Nebiyat F. Belachew, MD

🚨 New trial alert! 🧠 For patients with late-window ischemic stroke (4.5-24 hours) due to a proximal middle cerebral artery (MCA) occlusion, does bridging with IV tenecteplase before endovascular treatment (EVT) improve outcomes? The TNK-PLUS RCT says no. ❌ Functional independence at 90 days was achieved by 44.2% of patients in the tenecteplase + EVT group versus 43.2% in the EVT alone group, showing no significant difference 📉. Ultimately, administering intravenous tenecteplase before EVT did not improve clinical outcomes compared to EVT alone in this time window. ⏱️🩸 #Stroke #Neurology #TNKPLUS #MedTwitter #ClinicalTrials Reference: Xiong Y, Che F, Wang H, et al. Intravenous Tenecteplase Prior to Endovascular Treatment for Ischemic Stroke at 4.5 to 24 Hours: The TNK-PLUS Randomized Clinical Trial. JAMA. Published online May 8, 2026. doi:10.1001/jama.2026.4292. doi.org/10.1001/jama.2026.42…

🚨 New Results from the EMMA-Can Randomized Clinical Trial! 🧠 Can we reduce the high recurrence rates of chronic subdural hematoma (cSDH)? The newly published EMMA-Can trial evaluated adjunctive embolization of the middle meningeal artery (EMMA) alongside standard surgical drainageacross 9 Canadian centers. 📊 Key 90-Day Outcomes: 📉 Symptomatic recurrence dropped by 6.5X: only 4.3% in the EMMA group vs. 28% with surgery alone. 🧠 Radiographic recurrence was also much lower: 14% for EMMA vs. 49.5% for the control group. ✅ Safety profile: Mortality and adverse event rates were similar between groups, and no serious adverse events or deaths were attributed to the EMMA procedure. 💡 The Takeaway: Performing EMMA with a liquid embolic agent within 72 hours of surgery is a safe and highly effective strategy to prevent cSDH recurrence compared to relying on surgery alone. #Neurosurgery #ClinicalTrials #EMMACan #MedicalResearch #Neurology Thoughts: 1) The data support that cSDH are vascular in origin. cSDH are a common encountered neurological entities with an aging population. 2) At our center we have unpublished data that SDH recurrence after craniotomy SDH evac surgery can be as high as 20% prior to MMA embolization. Recurrence was highest in those on chronic anticoagulation compared to those without anticoagulation. 3) If you talk to a neurosurgeon who does craniotomy and drainage of cSDH, they describe a hypervascular membrane being present that they try to remove as much as possible in a craniotomy flap. This along with some other studies about VEGF elevation support this “cSDH vascular hypothesis” that is treated by embolization. Comment: I once had a paper about subdural hematomas rejected by the typical major journals around this vascular SDH concept. Finally a good journal and reviewer asked “are cSDH really vascular ?” We said yes and provided and cited some early literature around this concept. Thankfully the J Stroke and Cerebrovascular journal published it ! 🎉 :-) PMID: 32434727 Source: Shankar J et al Management of Chronic Subdural Hematoma With Adjunctive Embolization of Middle Meningeal Artery: The EMMA-Can Randomized Clinical Trial jamanetwork.com/journals/jam… doi:10.1001/jama.2026.4910