusing on techniques, clinical applications, and patient outcomes. Flow diverters function by redirecting blood flow away from aneurysm sites, promoting thrombosis while maintaining normal cerebral circulation. The article addresses critical considerations including antiplatelet therapy protocols essential for preventing thrombotic complications and stent-assisted therapy approaches for managing particularly challenging aneurysm geometries. Key discussion points encompass complication prevention strategies, optimal patient selection criteria, and long-term clinical efficacy data. This work is particularly relevant for neurointerventionalists and neurosurgeons managing complex vascular lesions, as flow diverter techniques continue to expand treatment options beyond conventional coil embolization and surgical clipping. The advancement represents a paradigm shift in minimally invasive neuroendovascular intervention, potentially improving patient outcomes while reducing procedure-related morbidity and mortality associated with traditional approaches to complex intracranial aneurysm management.

Platelets contract forcefully after their activation, contributing to the strength and stability of platelet aggregates and fibrin clots during blood coagulation. Viscoelastic approaches can be used to assess platelet-induced clot strengthening, but they require thrombin and fibrin generation and are unable to measure platelet forces directly. Here, we report a rapid, microfluidic approach for measuring the contractile force of platelet aggregates for the detection of platelet dysfunction. We find that platelet forces are significantly reduced when blood samples are treated with inhibitors of myosin, GPIb-IX-V, integrin αIIbβ3, P2Y12, or thromboxane generation. Clinically, we find that platelet forces are measurably lower in cardiology patients taking aspirin. We also find that measuring platelet forces can identify Emergency Department trauma patients who subsequently require blood transfusions. Together, these findings indicate that microfluidic quantification of platelet forces may be a rapid and useful approach for monitoring both antiplatelet therapy and traumatic bleeding risk.

The platelet, once thought to be solely involved in clot formation, is now known to be a key mediator in various others processes such as inflammation, thrombosis, and atherosclerosis. Supported by the wealth of evidence from clinical trials demonstrating their benefits in patient outcomes, antiplatelet agents have become paramount in the prevention and management of various diseases involving the cardiovascular, cerebrovascular, and peripheral arterial systems. Despite being among the most widely used and studied classes of medical therapies, new discoveries regarding important clinical aspects and properties of these agents continue to be made. As our understanding of platelet biology expands, more effective and safer novel therapies continue to be developed. The use of more refined agents in conjunction with a better understanding of their effects will further the ability to provide more optimized care on an individual basis.

HEAL is an innovative, non-eluting surface modification technology that consists of a fibrin mesh with bound heparin. This unique combination mimics the last step of haemostasis, leading to anti-thrombogenic, anti-inflammatory and endothelialisation-promoting properties, creating the potential to quickly occlude aneurysms and reduce complications associated with endovascular treatment.

Flow diverters with anti-thrombogenic coatings resulted in significantly lower activation of coagulation (TAT) and platelets (β-TG) and lower adhesion of platelets compared with the uncoated DERIVO 2 flow diverter. There were no significant differences between the coated flow diverters in terms of TAT and β-TG levels, as well as platelet adhesion. However, significantly lower activation of the complement system (SC5b-9 and C5a) was observed for the DERIVO 2heal flow diverter in comparison with the Pipeline Flex Shield and the p64 MW HPC flow diverters emphasizing the improved hemocompatibility of the fibrin/heparin-coated DERIVO 2heal flow diverter.

# Summary This clinical case study examines the complex management challenges of a patient with newly diagnosed atrial fibrillation who experienced hemorrhagic transformation following acute ischemic stroke, subsequently developing early recurrent large vessel occlusion. The case highlights the critical dilemma clinicians face when balancing thromboembolic prevention against hemorrhage risk in anticoagulation-naive patients with concurrent cardioembolic disease and intracranial bleeding complications. The patient underwent initial mechanical thrombectomy for acute stroke treatment; however, following hemorrhagic transformation of the infarct, a recurrent large vessel occlusion developed within days of the initial event. The case underscores the profound challenges in determining optimal anticoagulation timing and the potential role of repeat mechanical thrombectomy in managing recurrent thromboembolism in patients with recently diagnosed atrial fibrillation complicated by intracranial hemorrhage. This presentation illuminates critical gaps in clinical guidelines for managing such rare but severe clinical scenarios, emphasizing the need for individualized risk stratification and interdisciplinary decision-making to optimize patient outcomes while minimizing iatrogenic complications.

This case report presents a clinical analysis of a giant cervical internal carotid artery aneurysm and its associated complications. The study examines the pathophysiology, diagnostic imaging characteristics, and treatment considerations for this rare but serious vascular condition affecting the internal carotid artery in the neck region. Giant aneurysms of the cervical internal carotid artery present significant clinical challenges due to their propensity for rupture, thromboembolism, and mass effect on adjacent neural structures. The article documents the clinical presentation, radiological findings, and management strategies employed in addressing this complex case. The research emphasizes the importance of accurate diagnosis through advanced imaging techniques and careful patient evaluation to determine appropriate therapeutic interventions. Understanding the natural history and complications of giant cervical internal carotid artery aneurysms is critical for clinicians, as these lesions carry substantial morbidity and mortality risks. This case contributes valuable clinical insights into the recognition and management of this uncommon but potentially life-threatening vascular pathology, informing best practices for patient care and surgical decision-making in similar presentations.

In recent years, flow diverting devices have become an effective alternative to conventional treatments of intracranial aneurysms. Understanding FDS’s effectiveness in inducing aneurysm occlusion may be fundamental for treatment planning. To achieve this aim, a computational investigation of the hemodynamics of a patient-specific intracranial aneurysm reconstructed from medical images and virtually treated with FDS was performed. The FDS porosity was taken into account as it plays a crucial role in the effectiveness of the device. This parameter affects the stent’s ability to redirect blood flow away from the aneurysm into the parent artery. A low porosity is desirable, but if the porosity is too low, the stent might become too rigid for deployment. Two possible post-operative conditions were simulated, with the deployment of flow diverter stents differing in porosity. A comparison of the devices in modifying cerebral aneurysm hemodynamics was analyzed. The flow diverter stents were virtually implanted in the parent vessel harboring the aneurysm, with the devices covering the entire neck area. The placement of the devices determined a substantial reduction in flow recirculation and velocity magnitude inside the aneurysm. A reduction of the TAWSS values and an increase in the OSI and ECAP values were found. In particular, the relative residence time RRT on the aneurysmal wall markedly increased, indicating blood flow stagnation in the dome and thrombogenic conditions for the aneurysm occlusion.

Researchers at Ming Wang Shu Wan Brain Center in China conducted a comprehensive analysis of flow diverter (FD) technology for treating complex intracranial aneurysms, including blister-like, dissecting, fusiform, and large or small wide-neck saccular variants. A systematic review by Maimaitiaili et al. examined ten retrospective studies from four databases through July 2025, focusing on adults with small aneurysms (≤10 mm) receiving FD treatment. Results demonstrated that flow diverters achieved an 86% pooled complete or near-complete occlusion rate with favorable safety profiles, including low treatment-related mortality, hemorrhagic events, and ischemic complications, alongside a 9% overall complication rate. Nearly 98% of patients achieved favorable functional outcomes. The analysis also examined stent-assisted embolization complicated by thromboembolic events, utilizing the VerifyNow™ assay to measure platelet reactivity through P2Y12 Reaction Units and Aspirin Reaction Units. These findings suggest flow diverters represent a viable therapeutic option for complex aneurysms refractory to conventional approaches, though large-scale comparative trials remain necessary for comprehensive validation and clinical implementation guidance.

Endovascular thrombectomy has emerged as a critical intervention for acute ischemic stroke, representing a significant advancement in stroke treatment protocols. This procedure involves the mechanical removal of blood clots from cerebral vessels using specialized catheter-based devices, restoring blood flow to affected brain tissue. The technique addresses a major clinical challenge: time-sensitive intervention is essential to minimize neurological damage and improve patient outcomes. Multiple landmark clinical trials have demonstrated that endovascular thrombectomy, particularly when combined with intravenous thrombolysis, substantially improves functional recovery compared to medical management alone. Key benefits include reduced disability rates and improved long-term neurological outcomes in eligible patients. The procedure's success depends on factors including time from symptom onset, clot location, and patient selection criteria. Despite its efficacy, endovascular thrombectomy requires specialized infrastructure, trained neurointerventional teams, and rapid patient transport to comprehensive stroke centers. This intervention has fundamentally transformed acute stroke management, establishing mechanical thrombectomy as a cornerstone therapy for large vessel occlusions. Widespread adoption continues to expand access to this life-saving treatment, though geographic and resource limitations remain challenges in some regions.

Giant cerebral aneurysms (GCAs), defined as those measuring 25 millimeters or larger in diameter, represent a rare but clinically serious subset of cerebral aneurysms, comprising approximately 2–5% of all cases. These lesions predominantly affect older adults with a female predominance and are associated with disproportionately high morbidity and mortality rates, with annual rupture risk exceeding 6% and untreated cases showing mortality rates reaching 65% within two years. Key rupture predictors include aneurysm size, irregular morphology, anterior communicating artery location, smoking status, and younger age. Posterior circulation GCAs demonstrate approximately 50% five-year cumulative rupture rates compared to 40% in anterior circulation. Contemporary treatment approaches have shifted from traditional microsurgical options toward neuroendovascular techniques, with flow diversion and parent artery occlusion now serving as primary treatment modalities. These techniques enable personalized, anatomy-specific management for complex aneurysms not amenable to vessel-preserving strategies. Treatment planning must comprehensively assess aneurysm morphology, wall characteristics including thrombosis and calcification, collateral circulation, and stability indicators such as perianeurysmal edema and mural enhancement patterns.

Galaxy Therapeutics has obtained CE mark approval from the European Medical Device Regulation for its Seal embolization system, following assessment by German notified body DQS Medizinprodukte. This milestone enables commercialization across the European Economic Area and validates compliance with EU requirements for quality management, safety, and clinical performance. The company now plans phased market introduction across selected European territories while pursuing FDA premarket approval in the United States. The Seal system represents a novel intrasaccular approach designed for endovascular treatment of ruptured and unruptured wide-neck intracranial aneurysms, developed to simplify complex aneurysm procedures across diverse anatomies. Developed through years of clinical investigation including the rapid-enrolling SEAL IT investigational device exemption trial in the US, the technology addresses significant physician challenges in treating complex cerebral aneurysms. CEO Sam Zaidat characterized the approval as Galaxy's most significant achievement, emphasizing that it delivers innovative treatment options to European physicians and patients seeking alternatives for managing complex brain aneurysms.

Cerebral aneurysms pose significant health risks, with undetected cases at risk of progressive expansion and potentially fatal rupture. Researchers demonstrated the capability of Magnetic Particle Imaging (MPI) to monitor blood flow in aneurysms with millisecond temporal resolution using patient-specific CT data and artificial artery phantoms. The study compared MPI measurements in untreated aneurysm models with those containing flow diverter stents, which are an established endovascular treatment designed to redirect blood away from the aneurysm and promote clot formation. MPI employs magnetic nanoparticles as tracers to track bolus movement through vascular structures with exceptional temporal and spatial precision. The results reveal MPI's promising potential for detecting and quantifying hemodynamic changes in both untreated and treated aneurysms, offering valuable insights for future clinical applications. This advancement addresses a critical need in aneurysm management by enabling detailed assessment of treatment efficacy, particularly for flow diverter stent placement, potentially improving patient outcomes through better visualization of blood flow dynamics.