Comparative effectiveness of combined antiplatelet treatments in acute minor ischaemic stroke

Background No study has thoroughly compared the effectiveness of combined antiplatelet treatments(other than clopidogrel–aspirin)versus clopidogrel–aspirin or aspirin alone for early secondary prevention in acute ischaemic stroke.Methods We identified patients with acute,minor,non-cardiogenic ischaemic stroke treated with aspirin alone,clopidogrel–aspirin or other combination treatment.Propensity scores considering the inverse probability of treatment weighting were used to adjust for baseline imbalances.The primary outcome was the composite of all strokes(ischaemic or haemorrhagic),myocardial infarction and all-cause mortality at 3 months.Results Among 12234 patients(male:61.9%;age:65.5±13 years)who met the eligibility criteria,aspirin,clopidogrel–aspirin and other combination treatments were administered in 52.2%,42.9%and 4.9%of patients,respectively.In the crude analysis,the primary outcome event at 3 months occurred in 14.5%of the other combination group,14.4%of the aspirin group and 13.0%of the clopidogrel–aspirin group.In the weighted Cox proportional hazards analysis,the 3-month primary outcome event occurred less frequently in the clopidogrel–aspirin group than in the other combination group(weighted HR:0.82(0.59–1.13)),while no association was found between the aspirin group(weighted HR:1.04(0.76–1.44))or other combination group and the 3-month primary outcome.Conclusion Other combined antiplatelet treatment,compared with aspirin alone or clopidogrel–aspirin,was not associated with reduced risks of primary composite vascular events or recurrent stroke during the first 3 months after stroke.Therefore,the results suggest that other combination treatments,particularly the cilostazol-based combination,may not be effective alternatives for clopidogrel–aspirin to prevent early vascular events in patients with acute minor stroke.Further exploration in clinical trials will be needed.

Gene panel for Mendelian strokes

background Mendelian stroke causes nearly 7% of ischaemic strokes and is also an important aetiology of cryptogenic stroke.Identifying the genetic abnormalities in Mendelian strokes is important as it would facilitate therapeutic management and genetic counselling.Next-generation sequencing makes large-scale sequencing and genetic testing possible.Methods A systematic literature search was conducted to identify causal genes of Mendelian strokes,which were used to construct a hybridization-based gene capture panel.Genetic variants for target genes were detected using Illumina HiSeq X10 and the Novaseq platform.The sensitivity and specificity were evaluated by comparing the results with Sanger sequencing.results 53 suspected patients of Mendelian strokes were analysed using the panel of 181 causal genes.According to the American College of Medical Genetics and Genomics standard,16 likely pathogenic/variants of uncertain significance genetic variants were identified.Diagnostic testing was conducted by comparing the consistency between the results of panel and Sanger sequencing.Both the sensitivity and specificity were 100%for the panel.Conclusion This panel provides an economical,time-saving and labour-saving method to detect causal mutations of Mendelian strokes.

Recovery of injured corticospinal tracts after late recanalisation of basilar artery occlusion

In this study,we performed emergency stent angioplasty in a patient with basilar artery occlusion(BAO)at 21 hours after onset.Serial diffusion tensor tract imaging revealed that the ischaemic corticospinal tracts(CSTs),which passed through pontine infarct,rapidly recovered to normal level even after delayed reperfusion.This case provided in vivo evidences that ischaemic white matter was still salvageable even after prolonged ischaemia.It also provided a new method(diffusion tensor tract imaging)and a novel therapeutic target(white matter)in the evaluation and treatment of acute BAO.

Clopidogrel loading dose versus maintenance dose to treat patients with acute ischaemic stroke in China(CLASS-China):results from a prospective double-blind randomised clinical trial

Aim The role of clopidogrel in treating patients with acute ischaemic stroke is unclear.We have conducted the clinical trial in order to evaluate the efficacy and safety of clopidogrel with a loading dose in treating patients with non-cardiogenic acute ischaemic stroke.Method Clopidogrel loading dose versus maintenance dose to treat patients with acute ischaemic stroke in China(CLASS-China)was a prospective,randomised,double-blind and placebo-controlled clinical trial in China.Patients with acute ischaemic stroke of non-cardiogenic origin within 48 hours of onset were enrolled and those received thrombolysis were excluded.Enrolled patients were divided into two treatment groups:loading dose and routine dose.The primary outcome was the incidence of stroke recurrence or progression within 7 days.Primary safety outcome was measured by life-threatening haemorrhage.An intent-to-treat analysis was used for the statistical analysis.results From March 2008 to March 2010,a total of 303 patients from 16 centres were recruited into this study;six were excluded because of lack of basic information.Since the enrolment was slow and the study drug expired in March 2010,this clinical trial was stopped earlier than planned.No significant baseline and demographic differences were seen between the two groups.There was no difference in primary outcome between the loading dosage group 16.1%(24/149)and control group 14.9%(22/148),respectively(p=0.782).The mortality and disability rate within 90 days in loading dose group(19.6%)was slightly lower than that in controlled group(23.4%),p=0.444.Loading dose group had two(1.3%)cases of fatal haemorrhage and control group had four(2.7%)within 90 days,p=0.674.No significant difference was detected in other adverse events between the groups.conclusion In our study stopped early due to slow enrolment,loading dose of clopidogrel does not reduce the risk of recurrent stroke.Future trials with sufficient number of patients enrolled are needed to re-examine this hypothesis.

Intra-arterial tenecteplase during thrombectomy for acute stroke(BRETIS-TNK II):rationale and design

Background Our recent pilot study suggests intra-arterial tenecteplase(TNK)during the first pass of endovascular treatment(EVT)seems safe,may increase first-pass reperfusion and good outcome in acute ischaemic stroke(AIS)patients with large-vessel occlusion(LVO).Aims To determine the efficacy and safety of intra-arterial TNK administration during EVT in AIS-LVO patients presenting up to 24 hours from symptom onset.Sample size estimates A maximum of 380 patients are required to test the superiority hypothesis with 80%power according to a two-side 0.05 level of significance,stratified by age,gender,baseline systolic blood pressure,prestroke modified Rankin Scale(mRS),baseline National Institute of Health stroke scale,baseline ASPECTS,time from onset to groin puncture,intravenous thrombolysis before EVT,stroke territory and stroke aetiology.Design Intra-arterial TNK during thrombectomy for acute stroke(BRETIS-TNK II)study is a prospective,randomised,adaptive enrichment,open-label,blinded end point,multicentre study.Eligible AIS-LVO patients are randomly assigned into the experimental group and control group with a ratio of 1:1.The experimental group will be treated with intra-arterial infusion of TNK during EVT.The control group will be treated with standard EVT.Outcome The primary end point is a favourable outcome,defined as an mRS score of 0–2 at 90 days.The primary safety end point is symptomatic intracranial haemorrhage within 48 hours,which is defined as an increase in the National Institutes of Health Stroke Scale score of≥4 points as a result of the intracranial haemorrhage.Conclusions The results of BRETIS-TNK II will provide evidence for the efficacy and safety of intra-arterial TNK administration during EVT in AIS patients with LVO.

Predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China:findings from the Chinese Stroke Center Alliance(CSCA)

Background and purpose Guidelines recommend dysphagia screening to identify those at high risk of pneumonia.However,little is known about the prevalence and predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China.Methods Using data from the Chinese Stroke Center Alliance,which is a multicentre,prospective,consecutive patient enrolment programme,univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with dysphagia screening and pneumonia during acute hospitalisation.Results Of 790811 patients admitted to 1476 hospitals,622718(78.7%)underwent dysphagia screening,and 64398(8.1%)developed pneumonia.Patients in stroke units were more likely to be screened for dysphagia than those not in stroke units(OR 1.50;95%CI 1.48 to 1.52),while patients with a past history of stroke were less likely to be screened(OR 0.87;95%CI 0.86 to 0.88).Dysphagia screening(OR 1.46;95%CI 1.30 to 1.65),dysphagia(OR 7.31;95%CI 7.15 to 7.46),and admission to stroke units(OR 1.17;95%CI 1.14 to 1.19)were significantly associated with a greater risk of pneumonia.Conclusions Dysphagia was a critical factor in the development of pneumonia.Nearly one in five patients with acute ischaemic stroke in the Chinese Stroke Center Alliance were not screened for dysphagia.Pneumonia prevention during acute hospitalisation is dependent not only on dysphagia screening but also on the effectiveness of subsequent dysphagia management interventions.Further studies are needed to elucidate the relationship between dysphagia screening,stroke unit care and pneumonia in patients with acute ischaemic stroke.

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry

Background and purpose Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment(EVT)for anterior circulation large vessel occlusion(AC-LVO)remains uncertain.This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry.Methods AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group.Off-hour(weekends,holidays,and 18:00-7:59 on weekdays)and on-hour(8:00-17:59 on weekdays except for holidays)were defined according to arrival and groin-puncture time points,respectively.Subgroup comparisons between patients both arrived and treated during off-hour(true off-hour)and on-hour(true on-hour)were performed.The primary outcome was the 90-day modified Rankin Scale(mRS)score.Secondary outcomes included favourable outcome(mRS 0-2 at 90 days),EVT-related time metrics,and other clinical outcomes.Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors.Results Of all 698 patients enrolled,435(62.3%)and 456(65.3%)patients were categorised into the off-hour arrival and off-hour puncture group,respectively.Shorter onset to door time(adjustedßcoefficient:−21.56;95%CI−39.96 to−3.16;p=0.022)was noted in the off-hour arrival group.Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions.Other time metrics and outcomes were comparable between the two groups.Of 595 patients both presented and were treated during off-hour or on-hour,394 patients were categorised into the true off-hour group and 201 into the true on-hour group.Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group.Conclusions The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.

Update in the treatment of intracranial atherosclerotic disease

This review highlights the recent evolution of the imaging,medical management,surgical options and endovascular therapies for symptomatic intracranial atherosclerotic disease(ICAD).Recent imaging developments including optical coherence tomography and other modalities to assess the intracranial arteries for symptomatic ICAD are reviewed,not only to diagnose ICAD but to determine if ICAD plaques have any high-risk features for treatment.Potential future developments in the treatment of ICAD are discussed,including the development of trackable drug-coated balloons for the cerebral circulation to treat primary or restenotic arteries,new iterations of self-expanding intracranial stents with easier delivery systems,and the re-examination of indirect surgical bypass techniques for revascularisation.In addition to these important technological developments,however,is the evolving evidence regarding the best treatment window for these techniques and additional factors in medical management which can improve patient outcomes in this devastating pathology.

Trendelenburg position for acute anterior circulation ischaemic stroke with large artery atherosclerosis aetiology(HOPES 3):rationale and design

Rationale The effect of the head position as a non-pharmacological therapy on acute ischaemic stroke(AIS)remains inconclusive.Our recent Head dOwn-Position for acutE moderate ischaemic Stroke with large artery atherosclerosis(HOPES 2)suggested the safety,feasibility and potential benefit of the head-down position(HDP)in AIS.Aim To investigate the benefit of HDP in acute moderate ischaemic stroke patients with large artery atherosclerosis(LAA).Sample size estimates Based on a two-sided 0.05 level of significance,600 patients are expected to yield the superiority hypothesis with 80%power,stratified by age,sex,history of diabetes,baseline systolic blood pressure,location of index vessel,National Institutes of Health Stroke Scale Score at randomisation,onset to randomisation time,progression to moderate neurological deficit due to early neurological deterioration and degree of responsible vessel stenosis.Design Head dOwn-Position for acutE moderate ischaemic Stroke with large artery atherosclerosis(HOPES 3)is a prospective,randomised,open-label,blinded endpoint and multicentre study.Eligible patients who had an ischaemic stroke will be randomly assigned(1:1)into the HDP group receiving-20°Trendelenburg plus standard medical care in compliance with national guidelines,or control group only receiving standard medical care in compliance with national guidelines.Outcome The primary outcome is favourable functional outcome,defined as modified Rankin Scale 0–2 at 90 days.Safety outcomes are HDP-related adverse events.All outcomes will have blinded assessment and will be analysed on the intention-to-treat basis.Conclusions The results of HOPES 3 will provide evidence for the effect of HDP in acute moderate ischaemic stroke patients with LAA within 24 hours of onset or in patients with progression from mild neurological deficit within 24 hours.Trial registration number NCT06010641.

Time to treat the climate and nature crisis as one indivisible global health emergency

Over 200 health journals call on the United Nations(UN),political leaders and health professionals to recognise that climate change and biodiversity loss are one indivisible crisis and must be tackled together to preserve health and avoid catastrophe.This overall environmental crisis is now so severe as to be a global health emergency.

Lesion-symptom mapping with NIHSS sub-scores in ischemic stroke patients

Background Lesion-symptom mapping(LSM)is a statistical technique to investigate the population-specific relationship between structural integrity and post-stroke clinical outcome.In clinical practice,patients are commonly evaluated using the National Institutes of Health Stroke Scale(NIHSS),an 11-domain clinical score to quantitate neurological deficits due to stroke.So far,LSM studies have mostly used the total NIHSS score for analysis,which might not uncover subtle structure–function relationships associated with the specific sub-domains of the NIHSS evaluation.Thus,the aim of this work was to investigate the feasibility to perform LSM analyses with sub-score information to reveal category-specific structure–function relationships that a total score may not reveal.Methods Employing a multivariate technique,LSM analyses were conducted using a sample of 180 patients with NIHSS assessment at 48-hour post-stroke from the ESCAPE trial.The NIHSS domains were grouped into six categories using two schemes.LSM was conducted for each category of the two groupings and the total NIHSS score.Results Sub-score LSMs not only identify most of the brain regions that are identified as critical by the total NIHSS score but also reveal additional brain regions critical to each function category of the NIHSS assessment without requiring extensive,specialised assessments.Conclusion These findings show that widely available sub-scores of clinical outcome assessments can be used to investigate more specific structure–function relationships,which may improve predictive modelling of stroke outcomes in the context of modern clinical stroke assessments and neuroimaging.

Treating supratentorial intracerebral haemorrhage: hopeless? Or rethink our strategy

Intracerebral haemorrhage(ICH)is the deadliest(40%)among all strokes.1 There are about 2 million ICHs annually worldwide,but effective treatment is still lacking.An ICH volume of<30 cm3 may have a 30-day mortality of 19%.2 Clinical research on treating ICH has been focusing on blood pressure control,haemostatic therapy,surgical evacuation of the clot and effective drainage of intraven-tricular blood.

Adenosine to facilitate the clipping of cerebral aneurysms:literature review

Cerebral aneurysms have a high mortality rate when ruptured.Endovascular techniques have improved substantially in treating this pathology.However,surgical clip ligation remains the preferred option for some aneurysms.Various techniques are used intraoperatively to assist the surgeon in dissecting the aneurysmal dome free of surrounding tissue and placing a clip around the neck safely and effectively so that no nearby perforating vessels are affected and no residual remains.These techniques include temporary clip ligation,endovascular balloon occlusion and cardiac standstill.Adenosine use is one viable option for induced cardiac arrest leading to a short period of controlled hypotension.Its predictable course of action,rapid onset and offset and rare incidence of adverse side effects make it an attractive agent in this regard.Below,we provide an introduction to adenosine use,describing its pharmacokinetic properties,indications,contraindications,complications and future directions.

Rationale and design of a randomised double-blind 2×2 factorial trial comparing the effect of a 3-month intensive statin and antiplatelet therapy for patients with acute mild ischaemic stroke or high-risk TIA with intracranial or extracranial atherosclerosis(INSPIRES)

Background It remains unclear if intensive antiplatelet and statin treatments begun within 24-72 hours of cerebral ischaemic events from intracranial or extracranial atherosclerosis is effective or safe.Methods The Intensive Statin and Antiplatelet Therapy for High-risk Intracranial or Extracranial Atherosclerosis(INSPIRES)trial is a randomised,double-blind,placebo-controlled,multicentre and 2×2 factorial trial.6100 individuals between the ages of 35 and 80 who have experienced a mild ischaemic stroke or high-risk transient ischaemic attack(TIA)within the previous 72 hours that is attributed to≥50%atherosclerotic stenosis of a major intracranial or extracranial artery or multiple infarctions of atherosclerotic origin will be enrolled in the trial.Eligible subjects will be randomised 1:1:1:1 to one of four groups:(1)intensive antiplatelet therapy(combined clopidogrel and aspirin for days 1-21,then aspirin placebo and clopidogrel for days 22-90)plus immediate intensive statin therapy(atorvastatin at a dose of 80 mg daily for the first 21 days,then 40 mg daily for days 22-90);(2)intensive antiplatelet therapy plus delayed intensive statin therapy(atorvastatin placebo for days 1-3,followed by 40 mg per day of atorvastatin for days 4-90);(3)standard antiplatelet therapy(combination of clopidogrel placebo with aspirin for 90 days)plus immediate intensive statin therapy and(4)standard antiplatelet therapy plus delayed intensive statin therapy.The primary efficacy endpoint is any new stroke(ischaemic or haemorrhagic)within 90 days after randomisation.The primary safety endpoint is moderate to severe bleeding at 90 days.Conclusion The INSPIRES trial will assess the efficacy and safety of intensive antiplatelet therapy and immediate intensive statin therapy begun within 72 hours of onset in decreasing the recurrent stroke at 90 days in patients with acute mild ischaemic stroke or high-risk TIA of intracranial or extracranial atherosclerosis origin.

Treating acute large vessel occlusion stroke:to bridge or not to bridge?

Hot debates exist regarding whether patients who had an acute large vessel occlusion stroke(LVOS)can skip tissue plasminogen activator(tPA)and go directly to thrombectomy in comprehensive stroke centres.Three head-to-head randomised clinical trials(RCTs)of direct endovascular treatment(dEVT)versus bridge therapy(BT)with intravenous alteplase have been recently completed in the Asian population.The DIRECT-MT(Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals:a Multicenter Randomized Clinical Trial)Study randomly enrolled 656 patients who had an acute ischaemic stroke with anterior circulation LVOS across 41 large teaching hospitals in China to receive BT or dEVT within 4.5 hours after symptom onset.

Tranexamic acid for acute intracerebral haemorrhage growth based on imaging assessment (TRAIGE): a multicentre, randomised, placebo- controlled trial

Background Studies show tranexamic acid can reduce the risk of death and early neurological deterioration after intracranial haemorrhage.We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in intracerebral haemorrhage patients susceptible to haemorrhage expansion.Methods We did a prospective,double-blind,randomised,placebo-controlled trial at 10 stroke centres in China.Acute supratentorial intracerebral haemorrhage patients were eligible if they had indication of haemorrhage expansion on admission imaging(eg,spot sign,black hole sign or blend sign),and were treatable within 8 hours of symptom onset.Patients were randomly assigned(1:1)to receive either tranexamic acid or a matching placebo.The primary outcome was intracerebral haematoma growth(>33% relative or>6 mL absolute)at 24 hours.Clinical outcomes were assessed at 90 days.Results Of the 171 included patients,124(72.5%)were male,and the mean age was 55.9±11.6 years.89 patients received tranexamic acid and 82 received placebo.The primary outcome did not differ significantly between the groups:36(40.4%)patients in the tranexamic acid group and 34(41.5%)patients in the placebo group had intracranial haemorrhage growth(OR 0.96,95% CI 0.52 to 1.77,p=0.89).The proportion of death was lower in the tranexamic acid treatment group than placebo group(8.1%vs 10.0%),but there were no significant differences in secondary outcomes including absolute intracranial haemorrhage growth,death and dependency.Conclusions Among patients susceptible to haemorrhage expansion treated within 8 hours of stroke onset,tranexamic acid did not significantly prevent intracerebral haemorrhage growth.Larger studies are needed to assess safety and efficacy of tranexamic acid in intracerebral haemorrhage patients.

Expert consensus on prevention and control of COVID-19 in the neurological intensive care unit(first edition)

During the COVID-19 epidemic,the treatment of critically ill patients has been increasingly difficult and challenging.During the epidemic,some patients with neurological diseases also have COVID-19,which could be misdiagnosed and cause silent transmission and nosocomial infection.Such risk is high in a neurological intensive care unit(NCU).Therefore,prevention and control of epidemic in critically ill patients is of utmost importance.The principle of NCU care should include comprehensive screening and risk assessment,weighing risk against benefits and reducing the risk of COVID-19 transmission while treating patients as promptly as possible.

Red blood cell distribution width and ischaemic stroke

The red blood cell distribution width(RDW)is a measure of red blood cell(RBC)size heterogeneity,which is easily calculated by dividing the SD of erythrocyte volumes for the mean corpuscular volume.Recent reporter suggested that,besides haematological diseases and anaemia,many human disorders may be closely associated with the elevated RDW.A literature review has revealed the RDW may be closely related to the development of ischaemic stroke,carotid artery atherosclerosis and cerebral embolism.Higher RDW could independently predict adverse outcomes in patients in these conditions.

Comparison of carotid endarterectomy and repeated carotid angioplasty and stenting for in-stent restenosis(CERCAS trial):a randomised study

Background and aim In-stent restenosis(ISR)belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis.Some of these patients might be contraindicated to repeat percutaneous transluminal angioplasty with or without stenting(rePTA/S).The purpose of the study is to compare the safety and effectiveness of carotid endarterectomy with stent removal(CEASR)and rePTA/S in patients with carotid ISR.Methods Consecutive patients with carotid ISR(≥80%)were randomly allocated to the CEASR or rePTA/S group.The incidence of restenosis after intervention,stroke,transient ischaemic attack myocardial infarction and death 30 days and 1 year after intervention and restenosis 1 year after intervention between patients in CEASR and rePTA/S groups were statistically evaluated.Results A total of 31 patients were included in the study;14 patients(9 males;mean age 66.3±6.6 years)were allocated to CEASR and 17 patients(10 males;mean age 68.8±5.6 years)to the rePTA/S group.The implanted stent in carotid restenosis was successfully removed in all patients in the CEASR group.No clinical vascular event was recorded periproceduraly,30 days and 1 year after intervention in both groups.Only one patient in the CEASR group had asymptomatic occlusion of the intervened carotid artery within 30 days and one patient died in the rePTA/S group within 1 year after intervention.Restenosis after intervention was significantly greater in the rePTA/S group(mean 20.9%)than in the CEASR group(mean 0%,p=0.04),but all stenoses were<50%.Incidence of 1-year restenosis that was≥70%did not differ between the rePTA/S and CEASR groups(4 vs 1 patient;p=0.233).Conclusion CEASR seems to be effective and save procedures for patients with carotid ISR and might be considered as a treatment option.

Use of pCONUS HPC for the treatment of unruptured wide- necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy

Background In recent years,a growing number of stents and stent-like devices have become available to facilitate the treatment of challenging aneurysms.However,the need for dual antiplatelet therapy can limit their use,especially in ruptured aneurysms.The hydrophilic polymer coating(pHPC,phenox)is a novel glycan-based multilayer polymer that reduces platelet adhesion.This study aims to report our initial experience using the pCONUS HPC device for the treatment of unruptured wide-necked bifurcation aneurysms(WNBA)using acetylsalicylic acid(ASA)as single antiplatelet therapy(SAPT).Methods We retrospectively identified all patients who were treated with the pCONUS HPC for unruptured WNBA in a multi-staged procedure using ASA as SAPT.Records were made of periprocedural complications,clinical outcome and angiographic and clinical follow-up.Results We identified 15 patients with 15 WNBA.The average age was 69 years old(range,41-76).Seven aneurysms were located in the middle cerebral artery,five in the anterior communicating artery,two at the basilar tip and one in the posterior communicating artery.Immediate post-treatment angiography showed five aneurysms with modified Raymond-Roy classification(mRRC)grade Ⅰ and four aneurysms with mRRC grade Ⅱ.There were no haemorrhagic complications.Four patients developed thrombus formation during the second treatment session,all of them completely resolving after administration of glycoprotein Ⅱb/Ⅲa antagonists.Angiographic follow-up data were available for 10 patients and showed adequate occlusion(mRRC Ⅰ or Ⅱ)in eight aneurysms(80%).In-stent stenosis was observed in one patient whereas two patients showed de novo stenosis in one of the efferent branches.Conclusions This early experience on the use of the pCONUS HPC device suggests that it can be useful for treating unruptured WNBA under ASA as SAPT.Further investigation with a randomised treatment registry and larger cohort is needed.