The three therapeutic modalities for arteriovenous malformation (AVM) treatment (surgery, embolization, and radiotherapy) developed in the past years with specific tools, each tool with its own qualities. Soon after the implementation of embolization for treatment of AVMs, this technique was used in combination with microsurgery; since the development of radiosurgery, treatment algorithms combining embolization with surgery and eventual subsequent radiosurgery, embolization with radiosurgery, or surgery with subsequent radiosurgery have been reported. These different combinations have been in use under the term multimodality treatment for many years, but the algorithms regarding the combination of tools, which tool has priority, and how the risk levels of each tool are assessed shows great variability among institutions. Centers with a surgical background see embolization as a technique to increase surgical feasibility and radiosurgery as a tool to complete subtotal AVM excision. Institutions with an endovascular background embolize AVMs with the aim of maximal occlusion rates and view surgery or radiosurgery as a technique to be used if the goal of total endovascular occlusion cannot be achieved. Radiosurgeons receive patients after incomplete embolization or surgical extirpation or a combination of both.

To better understand the development of hydrocephalus of different origins, we evaluated cytokine and growth factor concentration in cerebrospinal fluid from patients with hydrocephalus. CSF was collected from patients developing hydrocephalus following hemorrhage (n = 15), patients with normal pressure hydrocephalus (n = 10), and following the embolization of unruptured intracranial aneurysms (n = 9). Myelography patients (n = 15) served as controls. Quantification of 11 molecules relating angiogenesis, inflammation, and wound healing in the CSF was performed using ELISA. All three hydrocephalus groups had decreased concentration of TIMP-4 compared to the normal group. The hemorrhage group showed increased concentration of IL-6, IL-8, MCP-1, MMP-9, and TIMP-1 compared to the control group. The unruptured aneurysm group had increased concentration of IL-6 and decreased concentration of TIMP-2 compared to the control group. Compared to the normal patients, increased concentrations of wound healing molecules were evident in all three groups. Increased inflammation was evident in the hemorrhage and unruptured aneurysm groups.

An experimental aneurysm model for in vivo testing of endovascular techniques is described. The aneurysm is produced surgically in the neck of the rabbit by partial anastomosis of the left to the right common carotid artery, thus creating an arterial bifurcation. Subsequently, a venous pouch is sutured into the artificial bifurcation. The size of the arteries, coagulation profile and hemodynamic features in this aneurysm model closely mimic human conditions. Surgical technique and our preliminary experience with this model are discussed.

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Backround Stroke is a frequent disorder in patients with an antiphospholipid syndrome (APS). Due to a high risk for further thromboembolic events, appropriate anticoagulation therapy in patients with an APS-associated stroke seems mandatory but drug eluting and duration is a matter of debate. Case A 48-year-old female patient presented with Broca’s aphasia and mild hemiparesis on the right side. Diagnostic work-up revealed left middle cerebral artery (MCA) occlusion yet without diffusion-weighted lesions. Due to a thrombocytopenia (67.00 g/l) systemic thrombolysis was not indicated and endovascular treatment was initiated 150 min after symptom onset. After successful clot retrieval, recurrent re-occlusions lead to the necessity of stent implantation and anticoagulation, respectively. On day 5 she developed a new severe right-sided hemiparesis. The magnetic resonance imaging (MRI) showed a subtotal restenosis of the left MCA despite the regular anticoagulation regime leading to a new left MCA ischaemic stroke. In the meantime, the unknown aetiology, the patients’ age and the thrombocytopenia let to further diagnostic workup. Elevated blood parameters such as lupus anticoagulant (LA)-1, LA-ratio, positive anti-nuclear antibody (ANA), p-anti-neutrophil cytoplasmic antibodies (ANCA), c-ANCA confirmed the diagnosis of APS. Conclusion This case report showed the feasibility of mechanical clot retrieval and stent implantation in patients with APS. Due to the elevated risk of in-stent thrombosis a prolonged therapy with glycoprotein (GP)IIb/IIIa receptor antagonists in the initial postoperative period and further anticoagulation with coumarin derivate might be needed.

Endovascular thrombectomy is now the standard of care for large vessel occlusion stroke. The aim is to achieve rapid and complete recanalisation while avoiding complications. Apart from the conventional complications of neurointerventional procedures, mechanical thrombectomy has its unique set of complications, inherent to the disease pathophysiology. We describe an unusual complication of catheter fracture and subsequent distal embolisation into the cerebral vasculature, which was noticed 24 hours after the procedure. Due to a lack of clinical consequences, we decided to manage it conservatively. The patient died within the following few days from respiratory complications unrelated to the stroke or the endovascular thrombectomy procedure. Consequently, we were able to retrieve the fractured segment and carry out histopathological analysis, which helped us to identify exactly its origin from the guide catheter. We believe that systematic reporting and database compilation of such device-related complications will aid in the design and development of neurointerventional devices in the future.

Stent misplacement during endovascular treatment of middle cerebral artery (MCA) aneurysms can cause challenges and be problematic, if clipping becomes necessary. This article reports on a 56-year-old woman with an unruptured, multi-lobulated MCA aneurysm, whom primarily refused surgery; therefore, she was scheduled for stent-assisted coiling. After successful deployment of the stent, it unfortunately then became snagged by the microcatheter and was pulled backwards. The subsequent surgical procedure (i.e. clipping of the MCA aneurysm) was challenging, due to the position of the dislodged stent. Such as misplacement of the stent is rarely documented: It resulted in the difficult handling of a MCA aneurysm. Aneurysms of the MCA should primarily be considered for surgical clipping. In conclusion, an increased risk for eventual surgery should be considered, in cases where endovascular treatments with stents are performed.

Neurointervention is a subspecialty of neurosciences which offers a minimally invasive therapy for the vascular lesions of the central nervous system. The resources, techniques, and indications of neurointervention therapy are rapidly expanding and becoming diverse. With the support of robust scientific data, neurointervention has established itself as a first line therapy for many neurovascular diseases. This article provides an overview about the various material used in neurointervention, basic steps followed in some common neurointerventional procedures, and its related complications. In the era of 21st century, any young physician or surgeon as well as residents-in-training dealing with neurovascular cases should have some insight into these basic concepts so as to provide better care to their patients.