The CSI-based 3-group categorization provides a more clinically meaningful assessment of PTIAs treated with FDs than conventional angiographic classifications, because it uniquely captures size changes of the thrombosed mass and correlates with functional outcomes.

Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

The FREDX device shows improved complete occlusion rates at 1 year compared with the FRED device while maintaining a favourable safety profile, indicating its potential advantage in the treatment of cerebral aneurysms.

p64/p48 MW HPC flow diverters with prasugrel single antiplatelet therapy were associated with safety from aneurysm re-rupture and high occlusion rates at medium- and long-term follow-up in managing ruptured aneurysms. Adequate management of single antiplatelet therapy with prasugrel is crucial, particularly with higher doses than usual, to avoid both ischemic and hemorrhagic complications.

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.

This case report, published in the Chinese Neurosurgical Journal in September 2026, documents a complex clinical scenario involving a recurrent perforator aneurysm of the A1 segment of the anterior cerebral artery. The patient had previously undergone endovascular electrocoagulation therapy, a minimally invasive technique designed to occlude the aneurysm through electrical coagulation delivered via catheter. Despite this initial intervention, the aneurysm recurred, necessitating a more definitive surgical approach. The clinical team elected to perform surgical clipping, the traditional open neurosurgical technique involving direct microsurgical access to place a clip across the aneurysm neck. This case illustrates an important clinical challenge in cerebrovascular surgery: treatment failure and recurrence following endovascular approaches, particularly in anatomically difficult locations such as perforator vessels. The report highlights the ongoing role of conventional microsurgical techniques as a salvage strategy when less invasive interventions prove inadequate, emphasizing the need for careful patient selection and multimodal treatment planning in managing recurrent intracranial aneurysms.

Perfuze announced final results from the MARRS pivotal study, published in the Journal of Neurointerventional Surgery, demonstrating strong efficacy for its Millipede Aspiration System in acute stroke treatment. The prospective, multicenter trial enrolled 180 patients across 22 hospitals in the United States and Europe, with all imaging and safety endpoints independently adjudicated. The study met its primary endpoint, achieving successful reperfusion (mTICI 2b-3) in 89% of patients without rescue therapy, exceeding the prespecified performance goal. Notably, the Millipede88 super-bore aspiration catheter delivered a 75% first-pass effect in middle cerebral artery M1 occlusions with 96% delivery success, representing the highest first-pass rates reported in a prospective thrombectomy study. The device demonstrated a favorable safety profile with 2.3% symptomatic intracranial hemorrhage, no vessel perforations, and no device-related serious adverse events. Rescue therapy was required in fewer than 8% of cases. The results support the FDA 510(k) clearance of the Millipede88, utilizing Perfuze's patented Corrugated technology to maintain aspiration force and enable standalone direct aspiration without adjunctive devices in most cases.

# Professional Summary A comprehensive subgroup analysis of the ECOSA registry examined the safety, efficacy, and angiographic outcomes of endovascular coiling for very small unruptured intracranial aneurysms measuring 3mm or smaller. This study, led by Yazan Ashouri and colleagues across multiple institutions, evaluated treatment approaches including balloon-assisted coiling and stent-assisted coiling techniques for this challenging patient population. The research integrated findings with established risk stratification tools such as the PHASES score and ISUIA natural history data to contextualize procedural outcomes. This analysis is clinically significant as it addresses a critical evidence gap regarding optimal management strategies for very small aneurysms, where treatment decisions traditionally involve careful consideration of rupture risk versus intervention-related morbidity. By providing detailed safety and efficacy data from a large multicenter registry, this work informs clinical decision-making for neurointerventionalists managing patients with diminutive aneurysms and contributes to the evidence base for personalizing treatment recommendations based on individual patient risk profiles and anatomical characteristics.

Mechanical thrombectomy has revolutionized acute ischemic stroke treatment by enabling the physical removal of blood clots from cerebral vessels. This comprehensive review examines the current evidence landscape and future trajectory of the field. The article traces the evolution of mechanical thrombectomy techniques and highlights significant advances in patient selection strategies and imaging protocols that have improved treatment outcomes. A key focus area is the expanding application of thrombectomy to more distal vessel occlusions, which were previously considered beyond the reach of intervention. The review also addresses ongoing technical developments that continue to enhance procedural efficacy and safety. Understanding where the evidence currently stands is critical for clinicians making treatment decisions, while insights into emerging directions—such as improved patient identification criteria and extended anatomical reach—promise to further optimize outcomes and potentially expand the eligible patient population for this life-saving intervention.

Activase (alteplase), a thrombolytic agent used in acute ischemic stroke treatment, carries significant risks that require careful clinical management. The medication can cause severe internal or external bleeding, particularly at arterial and venous puncture sites, with fatal hemorrhage cases reported following traumatic intubation. While heparin and aspirin have been used concomitantly with Activase in myocardial infarction and pulmonary embolism management, their concurrent use with Activase for acute ischemic stroke within 24 hours of symptom onset remains uninvestigated, necessitating vigilant bleeding monitoring. Hemorrhage risk is substantially elevated in patients with recent major surgery, cerebrovascular disease, intracranial hemorrhage, gastrointestinal or genitourinary bleeding, trauma, hypertension, hepatic or renal dysfunction, pregnancy, diabetic retinopathy, or those receiving oral anticoagulants. Additionally, hypersensitivity reactions including urticarial responses, anaphylaxis, and angioedema have been documented, with rare fatal outcomes reported. Close patient monitoring during and after Activase infusion is essential to detect and manage bleeding complications and hypersensitivity reactions promptly, ensuring therapeutic benefits outweigh inherent risks.

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 alongside complications including distal embolization and recurrent thrombosis. Researchers from ORDOS Central Hospital developed and tested the RESCUE technique—a novel stepwise endovascular strategy incorporating retrievable stent deployment, tirofiban infusion, and microcatheter-guided extraction—against the standard Solumbra technique in a prospective randomized trial of 85 patients. The RESCUE group demonstrated superior first-pass reperfusion rates of 86.0% compared to 61.9% with Solumbra, achieving modified Thrombolysis in Cerebral Infarction grade 2c-3 scores significantly more frequently. Additionally, RESCUE procedures required substantially shorter operative duration—median 40 minutes versus 60 minutes—without compromising safety. Both techniques yielded comparable favorable 90-day functional outcomes and similar safety profiles regarding symptomatic intracranial hemorrhage and mortality. These findings suggest RESCUE represents a promising lesion-specific approach for this challenging patient population, warranting larger multicenter validation studies.

This editorial by Wang and Wan examines recent advances in flow diverter interventions for treating complex intracranial aneurysms. Flow diverters represent a significant innovation in endovascular neurosurgery, offering minimally invasive alternatives to traditional surgical approaches for managing difficult-to-treat aneurysms. The publication, appearing in Frontiers in Neurology in 2026, synthesizes current knowledge on flow diverter techniques, their clinical applications, and patient outcomes. Key topics covered include stent-assisted therapy approaches, antiplatelet therapy protocols essential for preventing thrombotic complications, and strategies for complication prevention during interventional procedures. The work emphasizes the importance of understanding both the technical aspects of device deployment and the medical management required to optimize patient safety and efficacy. These advances have meaningful implications for neurovascular specialists, as improved flow diverter techniques and refined treatment protocols expand the population of aneurysm patients who can be treated safely, potentially reducing morbidity and mortality associated with complex intracranial aneurysms.

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.