ADL Activities of daily living AIS Acute ischemic stroke(s) BCI Brain-computer interface(s) BGC Balloon guide catheter CSF Cerebrospinal uid CSFVF Cerebrospinal uid-venous stula

DEFUSE 3 Endovascular Therapy Following Imaging

Evaluation for Ischemic Stroke 3

DEVT Direct Endovascular Thrombectomy vs.

Combined IVT and Endovascular Thrombectomy for Patients with Acute Large Vessel Occlusion in the Anterior Circulation

ETCHES I Endovascular Treatment of

Communicating Hydrocephalus with the eShunt System

Endovascular Treatment for Acute Ischemic Stroke in the Netherlands

MR CLEAN-NO IV Multicenter Randomized Clinical trial of

Acute Stroke Due to Anterior Occlusion

Circulation Large Vessel Occlusion

Presenting within Eight Hours of

Acute LVO Stroke SWIFT PRIME Solitaire With the Intention For

Neurointervention is a thriving and dynamic specialty whose practitioners are actively forging new paths and championing rev­olutionary new therapies. Many of these procedures are providing minimally invasive treatment alternatives in lieu of historic open surgical options or adjunctive surgical therapies. In reection of the exponential growth potential, the number of trainees in neuro­intervention is also increasing to provide sufcient coverage and availability of these novel therapies to patients. Several challenges arise hand in hand with a constantly shifting landscape of innova­tive therapies and new devices for endovascular practitioners who must also be skilled in the systems- and practice-based implemen­tation of these advancements in patient populations. This chapter describes the benets and obstacles originating from this fast­paced environment, examines some of the newest procedures and training requirements, and discusses challenges facing the neuro­endovascular eld in pushing the frontier of cerebrovascular dis­ease treatment.

then, it took two decades to rmly establish the superiority of these techniques over medical therapy [1, 2]. As a joint effort within the global neurointervention community, the publication of multiple randomized trials in 2015 (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) dramatically changed the treatment scenario for AIS [3]. Mechanical throm­bectomy (MT) with stent retrievers became the gold standard treatment for AIS due to anterior large vessel occlusion (LVO) for patients presenting within early time windows. With the assis­tance of perfusion imaging, the MT window also rapidly changed toward the present 24-hour therapeutic window for selected patients based on the results of the DAWN and DEFUSE 3 trials published in 2018 [4–6]. Furthermore, the development of more exible and navigable large-bore distal aspiration catheters intro­duced equipoise between the use of these devices and the estab­lished stent retrievers, with subsequent randomized trials reporting noninferiority of one device over another [7]. Stent retrievers and distal aspiration catheters have undergone technological evolution to miniaturized and adjustable-expansion versions to keep up with ongoing debates about endovascular treatment of smaller vessels (i.e., distal and medium vessel occlusions). Present debates also exist regarding the use of newer generation balloon guide cathe­ters (BGCs) to arrest ow and minimize clot fragmentation and distal embolization, which have been largely adopted due to their better exibility, versatility, and navigability in comparison to older generation BGCs [8–13]. Although these few examples rep­resent the astounding technological advancement that requires trainees and operators to be up to date with their skills and options, there are even more radical paradigm shifts in discussion. The benet of intravenous thrombolysis, as aforementioned to have once been the rst-line treatment for all AIS, is now in question for LVO patients after the publication of the results of four ran­domized trials (SKIP, DEVT, DIRECT-MT, and MR CLEAN-NO IV) comparing MT alone versus MT plus intravenous alteplase [14–17]. All these robust changes not only create challenges to trainees, established operators, and researchers but also signal the evolution of the eld as a whole toward improving patient care through evidence-based practice.