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AimTo save brain cells in acute cerebral infarction by injecting hemoglobin oxygen carrier (HBOC) into the blood vessel blockage of the cerebral infarction site through a microcatheter.Methods120 male rats were divided into four groups: control (CTRL), ischemia (I), ischemia + low perfusion (I + LP), and ischemia + high perfusion (I + HP). Perfusion groups (ischemia, I + LP, and I + HP) underwent MCAO surgery with intraluminal monofilament. These groups were subdivided into 6 h, 12 h, and 24 h (n = 10/group). RT-PCR, Western-Blot, immunohistochemistry, and apoptosis assays were used to detect apoptosis, hypoxia range and extent, and ischemia.ResultsCompared with the I group, the neurological deficit sign scores of the I + HP group were statistically significant at 12 h. Compared with the I group, the neurological deficit sign scores of the I + LP group and the I + HP group were statistically significant at 24 h. At all time points, compared with the I group and the I + LP group, Caspase-3, HIF-1α, and Cytochrome C protein levels were significantly decreased in the I + HP group. Bcl-2 and BAX mRNA levels were also significantly decreased in the same group. TNF-α, IL-6, and IL-1β cytokines were significantly decreased in the I + HP group as well. The infarct size of rats in the I + HP group was smaller than that of the I + LP group, which was smaller than ischemia alone. Time of perfusion had an obvious effect as infarct size was smaller with longer perfusion. The number of Nissl stained cells in the I + HP group was increased compared with the ischemia and the I + LP group, and was proportional to the time of perfusion.ConclusionTime- and rate-controlled perfusion of HBOC to acutely occluded cerebral vascular regions through microcatheters can effectively protect ischemic brain tissue in rats.

Psychoceuticals have brought benefits to the pharmacotherapeutic management of central nervous system (CNS) illnesses since the 19th century. However, these drugs have potential side effects or lack high response rates. This review covers twenty drugs' biochemical mechanisms, benefits, risks, and clinical trial reports. For this study, medications from seven psychoceutical organizations were reviewed and evaluated. Nineteen drugs were chosen from the organizations, and one was selected from the literature. The databases used for the search were Pubmed, Google Scholar, and NIH clinical trials. In addition, information from the organizations' websites and other sources, such as news reports, were also used. From the list of drugs, the most common targets were serotonergic, opioid, and N-methyl-D-aspartate (NMDA) receptors. These drugs have shown promise in psychiatric illnesses such as substance abuse, post-traumatic stress disorder (PTSD), anxiety, depression, and neurological conditions, such as Parkinson's disease, traumatic brain injury, and neuroinflammation. Some of these drugs, however, are still early in development, so their therapeutic significance cannot be determined. These twenty drugs have promising benefits, but their clinical usage and efficacy must still be explored. [ABSTRACT FROM AUTHOR]

Transfemoral access for neurointerventions has been a time-tested technique of entering the vascular network of the body and reaching the intended targets. However, it has its own share of shortcomings in the form of long admission times leading to increased costs, patient inconvenience and local (though infrequent) adverse affects. Transradial route has taken the interventional cardiology domain by storm and is staring now at other vascular domains especially neurointervention. It has shown better outcomes than the transfemoral route in many aspects. The current article discusses the vascular access perspectives with an exhaustive overview of the transradial route concerning its historical perspectives, its requirement in the current clinical scenario, the procedure per se including the adverse effects and whether it has the real world charm to displace the transfemoral route into the backseat. Transradial access in neurointervention is here to stay, however it would require training, certain modifications in the standard catheters that one currently uses for cerebral procedures and constant practice by the operator to cross the learning curve and attain a certain level of competence before he becomes comfortable with the technique. [ABSTRACT FROM AUTHOR]

Background: Artifacts from surrounding bony structures, especially from the petrous bones, regularly impair soft tissue computed tomography (CT) imaging of the middle and posterior fossa. This affects flat-panel CT in particular. Sinusoidal movement of the C‑arm during acquisition (i.e. craniocaudal tilting along with semicircular rotation) is supposed to reduce artifacts, thus enhancing soft tissue imaging quality. Methods: In the work-up of ischemic stroke or subarachnoid hemorrhage 40 patients underwent multi-slice CT (MS-CT) and either plain circular (cFP-CT; n = 20) or sinusoidal (sFP-CT; n = 20) flat-panel CT within a short interval. Two independent readers analyzed MS-CT and FP-CT datasets for recognizability of eight different brain structures and three typical types of artifacts according to a predetermined score. Results: Interrater reliability was moderate for cFP-CT (κ = 0.575) and good to very good for ratings of MS-CT and sFP-CT (κ = 0.651 to κ = 1). MS-CT was rated to be significantly better than cFP-CT and sFP-CT (p < 0.0001) in the overall score. Yet, sFP-CT was rated to be significantly superior to cFP-CT (overall p < 0.0001) regarding most anatomical regions and petrous bone artifacts. Conclusion: Compared to a standard circular protocol, sinusoidal C‑arm movement in cranial FP-CT can significantly reduce artifacts in the posterior fossa and, moreover, can improve visualization of most supratentorial and infratentorial anatomical structures. [ABSTRACT FROM AUTHOR]

Recognition of neurovascular variants is crucial for safe endovascular and neurosurgical interventions. We aim to review and highlight various uncommon neurovascular variants and anomalies with a discussion of their relevant embryology and pathology.A retrospective review of a prospectively maintained neurovascular database was performed to identify uncommon neurovascular variants and anomalies. A pictorial review of these neurovascular findings is provided along with relevant embryological development, clinical significance, and potential pathological associations.A pictorial review of selected neurovascular variants and anomalies is presented. These entities, divided between intra- and extra-cranial findings, include infra-optic origin of the anterior cerebral artery, meningo-ophtalmic artery, duplicated posterior cerebral artery, duplicate middle cerebral artery (MCA), MCA fenestration, twig-like MCA, pure arterial malformation, corkscrew basilar artery, persistent hypoglossal artery, persistent trigeminal artery and its variants, direct branches from the common carotid and cervical internal carotid arteries (ICA) (ascending pharyngeal artery from the ICA, thyroidal arteries from the CCA/brachiocephalic, arteria thyroidea ima), and extra-cranial carotid fenestration. The angiographic findings of these entities are presented with relevant 3D reconstruction and multimodal cross-sectional imaging correlation when available.This pictorial review highlights uncommon neurovascular variants and anomalies that neuroradiologists, interventionalists, and neurosurgeons should be aware of for accurate diagnosis and safe interventions. [ABSTRACT FROM AUTHOR]

Diffuse neurofibroma of the head and neck are rare tumours which have unique clinical and radiological findings. Presurgical diagnosis is important as these lesions are usually highly vascular and pre-operative embolisation can reduce the risk of intra-operative haemorrhage. In this article we describe four cases; two which underwent pre-operative embolisation, which should aid the reader in successfully diagnosing this entity before biopsy/surgery. [ABSTRACT FROM AUTHOR]

• Suboptimal Compliance: only 42% adhered to follow-up despite patient education. • Specialist Care Matters: consulting UIA specialists improved compliance. • Insurance Influence: uninsured patients had decreased compliance. • Transition Challenges: shift from emergency to specialists led to non-compliance. • Non-Compliance Reasons: patient understanding, care transfer, and insurance status. Periodic imaging follow-up for patients with unruptured intracranial aneurysms (UIA) is crucial, as studies indicate higher rupture risk with aneurysm growth. However, few studies address patient adherence to follow-up recommendations. This study aims to identify compliance rates and factors influencing follow-up adherence. Patients with a UIA were identified from our institution's database from 2011-2021. Follow-up imaging (CT/MR Angiogram) was advised at specific intervals. Patients were categorized into compliant and non-compliant groups based on first-year compliance. Factors contributing to compliance were assessed through multivariate logistic regression. Phone interviews were conducted with non-compliant patients to understand reasons for non-adherence. Among 923 UIA diagnosed patients, 337 were randomly selected for analysis. The median follow-up period was 1.4 years, with a 42% first-year compliance rate. The mean aneurysm size was 3.3 mm. Five patients had a rupture during follow-up, of which 4 died. Compared with patients consulting specialists at the initial diagnosis, those seen by non-specialists exhibited lower compliance (OR 0.25, p < 0.001). Loss to follow-up was greatest during transition from emergency service to specialist appointments. Patients who spoke languages other than English exhibited poorer compliance than those speaking English (OR 0.20, p = 0.01). Significant amounts of UIA patients at low rupture risk were lost to follow-up before seeing UIA specialists. Main non-compliance factors include inadequate comprehension of follow-up instructions, poor care transfer from non-specialists to specialist, and insurance barriers. [ABSTRACT FROM AUTHOR]

We present the first case of endovascular treatment of a ruptured anterior circulation aneurysm via a transradial approach in a patient with undiscovered aortic coarctation (CoA).A 29 year old male patient presented to the emergency department with a 1 day history of sudden-onset headache and vomiting.CT and CTA confirmed presence of acute subarachnoid haemorrhage and an anterior communicating (ACOM) artery aneurysm.Transfemoral endovascular angiography with a view to coiling was performed, however resistance was encountered distal to the aortic arch. On-table chest radiography demonstrated bilateral inferior rib notching confirming suspicion of a CoA.The procedure was converted to transradial access. The ACOM aneurysm was successfully coiled.This case highlights several important learning number points with particular regard to the rising era of transradial neuroendovascular management.

Despite advances in transcatheter aortic valve replacement (TAVR), periprocedural acute ischemic stroke remains a concern. The aims of this study were to investigate acute ischemic stroke complicating TAVR (AISCT) and to describe the indications and outcomes of interventions to treat AISCT. An international multicenter registry was established focusing on AISCT within 30 days of TAVR. Stroke severity was assessed using the National Institutes of Health Stroke Scale. Primary outcomes were 1-year all-cause death and neurologic disability status at 90 days according to modified Rankin scale score. Of 16,615 TAVR procedures, 387 patients with AISCT were included (2.3%). Rates of 1-year death were 28.9%, 35.9%, and 77.5% in patients with mild, moderate, and severe stroke, respectively (P < 0.001). Although 348 patients were managed conservatively, 39 patients (10.1%) underwent neurointervention (NI) with either mechanical thrombectomy (n = 26) or thrombolytic therapy (n = 13). In a subanalysis excluding patients with mild stroke, there was no clear 1-year survival benefit for NI compared with conservative management (47.6% vs 41.1%, respectively; P = 0.78). In a logistic regression model controlling for stroke severity, NI was associated with 2.9-fold odds (95% CI: 1.2-7.0; P = 0.016) of independent survival at 90 days. AISCT carries significant morbidity and mortality, which is correlated with stroke severity. The present findings suggest that neurologic disability for patients with moderate or worse stroke could potentially be improved by timely intervention and highlight the importance of collaboration between cardiologists and neurologists to optimize AISCT outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Small studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT. Methods: A comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages. Results: A total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594). Conclusion: In this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population. [ABSTRACT FROM AUTHOR]

The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS. Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015–2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30 days of CAS. Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30 days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death. These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS. [ABSTRACT FROM AUTHOR]

Purpose: Spinal dural arteriovenous fistulas (SDAVFs) represent the most common indication for a spinal angiography. The diagnostic reference level (DRL) for this specific endovascular procedure is still to be determined. This single-center study provides detailed dosimetrics of diagnostic spinal angiography performed in patients with SDAVFs. Methods: Retrospective analysis of all diagnostic spinal angiographies between December 2011 and January 2021. Only patients with an SDAVF who had baseline magnetic resonance angiography (MRA), diagnostic digital subtraction angiography (DSA), treatment and follow-up at this institution were included. Dose area product (DAP, Gy cm2) and fluoroscopy time were compared between preoperative and postoperative angiographies, according to SDAVF locations (common versus uncommon), MRA results at baseline (positive versus negative) and DSA protocols (low-dose, mixed-dose, normal-dose). The 75th percentile of the DAP distribution was used to define the local DRL. Results: A total of 62 spinal angiographies were performed in 25 patients with SDAVF. Preoperative angiographies (30/62, 48%) yielded a significantly higher DAP and longer fluoroscopy time when compared to postoperative angiographies (32/62, 53%) (p < 0.01). The local DRL was 329.41 Gy cm2 for a nonspecific (n = 62), 395.59 Gy cm2 for a preoperative and 138.6 Gy cm2 for a postoperative spinal angiography. Preoperative angiography of uncommonly located SDAVFs yielded a significantly longer fluoroscopy time (p = 0.02). The MRA-based fistula detection had no significant impact on dosimetrics (p > 0.05). A low-dose protocol yielded a 61% reduction of DAP. Conclusion: The results of the present study suggest novel DRLs for spinal angiography in patients with SDAVF. Dedicated low-dose protocols enable radiation dose optimization in these procedures. [ABSTRACT FROM AUTHOR]

Studies about the transradial technique and experience with this approach abound in the neurointerventional literature, but studies focusing on patient perspectives and preferences with respect to transfemoral or transradial access are scarce. Patients from our center who underwent both transradial and transfemoral approaches for diagnostic and interventional cerebral angiograms on distinct occasions between January 2016 and January 2021 were identified and interviewed by phone regarding their experience with these access approaches. The first question was regarding the choice for an eventual next procedure (radial, femoral, or no preference). The second question addressed reasons (pain, bruising, complications, recovery time, mobility, failure of one approach, and comfort associated with puncture of the respective area). Forty-four patients were interviewed. Thirty-one (70.4%) preferred radial, 9 (20.5%) preferred femoral, and 4 (9.1%) had no preference. Most frequent reasons for radial preference were recovery time (67.7%), bruising (51.6%), and pain (48.4%). Most frequent reasons in femoral preference were pain (55.6%), mobility (33.3%), and failure of the other approach (33.3%). Recovery time (67.7% vs. 22.2%; P = 0.023) and comfort of puncturing the area (45.2% vs. 0%; P = 0.015) were significantly more frequent reasons for radial preference, whereas failure of the other approach (0% vs. 33.3%; P = 0.008) was a significantly more frequent reason for femoral preference. Most patients preferred the transradial approach. Evaluating the reasons behind their preference can help operators to better understand patient perspectives and improve quality of care. [ABSTRACT FROM AUTHOR]

Endovascular treatment for isolated dural arteriovenous fistula (DAVF) in the middle cranial fossa (MCF) with pure cortical venous drainage poses challenges, including the absence of a safe access route for transvenous embolization (TVE) and the risk of ischemia to neuro feeding vessels and dangerous anastomosis at the sphenoid wing. Therefore, surgical treatment involving direct blockage of venous reflux via craniotomy is typically preferred. We describe the case of a 63-year-old woman presented with generalized seizures and was diagnosed with a Borden III left MCF-DAVF. Initial TVE was unsuccessful due to an occluded inferior petrosal sinus and a lack of connection between the cavernous sinus and the shunt point. After reducing the shunt flow with transarterial embolization, retrograde TVE through cortical drainage enabled successful treatment for the DAVF. We used a triple coaxial system (4-French guiding sheath, 3.2-French intermediate distal access catheter, and 1.5-French microcatheter) to retrogradely navigate a microcathter from the right jugular vein through the superior sagittal sinus, the vein of Trolard, and into the superficial middle cerebral vein, ultimately achieving shunt occlusion using several coils. This case demonstrates that TVE for MCF-DAVFs with pure cortical venous drainage is feasible when a safe anatomical route is established using appropriate strategies and instruments and provides a safe and effective treatment option for similar cases., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Introduction: Penetrating carotid artery injury is rare and particularly uncommon in zone 3 of the vessel. Due to anatomical challenges to open operative management in zone 3, there are minimal treatment recommendations for this highly morbid condition. The urgency associated with understanding proper management of this traumatic injury is further supported by the nearly 100 % rate of fatality in untreated penetrating carotid artery injuries., Presentation of Case: A 17-year-old male presented with a bullet wound to the right temple. He was intubated for airway protection given left-sided tracheal deviation secondary to a right neck hematoma. His Glasgow Coma Scale (GCS) was 11 on initial presentation, E3V2M6. The patient remained hemodynamically stable and underwent a CT angiogram of the head and neck. Imaging revealed a complete transection of the cervical (zone III) right internal carotid artery (RICA), a large pseudoaneurysm of the RICA distal to carotid bifurcation, and comminuted mandibular fracture. Collateral blood flow was preserved to the right hemisphere. Multi-disciplinary discussions deemed risks of operative intervention outweighed the benefits in the immediate peri-trauma period as the increased risk of hemispheric stroke, exsanguination, and death was thought to be prohibitive. Therefore, treatment of delayed intervascular stenting of the RICA was performed as opposed to emergent open RICA ligation or repair., Discussion: Treatment decisions for zone 3 CAI rely on the patient's hemodynamic stability, with surgical ligation favored for immediate hemorrhage control in unstable cases, while stable patients may undergo observation or delayed endovascular intervention. Balancing the need for hemostasis to prevent further blood loss with the potential benefits of anticoagulation to maintain cerebral perfusion underscores the decision-making required in managing such cases., Conclusion: The rarity and challenge of ICA injury at this anatomical location presents unique challenges. Our description of observation and delayed revascularization outlines the precarious, yet validated, treatment method for hemodynamically stable patients., Competing Interests: Conflict of interest statement Authors state they have no conflicting interests financially or otherwise., (Copyright © 2024. Published by Elsevier Ltd.)

Rationale and Objectives: This study aimed to evaluate the safety and effectiveness of transbrachial access (TBA) and transradial access (TRA) compared to transfemoral access (TFA) for large-bore neuro stenting (≥7 F)., Methods: From January 2019 to January 2024, 4752 patients received large-bore neuro stenting in our center. The primary outcomes were procedural metrics. Safety outcomes were significant access site complications, including substantial hematoma, pseudoaneurysm, artery occlusion, and complications requiring treatment (medicine, intervention, or surgery). After propensity score matching with a ratio of 1:1:2 (TBA: TRA: TFA), adjusting for age, gender, aortic arch type, and neuro stenting as covariates, outcomes were compared between groups., Results: 46 TBA, 46 TRA and 92 TFA patients were enrolled. The mean age was 67.8 ± 11.2 years, comprising 127 (69.0%) carotid artery stenting and 57 (31.0%) vertebral artery stenting. The rates of technical success (TBA: 100%, TRA: 95.7%, TFA: 100%) and significant access site complications (TBA: 4.3%, TRA: 6.5%, TFA: 1.1%) were comparable between the groups (P > 0.05). Compared to TFA, the TRA cohort exhibited significant delays in angiosuite arrival to puncture time (14 vs. 8 min, P = 0.039), puncture to angiography completion time (19 vs. 11 min, P = 0.027), and procedural duration (42 vs. 29 min, P = 0.031). There were no substantial differences in procedural time metrics between TBA (10, 14, and 31 min, respectively) and TFA., Conclusion: TBA and TRA as the primary access for large-bore neuro stenting are safe and effective. Procedural delays in TRA may favor TBA as the first-line alternative access to TFA., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background and Aim: The impact of low platelet count on outcomes in patients with Acute Ischemic Stroke (AIS) undergoing Mechanical Thrombectomy (MT) is still unclear. In this study we have further explored the effect of thrombocytopenia on the safety and efficacy of MT in patients with anterior circulation Large Vessel Occlusion (LVO) stroke., Materials and Methods: Patients with AIS who underwent MT at our center between June 2015 and November 2021 were examined. Based on the platelet count recorded on admission patients were divided into two groups: those with thrombocytopenia (<150 × 109/L) and those without thrombocytopenia (≥ 150 × 109/L). Symptomatic Intracranial Hemorrhage (sICH) was the primary safety outcome. The efficacy outcome was functional independence defined as a 90-day modified Rankin Scale (mRS) score of 0-2. Multivariate logistic regression models were used to determine the risk factors for post-procedure sICH and 90-day functional outcomes., Results: Among 302 patients included in the study, thrombocytopenia was detected in 111 (36.8%) cases. Univariate analysis showed age, the proportion of atrial fibrillation, the rates of sICH, 90-day poor outcomes, and mortality to be higher in patients with thrombocytopenia (all p &#60; 0.05). Multivariable analysis showed thrombocytopenia to be independently associated with a higher rate of sICH (OR 2.022, 95% CI 1.074-3.807, p =0.029) however, thrombocytopenia did not affect the 90-day functional outcomes (OR 1.045, 95%CI 0.490-2.230, p =0.909) and mortality (OR 1.389, 95% CI 0.467- 4.130 p = 0.554)., Conclusion: Thrombocytopenia may increase the risk of sICH but not affect the 90-day functional outcomes and mortality in patients with AIS treated with MT.

The basic patterns of the cerebral arteries development are highly conserved across vertebrates. Historical and recent studies based on human embryos, comparative anatomy, and cerebral angiographies allowed us to better understand the embryological development of the cerebral arteries. The knowledge and understanding of such embryological development are important for neurointerventionalists interested in neurovascular diseases, especially stroke, because we may encounter unexpected anatomical variants in neuroendovascular practice. Understanding the embryological processes is essential in understanding cerebral arterial anatomy. This review discusses the development of the aortic arch, great brachiocephalic vessels to the cerebral arteries, and their anatomical variations, with an embryological point of view.

IntroductionTrigeminocardiac reflex (TCR) is a brainstem reflexive response of hemodynamic instability during surgery. Identification of risk factors relevant to TCR during cerebrovascular intervention procedures is helpful to efficiently prevent and treat its occurrence. The purpose of this study was to demonstrate the risk factors for Onyx embolization during cerebrovascular intervention operation so as to optimize perioperative management strategies on TCR.MethodsWe performed a retrospective study on the patients with Onyx embolization under general anaesthesia over 6-years period from 2013 to 2018. 354 patients were finally eligible for inclusion, and then divided into TCR group (group T) and control group (group N). Patient characteristics, clinical diagnosis, comorbidities, lesion sites, hemodynamics changes, and complications were compared between two groups. Several multivariable regression models were applied to analyze the risk factors associated with TCR.ResultsTCR occurred in 59 patients (16.7%) among 354 patients. There was no significant difference in patient characteristics between two groups (P > 0.05). During DMSO/Onyx injection, HR and MAP were much lower in group T than group N (P

IntroductionSmall studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT.MethodsA comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages.ResultsA total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594).ConclusionIn this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population.

Background and Purpose: Women's representation in medicine has increased over time yet the proportion of women practicing neurointervention remains low. We conducted an anonymous online survey through which we could explore the gender gap in neurointervention, identify potential issues, difficulties, or obstacles women might face, and evaluate if men encounter similar issues. Methods: An online questionnaire was designed in SurveyMonkey®. Invitation to participate was emailed through national and international neurointerventional societies as well as directly through private mailing lists to men and women working in neurointervention. Responses were collected from 10 May 2019 to 10 September 2019. Results: There were 295 complete responses, 173 (59%) male and 122 (41%) female. Most respondents (83%) fell within age categories 35–60 years, with representation from 40 countries across five continents. In all 95% were working full time, 73% had worked as a neurointerventionalist for >6 years, 77% worked in University-affiliated teaching institutions. Almost half of the respondents indicated no female neurointerventionalist worked in their center. Female respondents were younger and age-adjusted analysis was undertaken. Significantly fewer females than males were married and had children. Significantly fewer females held supervisory roles, held academic titles, and significantly less had a mentor. Females were less satisfied in their careers. More females felt they receive less recognition than colleagues of the opposite sex. Males had a greater proportion of work time dedicated to neurointervention. Similar proportions of both genders experienced bullying in work (40%–47%); however, sexual harassment was more common for females. There were no differences between genders in how they dealt with complications or their effects on mental well-being. Conclusion: There are many potential reasons why women are underrepresented in neurointervention, however, the literature suggests this is not unique to our specialty. Multiple long-term strategies will be necessary to address these issues, some of which are discussed in the article. [ABSTRACT FROM AUTHOR]

Purpose: Dural arteriovenous fistulas (dAVF) account for approximately 10–15% of all intracranial arteriovenous abnormalities. dAVFs carry a significant risk of mortality, particularly in cases of acute hemorrhage, of up to 10%. A small proportion of these dAVFs are found in the anterior cranial fossa (ACF), of which the rate of hemorrhage can be as high as up to 91%. The Scepter Mini (SM) is the smallest dual-lumen micro-balloon (MB) available for neurointerventional practice. It consists of a 2.8 French outer diameter, with a 2.2 mm × 9 mm semi-compliant balloon providing a working length of 165 cm. The SM is navigated with a 0.008-inch wire making it a particularly attractive tool accessible to the pedicles normally reached with liquid embolization micro-catheters. Methods: Five consecutive patients over a 1-year period between 2020 and 2021 were evaluated and treated for ACF dAVF using a liquid embolization approach using the SM balloon. All patients were treated using ethylene–vinyl alcohol copolymer (EVOH), of which Squid 18 and/or Squid 12 were the chosen viscosities. Control angiograms were performed for all patients post-embolization. Results: All patients demonstrated complete occlusion of the ACF dAVF on immediate post-treatment angiography. No immediate complications were encountered; particularly, there were no reports of visual field deficit in any of the patients. Conclusion: The MB is a valuable adjunctive tool that can enhance the safety and efficacy of trans-ophthalmic embolization of ACF dAVFs, providing additional protection to the retinal and posterior ciliary arteries against unwanted reflux of liquid embolic agent. [ABSTRACT FROM AUTHOR]

Intracranial Atherosclerotic Stenosis (ICAS) is a common cause of Transient Ischemic Attack (TIA) and Ischemic Stroke. Stenosis is most common in Asians and the predilection generally affects the vertebrobasilar arteries. ICAS therapy until now still relies on conservative management, but now with an endovascular approach, the balloon angioplasty method, the morbidity and mortality of ICAS can now be controlled and reduced. A man, 49 years old, came with the chief complaint of spinning dizziness which suddenly occurred when he woke up. Complaints accompanied by nausea, vomiting and impaired walking in the lower extremities. Physical examination: nystagmus (+), dysmetria (+) gait ataxia (+) Romberg (+) Babinsky pathological reflex on the left plantar pedis (+), and decreased motor strength (-). Examination using DSA (Digital Subtraction Angiography) showed a 90% stenosis of the left vertebral artery segment V1. [ABSTRACT FROM AUTHOR]

Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications. [ABSTRACT FROM AUTHOR]

Although studies have continued to demonstrate the advantages of transradial access (TRA) for neurointervention, radial artery spasm (RAS) has remained a frequent cause of TRA failure. Dotter and Judkins initially described a technique to dilate areas of peripheral vascular stenosis by advancing sequentially larger catheters across the lesion over a guidewire. We have presented our institutional experience with the use of a modified Dotter technique with long radial sheaths to dilate areas of proximal flow-limiting RAS. In the present study, we reviewed the use of the Dotter technique for alleviating RAS in patients undergoing TRA for neurointervention. We performed a retrospective review of all patients undergoing TRA for neurointervention at our institution from 2018 to 2020 to identify patients with proximal flow-limiting RAS. For the identified patients, a modified Dotter technique had been used to dilate the stenosis. The demographic and periprocedural data were assessed to identify any adverse outcomes. Four patients with severe proximal flow-limiting RAS were identified. In each case, a hydrophilic long radial sheath and vascular dilator were sequentially advanced through the stenosis. In all cases, repeat angiography demonstrated improvement of the spasm, and the final radial angiograms demonstrated persistent improvement in caliber and regularity of the vessel. Each procedure was also completed via TRA with no periprocedural complications. Our modified Dotter technique was effective in bypassing areas of severe proximal flow-limiting RAS, obviating the need for access site conversion. Additional studies are warranted to understand the implication of the angioplasty-like effects seen within the radial artery after removal of the long radial sheaths. [ABSTRACT FROM AUTHOR]

Catheters are an integral part of interventional neuroradiology and have their uses distributed from diagnostic to therapeutic neurointerventions. They are of several types according to shape (e.g Cobra, Headhunter, Simmons etc), size, purpose (Onyx and Glue compatiable), Structure (Balloon mounted, Detachable tip etc). Detailed knowledge about their properties is crucial for deep learning and successful neurointervention. Here we try to provide a comprehensive review of various catheters used in various sections of interventional neuroradiology. [ABSTRACT FROM AUTHOR]

Purpose: The clinical significance of iatrogenic diffusion-weighted imaging lesions following endovascular procedures is currently not well understood, partly because they do not result in immediate clinical deficits (“silent brain infarcts” [SBI]) and often remain undiagnosed. Conversely, access site complications are well-documented. With the SILENT survey, we sought to gain an understanding of physicians' opinions regarding the relative importance of SBI compared to the more commonly discussed access site complications. Methods: Seven scenarios of access site complications of varying severity were provided. Within each scenario, participants were asked whether they would choose the access site complication or an increasing number of periprocedural SBI. Logistic regression clustered by respondent was performed to assess participant and scenario factors associated with preferential choice of SBI versus access site complications. Results: 67 participants (13 women; 19.4%) provided 469 responses to the survey. The majority (45; 67.2%) were neurointerventionalists. Regardless of scenario, any number of SBI was deemed unacceptable in 42.4% of cases, whereas 10.5% of physicians would accept >15 SBI to avoid any access site complications. Significant group differences for career stage (p=0.001) and specialty (p=0.007) for the number of tolerated SBI were observed. Regression analyses revealed that only hematoma severity was significantly associated with the willingness to accept an increasing number of SBI. Conclusion: In this survey, 4/10 physicians would accept even severe access site complications to avoid any SBI. The perceived importance of SBI among experienced physicians, and the uncertainty regarding their long-term sequelae, support their systematic assessment and reporting.

Headache associated with sexual activity is a difficult diagnosis for physicians and sometimes underlies grave etiologies. One such cause associated with high morbidity and mortality is subarachnoid hemorrhage due to aneurysm rupture. This is a case of a 39 year old male, presenting with coital headache for few episodes. CT showed subarachnoid hemorrhage, Fischer Grade 3. Digital subtraction angiography revealed Right Internal carotid artery very small aneurysm which was endovascularly managed with FRED (flow-redirection endoluminal device, Microvention, Aliso Viejo, California, USA) flow diverter placement across the aneurysm. Follow up revealed complete resolution of aneurysm with no residual clinical symptoms. The following case reveals the importance of identifying sexual headache as a presenting symptom of grave etiology like aneurysmal rupture and its early diagnosis and management to avoid mortality.

With the advent of minimally invasive neurosurgical techniques and rapid innovations in the field of neurointervention, there has been a sharp rise in diagnostic and therapeutic modalities requiring radiation exposure. Neuroanesthesiologists are currently involved in various procedures inside as well as outside the operating room (OR) like intensive care units, interventional suites, and gamma knife units. The ambit expands from short-lasting diagnostic scans to lengthy therapeutic procedures performed under fluoroscopic guidance. Hence, a modern-day neuroanesthesiologist has to bear the brunt of the radiation exposure in both inside and outside the OR. However, obliviousness and nonadherence to the relevant radiation safety measures are still prevalent. Radiation protection and safety are topics that need to be discussed with new vigor in the light of current practice.

Radial arterial access has gained interest for neurovascular procedures in recent years. Although there are no randomized control trials for neurointervention procedures using radial access, there is growing literature demonstrating its feasibility and favorable outcomes. Equipment technical improvements, like the recently introduced BENCHMARK™ BMX®81 System, have made radial navigation safer, with improved maneuverability and support for a variety of procedures. We present a multicenter case series highlighting our institutional radial access experience comparing the BMX®81 with alternative catheters.Multicenter retrospective cohort study of 80 patients who underwent neurovascular procedures through a radial approach. In half of the cases a BENCHMARK™ BMX®81 System was used. The comparison group consisted of the BENCHMARK™071 and 96, Neuron MAX®088 and BALLAST™ systems. Procedures included endovascular thrombectomy, carotid and brachiocephalic artery stenting, middle meningeal artery embolization, flow diverter stenting, vertebral artery sacrifice, aneurysm coiling, and WEB™ device deployment.In our series, the BMX®81 was successful in the navigation of the anatomy to the target location in 95% of cases. No radial access or BMX®81 related complications were identified. There was no significant difference in fluoroscopy time between the BMX81 and the comparison group. Four patients in the comparison group had catheter-related complications due to vasospasm. Eighty-six percent of BMX®81 cases had satisfactory outcomes and no technical difficulties. The remainder presented technical difficulties, but none of these were considered secondary to the puncture site or support structure.The BENCHMARK™ BMX®81 System is a recently developed guiding catheter which has design and size features supporting radial access for a variety of neurovascular interventions. Early multicenter experience highlights the ease of use and versatility of this new catheter as an alternative to transfemoral access as well as other catheters used for radial access. [ABSTRACT FROM AUTHOR]

• Heparin-induced thrombocytopenia results from heparin exposure and can be life-threatening. • Bivalirudin can substitute for heparin in patients with heparin-induced thrombocytopenia. • Bivalirudin can substitute for heparin in neuroendovascular interventions. Heparin-induced thrombocytopenia is a known complication of heparin exposure with potentially life-threatening sequelae. Direct thrombin inhibitors can be substituted for heparin in patients with heparin-induced thrombocytopenia that require anticoagulation. However, the use of direct thrombin inhibitors as a substitute for heparin has not been widely reported in the neuroendovascular literature. Here we report the first use of the direct thrombin inhibitor bivalirudin in a neuroendovascular procedure as a substitute for heparin in a patient with a ruptured pseudoaneurysm and heparin-induced thrombocytopenia, and review the literature on the use of bivalirudin and argatroban for such patients. Bivalirudin was safely and effectively used in the case reported, with no thrombotic or hemorrhagic complications. Our literature review revealed a paucity of studies on the use of heparin alternatives, including bivalirudin, in neuroendovascular procedures in patients with heparin-induced thrombocytopenia. Heparin-induced thrombocytopenia is an important iatrogenic disease process in patients undergoing neuroendovascular procedures, and developing protocols to diagnose and manage heparin-induced thrombocytopenia is important for healthcare systems. While further research needs to be done to establish the full range of anticoagulation options to substitute for heparin, our case indicates bivalirudin as a potential candidate. [ABSTRACT FROM AUTHOR]

Middle meningeal artery (MMA) embolization for subdural hematomas (SDH) and dural arteriovenous fistulas (dAVFs) has gained momentum in the neuroendovascular space. However, there is variability in the technique for safe and effective embolization. The aim of this report is to describe the technical feasibility and clinical performance of using Zoom™ 45 catheter for MMA access to facilitate embolization.We analyzed all cases of MMA embolization in which the Zoom™ 45 catheter was used and performed in our institution from February 2021 to March 2023 for SDH and dAVFs.A total of 32 patients were included. Mean age was 64.0 ± 18.0 years, 75.0% (4/32) were male, and 56.7% (17/30), were black. The technical success was achieved in 93.8% (30/32) of cases, with selective embolization utilizing microcatheter directly into frontal and parietal branches for most patients (96.9%, 31/32). Identification of dangerous collaterals, such as lacrimal and petrous branches, prior to embolization, was achieved in most patients (96.9%, 31/32). Bilateral MMA embolization was done in 50.0% (16/32) of patients. The transradial approach and transfemoral approach were used in 53.1% (17/32) and 46.9% (15/32) of patients, respectively. The most common embolization material was n-butyl cyanoacrylate (84.4%, 27/32). There were no access site complications or complications related to the MMA embolization procedures and used devices.The use of Zoom™ 45 Catheter seems to be technically feasible, safe, and effective for facilitating MMA access for embolization in the context of SDH and dAVFs. [ABSTRACT FROM AUTHOR]

Thromboembolism is a complication of neurointerventional procedures that requires patients to be placed under antiplatelet therapy. Current options for antiplatelet therapies have a delayed onset of action that prevents a rapid door to puncture transition for patents presenting in acute settings. Cangrelor (Kengreal, Chiesi, USA) is an intravenous P2Y12 platelet inhibitor approved in percutaneous coronary interventions that has an immediate onset of action and half-life between 2 and 6 min. Thus, the goal of this study is to report on the safety, effectiveness, and indications for using Cangrelor in neurointerventional procedures. A systematic review of studies describing the use of Cangrelor in neurointervention was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was conducted on PubMed, Ovid Medline, and Embase databases through June 2023. Seventeen studies with 314 patients met inclusion criteria. The most common indication for Cangrelor use was acute ischemic strokes: 70% followed by aneurysms 27.4%. The Infusion protocol varied from 5 to 30 μg/kg bolus and 1 to 4 µg/kg/min infusion with 30 μg/kg bolus and 4 µg/kg/min infusion being reported in 64.7% of studies. Intra-operative platelet reacting unit levels were below 200 in all the studies that reported it, and the percentage of hemorrhagic, thromboembolic, and deaths occurrence in this patient cohort was respectively 11.1%, 4.8%, and 8.6%. Cangrelor appears to be a promising P2Y12 platelet inhibitor for neurointerventional procedures. However, large, randomized trials are needed to determine the full range of its effects in neurointerventional procedures. [ABSTRACT FROM AUTHOR]

Background Timely performed Neurointervention procedures in patients with neurovascular disorders save them from mortality and lifelong morbidity, in addition to relieving the immense economic and social burden associated with these diseases. Materials and Methods We retrospectively reviewed data of neurointerventions performed in our hospital from November 2019 till March 2021. Patient age, sex, diagnosis, preoperative, and postoperative imaging findings were collected and analyzed. Types of procedures, success/failure, procedure-related and procedure-unrelated complications were noted and described. Results Total 161 procedures were done (diagnostic n = 89, therapeutic n = 72). Among the 72 cases of therapeutic procedures, angiographic success was noted in 60 cases, partial success was noted in 5 cases (RR grade 3 occlusion) and failure was noted in 7 cases [mechanical thrombectomy (n = 2), coiling (n = 1), flow diverter (n = 1), Caroticocavernous fistula (n = 1), cerebral Arteriovenous malformation (n = 2)]. Among therapeutic cases (n = 72), patient outcome was categorized as improved (with mRS 0-2 at discharge) in 64 cases (60 neurointerventions, 4 converted to surgery), morbidity in form of weakness was noted in 2 cases, mortality was noted in 8 cases. There were no hemorrhagic complications due to rupture or dissection. Ischemic complications were noted in form of thromboembolic complications in three cases and vessel occlusion (delayed MCA occlusion) in one case. Conclusion With recent efforts by medical associations and governments to provide access to these lifesaving, disability averting neuro-interventions, it's important to recognize and define challenges in implementation of neuro-intervention services. In this article, we share our early experience in establishing a neurointervention facility in a backward region of a low–middle income country. [ABSTRACT FROM AUTHOR]

Background The rapidly changing treatment landscape for large vessel occlusion acute ischemic stroke, now more than ever, has added to the complexity of emergent decision making and the demand for neurointerventionists. Ensuring exposure of neurology trainees to neurointervention and the availability of well‐defined pathways for those interested in this career is crucial. Here we report the results from our large survey of neurology trainee attitudes toward neurointervention training. Methods An online survey targeting trainee impressions on the current state of vascular neurology, neurocritical care, and neurointervention training was conducted as a mandatory requirement for trainee registration in the Society for Vascular and Interventional Neurology Break meeting in April 2020. Quantitative results are reported in proportions, and qualitative results are described. Chi‐square test was used to determine association between categorical variables. Results Of the 725 respondents from 49 countries who participated in this conference, 450 (62%) were trainees. A total of 30% of trainees did not have access to neurointervention training, and 40% believed that neurology residency, vascular neurology, or neurocritical care fellowship do not adequately prepare them for a career in neurointervention. A total of 237/321 (73%) trainees whose institutional neurointervention practice included neurologists or a mix of subspecialty backgrounds including a neurologist had an opportunity to spend elective time in a neurology–angiography suite compared with 49/89 (55%) if the institutional neurointervention practice consisted of neurosurgeons or radiologists alone (P=0.001). A total of 49% of trainees each preferred the introduction of a mandatory or an elective neurointervention module during residency. A total of 60% of trainees preferred no to minimal exposure at the medical student level. Conclusions This international survey of trainees reinforces the existing gap in neurointervention exposure for neurology trainees. Inclusion of neurointervention faculty that come from a neurology training background and exposure to neurointervention will be crucial to support trainees interested in a neurointervention career pathway.

The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.

The coronavirus disease 2019 (COVID-19) is a major health emergency in today’s time. In December 2019, a cluster of pneumonia cases in Wuhan, China was attributed to a novel coronavirus. The World Health Organization declared it as a pandemic. As the majority of the cases suffering from COVID-19 are mildly symptomatic or asymptomatic, it becomes a great challenge to identify the infected persons in the absence of extensive testing. In the hospital environment, it can infect several other vulnerable patients and healthcare providers, significantly impacting the hospital services. Anesthesiologists are at an increased risk of COVID-19 transmission from the patients, as they are frequently involved in several aerosol-generating procedures. It is not possible to identify asymptomatic COVID-19 patients solely based on history-taking during their first point of contact with the anesthesiologists at the preanesthetic checkup clinic. Most of the neurosurgical conditions are of urgent in nature and cannot be postponed for a longer duration. In view of this, the position statement and practice advisory from the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) provides guidance to the practice of neuroanesthesia in the present scenario. The advisory has been prepared considering the current disease status of the COVID-19 pandemic, available literature, and consensus from experts in the field of neuroanesthesiology. Since the pandemic is still progressing and the nature of the disease is dynamic, readers are advised to constantly look for updated literature from ISNACC and other neurology and neurosurgical societies.

Background As much of the scope of neurointerventional practice falls outside data covered by existing randomized clinical trials, and, as a result, may have failed to enter into existing guidelines, an evidence‐based framework for guideline and standards development is needed. We establish an evidence‐based framework to guide all subsequent guidelines and brief practice updates produced by the Society of Vascular and Interventional Neurology (SVIN). Methods The SVIN formed the Guidelines and Practice Parameters committee to develop the structure and procedures for guidelines and brief practice updates. Results In this article, the Guidelines and Practice Parameters committee has outlined the process by which the guidelines will be created and approved by the SVIN. Additionally, the Guidelines and Practice Parameters committee has adopted the American College of Cardiology/American Heart Association framework of Class of Recommendation and Level of Evidence. A unique, additional separation of the Expert Opinion endorsement category has been developed when high‐quality evidence does not exist at the time of the publication. Conclusions The SVIN has developed an evidence‐based framework for all guideline statements and brief practice updates. The SVIN guidelines and brief practice updates will guide clinicians in the field of interventional neurology to improve and standardize patient care.

Psychoceuticals have brought benefits to the pharmacotherapeutic management of central nervous system (CNS) illnesses since the 19th century. However, these drugs have potential side effects or lack high response rates. This review covers twenty drugs’ biochemical mechanisms, benefits, risks, and clinical trial reports. For this study, medications from seven psychoceutical organizations were reviewed and evaluated. Nineteen drugs were chosen from the organizations, and one was selected from the literature. The databases used for the search were Pubmed, Google Scholar, and NIH clinical trials. In addition, information from the organizations’ websites and other sources, such as news reports, were also used. From the list of drugs, the most common targets were serotonergic, opioid, and N-methyl-D-aspartate (NMDA) receptors. These drugs have shown promise in psychiatric illnesses such as substance abuse, post-traumatic stress disorder (PTSD), anxiety, depression, and neurological conditions, such as Parkinson’s disease, traumatic brain injury, and neuroinflammation. Some of these drugs, however, are still early in development, so their therapeutic significance cannot be determined. These twenty drugs have promising benefits, but their clinical usage and efficacy must still be explored.

Peri-medullary arteriovenous fistula (PMAVF) is a rare spinal vascular malformation that manifests as progressive neurologic deficits or hemorrhage in the spinal canal. We report a case of high-flow PMAVF in a child, with a single feeder artery and a large venous pouch, which was successfully treated with transarterial endovascular intervention. A 2-year-old boy was referred with a progressive 2-year history of myelopathy. The MRI revealed a large venous pouch at the midthoracic spinal cord with segmental surrounding edema. A spinal angiogram confirmed high-flow PMAVF with a single feeder artery from the anterior radiculomedullary artery, draining into the peri-medullary vein. The patient underwent transarterial embolization at the distal feeder artery, resulting in gradual motor strength improvement. PMAVF is classified as type IV spinal vascular malformation, usually presenting as a large, high-flow fistula with multiple feeders, although there was only one in this case. PMAVFs are intradural and may cause severe neurologic deficits due to mass effect, venous congestion, or hemorrhage, hence requiring prompt treatment. Treatment options for PMAVF include microsurgery, endovascular intervention, or a combination of the 2. Endovascular intervention with coil or liquid embolic material is considered first-line treatment for IVc PMAVF, and effective in type IVb with good clinical outcome. PMAVF is a rare spinal vascular malformation commonly manifesting as severe neurologic deficits but has the potential of favorable outcomes with endovascular therapy. This case demonstrates a unique angioarchitecture of high-flow PMAVF with a single feeder artery and large venous pouch, treated successfully with endovascular therapy., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Purpose: To investigate the differences in endovascular thrombectomy (EVT) outcomes of patients treated for acute ischaemic stroke (AIS) during business versus off-business hours. Methods: A single-centre retrospective cohort study of patients with AIS treated with EVT from February 1, 2015, to May 31, 2021, was performed at a comprehensive stroke centre (CSC). Patients were divided into business (Monday to Friday, 8 AM-5 PM) versus off-business hours groups. The primary outcome was functional neurological disability, scored using the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included the rate of successful reperfusion and procedural workflow time delays. Differences in proportions were assessed using Fisher's exact and Chi-Square tests as appropriate. For continuous variables, differences in medians between groups were assessed using Mann-Whitney U tests. Results: A total of 676 patients were included, with 399 patients (59%) comprising the off-business-hour group. No significant differences were seen in age, sex, ASPECTS score, or NIHSS at arrival. Off-business hours strokes had a longer delay between CSC arrival to groin puncture (minutes: 81 vs 44, P < .0001) and between imaging to groin puncture (minutes: 67 vs 32, P < .0001) compared to the business hours strokes. There were no differences in the rate of successful reperfusion (mTICI ≥2b) between groups (82% vs 83%, P = .61). At 90 days, 65% of patients in both groups had an mRS ≤2 ( P = .91). Conclusion: Despite workflow delays in initiating EVT during off-business hours, there were no differences in the rate of successful reperfusion or functional outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Middle meningeal artery (MMA) embolization for subdural hematomas (SDH) and dural arteriovenous fistulas (dAVFs) has gained momentum in the neuroendovascular space. However, there is variability in the technique for safe and effective embolization. The aim of this report is to describe the technical feasibility and clinical performance of using Zoom ™ 45 catheter for MMA access to facilitate embolization., Methods: We analyzed all cases of MMA embolization in which the Zoom ™ 45 catheter was used and performed in our institution from February 2021 to March 2023 for SDH and dAVFs., Results: A total of 32 patients were included. Mean age was 64.0 ± 18.0 years, 75.0% (4/32) were male, and 56.7% (17/30), were black. The technical success was achieved in 93.8% (30/32) of cases, with selective embolization utilizing microcatheter directly into frontal and parietal branches for most patients (96.9%, 31/32). Identification of dangerous collaterals, such as lacrimal and petrous branches, prior to embolization, was achieved in most patients (96.9%, 31/32). Bilateral MMA embolization was done in 50.0% (16/32) of patients. The transradial approach and transfemoral approach were used in 53.1% (17/32) and 46.9% (15/32) of patients, respectively. The most common embolization material was n-butyl cyanoacrylate (84.4%, 27/32). There were no access site complications or complications related to the MMA embolization procedures and used devices., Conclusions: The use of Zoom ™ 45 Catheter seems to be technically feasible, safe, and effective for facilitating MMA access for embolization in the context of SDH and dAVFs., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Our primary objective was to determine the successful rate of recanalization of M1 large vessel occlusion using either the Trevo 4 × 30 mm or 6 × 25 mm stent during mechanical thrombectomy. Our secondary objectives were to determine differences between the use of these two stent retrievers regarding first-pass effect, periprocedural complications, and mortality in the first 90 days. Methods: This is a retrospective cohort study. Data regarding the stent used, recanalization, number of passes, periprocedural complications, and mortality were determined via our mechanical thrombectomy database along with chart review. Conclusion: When comparing Trevo 4 × 30 mm to 6 × 25 mm stent retrievers used in mechanical thrombectomy for middle cerebral artery large-vessel occlusion causing stroke, there is no statistically significant difference in successful recanalization rates, first-pass effect, perioperative complications, or mortality at 90 days. Studies like this will hopefully lead to further prospective, randomized controlled trials that will help show experts in the field an additional way to perform this procedure effectively and safely. [ABSTRACT FROM AUTHOR]

Background: Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging. Devices and tools are rapidly evolving. We aimed to gain insight into preferences and global perspectives on the usage of endovascular tools in treating MeVOs. Methods: We conducted an international survey with seven scenarios of patients presenting A3, M2/3, M3, M3/4, or P2/3 occlusions. Respondents were asked for their preferred first-line endovascular approach, and whether they felt that the appropriate endovascular tools were available to them. Answers were analyzed by occlusion location and geographical region of practice, using multinomial/binary logistic regression. Results: A total of 263 neurointerventionists provided 1836 responses. The first-line preferences of physicians were evenly distributed among stent-retrievers, combined approaches, and aspiration only (33.2, 29.8, and 26.8%, respectively). A3 occlusions were more often treated with stent-retrievers (RR 1.21, 95% CI: 1.07–1.36), while intra-arterial thrombolysis was more often preferred in M3 (RR 2.47, 95% CI: 1.53–3.98) and M3/4 occlusions (RR 7.71, 95% CI: 4.16–14.28) compared to M2/3 occlusions. Respondents who thought appropriate tools are currently not available more often chose stent retrievers alone (RR 2.07; 95% CI: 1.01–4.24) or intra-arterial thrombolysis (RR 3.35, 95% CI: 1.26–8.42). Physicians who stated that they do not have access to optimal tools opted more often not to treat at all (RR 3.41, 95% CI: 1.11–10.49). Stent-retrievers alone were chosen more often and contact aspiration alone less often as a first-line approach in Europe (RR 2.12, 95% CI: 1.38–3.24; and RR 0.49, 95% CI 0.34–0.70, respectively) compared to the United States and Canada. Conclusions: In EVT for MeVO strokes, neurointerventionalists choose a targeted vessel specific first-line approach depending on the occlusion location, region of practice, and availability of the appropriate tools. [ABSTRACT FROM AUTHOR]