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Background Recent advances in endovascular devices have allowed access and targeting of perivascular tissues of the peripheral circulation. The perivascular tissues of the cervical and cranial circulations have many important structures of clinical significance, yet the feasibility and safety of such an approach has not been demonstrated. Objective To evaluate the safety of a novel endovascular transmural approach to target the perivascular tissues of the common carotid artery in swine. Methods A micro- infusion device was positioned in the carotid arteries of three Yorkshire pigs (six carotid arteries in total), and each carotid artery was punctured 10 times in the same location to gain access to the perivascular tissues. Digital subtraction angiography was used to evaluate vessel injury or contrast extravasation. MRI and MR angiography were used to evaluate evidence of cerebral ischemia or vessel injury. Postmortem tissue analysis was performed to assess the level of extravascular hematoma and intravascular dissection. Results None of the tested carotid arteries showed evidence of vessel injury (dissection or perforation) or intravascular thrombosis. MRI performed after repeated puncture was negative for neck hematoma and brain ischemia. Post- mortem tissue analysis of the carotid arteries showed mild adventitial staining with blood, but without associated hematoma and without vessel dissection. Conclusion Repeated puncture of the carotid artery to gain access to the perivascular tissues using a novel endovascular transmural approach is safe in a swine model. This represents a novel approach to various tissues in close proximity to the cervical and cranial vasculature. [ABSTRACT FROM AUTHOR]

Background Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases. Objective To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity. Methods The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity. Results 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016--2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%. Conclusion There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals. [ABSTRACT FROM AUTHOR]

Background Malignant gliomas continue to have a poor clinical outcome with available therapies. In the past few years, new targeted biologic therapies have been studied, with promising results. However, owing to problems with ineffective IV delivery of these newer agents, an alternative, more direct delivery mechanism is needed. Simultaneously, advancements in neuroendovascular technology have allowed endovascular selective intra-arterial approaches to delivery. This method has the potential to increase drug delivery and selectively target tumor vasculature. Objective To review the history of IA therapy for brain tumors, prior failures and successes, the emergence of new technologies and therapies, and the future direction of this young field. Methods A comprehensive literature search of two databases (PubMed, Ovid Medline) was performed for several terms including 'brain tumor', 'glioma', and 'endovascular intra-arterial'. Forty-five relevant articles were identified via a systematic review following PRISMA guidelines. Additional relevant articles were selected for further in-depth review. Emphasis was given to articles discussing selective intra-arterial intracranial delivery using microcatheters. Results Endovascular intra-arterial therapy with chemotherapy has had mixed results, with currently active trials using temozolomide, cetuximab, and bevacizumab. Prior attempts at IA chemotherapy with older-generation medications did not surpass the efficacy of IV administration. Advances in neuro-oncology have brought to the forefront new targeted biologic therapies. Conclusions In this review, we discuss the emerging field of endovascular neuro-oncology, a field that applies modern neuroendovascular techniques to the delivery of new therapeutic agents to brain tumors. The development of targeted therapies for brain tumors has been concurrent with the development of microcatheter technology, which has made superselective distal intracranial arterial access feasible and safe. [ABSTRACT FROM AUTHOR]

Background The pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA. Methods Institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study. Results 10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up. Conclusions The PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection. [ABSTRACT FROM AUTHOR]

Background Anterior choroidal artery (AChA) aneurysms represent a small subset of cerebral aneurysms. The Pipeline Embolization Device (PED) has been successfully applied to various aneurysms of the supraclinoid internal carotid artery (ICA). The treatment of these aneurysms requires special attention due to the eloquent territory supplied by the AChA. We report the largest and first dedicated series of flow diversion treatment of AChA aneurysms. Methods Four institutional neurointerventional databases were reviewed for cases of intracranial aneurysms treated with PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of AChA aneurysms treated with PED. AChA aneurysms were defined as aneurysms distal to the AChA and proximal to the ICA terminus, with or without the incorporation of the AChA. Results Eighteen AChA aneurysms were treated during the study period. All aneurysms were successfully treated with a mean follow-up of 19.1 months. The large majority of aneurysms (15/18, 83.3%) were completely obliterated. No patients suffered from intra- or post-procedural complications. A1 stenosis was a common occurrence, seen in 10 of 16 (62.5%) covered anterior cerebral arteries (ACAs), although all were asymptomatic. All AChAs remained patent at last follow-up. Conclusions The PED can be used successfully in AChA aneurysms with a good safety and efficacy profile. All AChAs remained patent. Collateral flow networks, especially for the ACA, affect long-term branch vessel patency. Treatment with PED for AChA aneurysms appears to be a reasonable option to consider and should be evaluated in a larger cohort. [ABSTRACT FROM AUTHOR]

Aim To explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT). Methods We retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008-2013/2010-2013). Sixty patients selected by MRI or CT perfusion presenting within <24 h of onset with modified Thrombolysis In Cerebral Infarction (mTICI) grade 3 or 2c reperfusion were included. Significant infarct growth (SIG) was defined as infarct expansion >11.6 mL. Results Mean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7 ±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG. Conclusions Despite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion. [ABSTRACT FROM AUTHOR]

We report a case of visual deterioration after Onyx HD 500 embolization of a left 7 mm superior hypophyseal artery (SHA) aneurysm. After the procedure, the patient experienced a right incongruous homonymous hemianopia, and MRI showed an infarct of the ipsilateral optic chiasm/tract but no evidence of aneurysm mass effect or embolic cortical infarcts. The optic pathway ischemia is believed to be secondary to Onyx penetration and occlusion of an SHA branch near the aneurysm neck. Caution is advised when using liquid embolic agents to treat SHA aneurysms as SHA occlusion may lead to visual deficits. [ABSTRACT FROM AUTHOR]

Background: Sympathetic-mediated vasoconstriction from the superior cervical ganglion (SCG) is a significant contributor to cerebral vasospasm. Inhibition of the SCG has been shown to improve cerebral blood flow and reverse cerebral vasospasm in swine models. We evaluated the efficacy of a novel minimally invasive endovascular approach to target and pharmacologically inhibit the SCG, using a Micro-Infusion Device for transmural drug delivery., Methods: Eight SCGs in four Yorkshire swine were surgically identified. After confirming appropriate sympathetic-mediated intracranial vasoconstriction response with SCG stimulation, an endovascular Micro-Infusion Device was used for transmural targeting of the SCG and delivery of 1.5-2 mL of 1% lidocaine-contrast mixture to the perivascular space. Digital subtraction angiography was obtained at: (1) baseline; (2) with SCG stimulation; and (3) after lidocaine delivery to the SCG using the Micro-Infusion Device with concurrent SCG stimulation. Vessel diameters were measured and compared., Results: Endovascular transmural delivery of lidocaine to the SCG and carotid perivascular tissue using the Micro-Infusion Device successfully inhibited sympathetic-mediated vasoconstriction response. Measured vessel diameters after lidocaine delivery were comparable to baseline despite SCG stimulation., Conclusion: A novel endovascular technique of transmural delivery of lidocaine to the SCG and carotid artery perivascular tissues successfully inhibits the sympathetic input to the cerebral vasculature and modulates sympathetic-mediated cerebral vasospasm. These results suggest promising steps towards translation to potential clinical use for patients suffering from cerebral vasospasm., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)