Large Cores, Distal Vessels, Rural Reach: Biplane Weekly No. 8

Large-core randomised trials such as SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT and TENSION mostly enrolled ASPECTS 3–5. LASTE is the main randomised source that also included ASPECTS 0–2, so the extensive-infarct end of the range still rests on few randomised patients. This analysis of the German Stroke Registry–Endovascular Treatment (23 centres, 2015–2023) looked at thrombectomy-treated patients with baseline ASPECTS 0–5. Of 1,155 such patients, 1,050 had an anterior-circulation occlusion (ICA, M1 or M2), and 889 were analysed: 89 with ASPECTS 1–2 and 800 with ASPECTS 3–5. No patient had ASPECTS 0.

Crude outcomes were numerically worse with ASPECTS 1–2, but none of the differences was significant: mRS 0–3 at 90 days 20.2% versus 28.5%, and mortality 55.1% versus 45.4%. After adjustment, the common odds ratio for the extensive-infarct group was 0.80 (95% CI 0.53–1.23). That interval still allows a clinically relevant prognostic penalty. Successful reperfusion (mTICI 2b–3) was associated with better outcome (common odds ratio 3.68, 2.31–5.85). It was achieved in 73 of 88 patients (83.0%) with ASPECTS 1–2. Symptomatic intracranial haemorrhage was 5.8% versus 6.6%.

Every patient was treated, so the study describes prognosis after thrombectomy. It cannot show whether thrombectomy beats medical management at ASPECTS 1–2, and the 89 patients in that group were selected by their treating teams. What it does show is that in this selected group reperfusion was achieved in most patients, without a clear excess of symptomatic haemorrhage.

DISTAL randomised patients with medium or distal vessel occlusion to thrombectomy plus best medical treatment or to medical treatment alone. It found no overall benefit on 90-day disability, as did ESCAPE-MeVO. This post hoc analysis asks whether that neutral average hides patients who differ in their response. A machine-learning model was trained on medical-treatment-only patients in the Bernese Stroke Registry to predict early excellent neurological outcome without thrombectomy (NIHSS 0–2 at 24 hours). The model was then applied to the 539 DISTAL patients. Its external discrimination was moderate (AUC 0.73).

The 152 patients predicted to do well on medical treatment alone had a worse 90-day mRS distribution with thrombectomy (common OR 0.48, 95% CI 0.27–0.84). The 387 predicted not to do well showed no difference (1.13, 0.79–1.60), with an interaction P value of 0.012. Admission NIHSS of 4 or less split the cohort almost identically (common OR 0.47, 0.25–0.89), so the model adds little beyond the bedside examination.

The subgroup is post hoc and model-defined, and no safety data are reported that would explain the result. The direction is still notable: in this subgroup the analysis raises the possibility of harm from thrombectomy, not merely of no benefit.

In rural Southeast Bavaria, the TEMPiS telemedicine network compared two routes to thrombectomy for large vessel occlusion. Either a flying intervention team treated patients at the regional hospital, or patients were transferred to a tertiary centre. The same network reported the time saving in JAMA in 2022. This retrospective cohort of prospectively collected data adds outcome and cost-utility data for 492 patients, 322 treated by the flying team and 170 transferred.

Median decision-to-groin time was 69 minutes with the flying team and 140 minutes with transfer. The ordinal 90-day mRS distribution did not differ significantly (P=0.271). The pre-specified dichotomy of mRS 0–3 versus 4–6 favoured the flying team, with an odds ratio of 1.50 (95% CI 0.99–2.28; P=0.048). In the exploratory cost-utility analysis, the flying team gained 0.291 modelled lifetime QALYs per patient (−0.109 to 0.711), an interval that includes no gain.

A saving of more than an hour is the robust finding. The outcome difference rests on a secondary cut at the edge of significance. The case for moving the operator rather than the patient therefore rests on time to groin puncture (median 69 versus 140 minutes), and not yet on proven better recovery. The authors call for prospective evaluation.

Intracranial atherosclerotic stenosis underlies an estimated 7% to 40% of large vessel occlusions, with a disproportionately higher prevalence in Asian, Black and Hispanic populations. It is also the setting where reocclusion after thrombectomy is common, affecting nearly half of cases in the studies cited. The Society of Vascular and Interventional Neurology has now issued a brief practice update and consensus statement. It is a US society document, not an ESO or ESMINT guideline.

The writing group considers stent retriever and direct aspiration both acceptable first-line strategies, but notes that durable recanalisation is achieved in only about half of cases. Observational studies associated adjunctive glycoprotein IIb/IIIa inhibition, balloon angioplasty and rescue stenting with better recanalisation and outcomes, without clear excess haemorrhage. The group rates that evidence as weak and advises individualising treatment by presentation, imaging and operator expertise.

The one randomised test is less clear-cut. In ANGEL-REBOOT, bailout angioplasty or stenting led to more intracranial haemorrhage and arterial dissection without better 90-day outcomes, although heavy tirofiban use in both arms may have blunted any difference. At one year the statement reports delayed functional benefit and less recurrent stroke in the treated artery, and it says rescue stenting may improve durability in carefully selected small-core patients. Until further trials report, rescue stenting is a judgement for the individual reocclusion.

Carotid dissection, trauma and fibromuscular dysplasia are different diseases from atherosclerotic stenosis, and the evidence for TCAR in them is thin. This analysis of the North American Vascular Quality Initiative (2017–2024) compared 541 TCAR with 2,348 transfemoral carotid stenting procedures for non-atherosclerotic disease, excluding atherosclerosis and restenosis. Propensity matching produced 527 pairs.

After matching, perioperative stroke was 1.7% with TCAR and 4.4% with transfemoral stenting (P=0.0118). Death was 0.4% versus 4.4% (P<0.001), and stroke or death 1.9% versus 7.6% (P<0.001). Contrast volume and fluoroscopy time were lower with TCAR. For dissection, unadjusted stroke or death was 1.9% with TCAR and 7.1% with transfemoral stenting.

The death difference is the clue. A gap in perioperative death of 0.4% versus 4.4% between two access routes is more plausibly explained by who was treated, such as injured or unstable patients stented transfemorally, than by flow reversal itself, and the reasons for each route are not reported. These are North American vascular-surgery registry data. For a dissection that needs stenting, they support considering flow reversal where it is available, but do not show that it is safer.

Thrombocytopenia complicates the management of chronic subdural haematoma, and the randomised embolisation trials were not designed around it. This TriNetX analysis made three propensity-matched comparisons in adults with platelets below 100×10⁹/L, with 147 to 373 patients per matched group and 90-day all-cause mortality as the primary outcome.

In the comparison of MMA embolisation alone with medical management, mortality was 26.9% versus 37.3% (HR 0.65, 95% CI 0.50–0.85). For surgery plus embolisation versus surgery alone, it was 20.5% versus 30.7% (HR 0.61, 0.38–0.97). In the severe subgroup with platelets below 50, mortality was 34.2% versus 44.0% (HR 0.72, 0.49–1.05), and this difference was not significant. Surgical evacuation rates did not differ in any comparison.

That combination is the problem. All-cause death was about a third lower with embolisation, but the need for evacuation did not change, in a population where more than a quarter die within 90 days. A plausible explanation is that fitter patients were selected for embolisation. Electronic health records cannot separate the two, and no procedural complication rates are reported. The result therefore does not settle whether embolisation is safe at low platelet counts.

Contour and the Woven EndoBridge are both intrasaccular devices for cerebral aneurysms. This study matched 277 Contour cases from ten European centres with cases from the WorldWideWEB Consortium, which held 1,363 WEB cases before matching. The aneurysms were mostly small and unruptured.

Complete occlusion did not differ (OR 1.01, 95% CI 0.67–1.52), and neither did adequate occlusion (0.85, 0.41–1.76) or thromboembolic complications (0.75, P=0.452). Estimates for good functional outcome (mRS 0–2: OR 0.48, 0.21–1.02, P=0.064) and retreatment (OR 2.23, P=0.086) did not reach significance. Before matching, the Contour cohort contained fewer acute subarachnoid haemorrhages (10.8% versus 26.2%).

This is a comparison between two registries, with wide intervals. Its practical value is that it gives no occlusion-based reason to prefer one device over the other. Choice between them still rests on aneurysm geometry, sizing and operator familiarity.