Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Despite extensive research efforts, the majority of trialed monotherapies to date have failed to demonstrate significant benefit. It has been suggested that this is due to the complex pathophysiology of TBI, which may possibly be addressed by a combination of therapeutic interventions. In this article, we have reviewed combinations of different pharmacologic treatments, combinations of non-pharmacologic interventions, and combined pharmacologic and non-pharmacologic interventions for TBI. Both preclinical and clinical studies have been included. While promising results have been found in animal models, clinical trials of combination therapies have not yet shown clear benefit. This may possibly be due to their application without consideration of the evolving pathophysiology of TBI. Improvements of this paradigm may come from novel interventions guided by multimodal neuromonitoring and multimodal imaging techniques, as well as the application of multi-targeted non-pharmacologic and endogenous therapies. There also needs to be a greater representation of female subjects in preclinical and clinical studies.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Despite extensive research efforts, the majority of trialed monotherapies to date have failed to demonstrate significant benefit. It has been suggested that this is due to the complex pathophysiology of TBI, which may possibly be addressed by a combination of therapeutic interventions. In this article, we have reviewed combinations of different pharmacologic treatments, combinations of non-pharmacologic interventions, and combined pharmacologic and non-pharmacologic interventions for TBI. Both preclinical and clinical studies have been included. While promising results have been found in animal models, clinical trials of combination therapies have not yet shown clear benefit. This may possibly be due to their application without consideration of the evolving pathophysiology of TBI. Improvements of this paradigm may come from novel interventions guided by multimodal neuromonitoring and multimodal imaging techniques, as well as the application of multi-targeted non-pharmacologic and endogenous therapies. There also needs to be a greater representation of female subjects in preclinical and clinical studies.

Introduction: Stenting is increasingly used for neurovascular atherosclerotic lesions, but standardized techniques and dedicated devices remain lacking. Objective: To report outcomes and technical considerations of off-label use of the coronary Onyx drug-eluting stents (DES) for intra- and extracranial neurovascular atherosclerotic lesions. Methods: We retrospectively reviewed all patients who underwent Onyx DES placement for neurovascular atherosclerotic lesions at our institution between January 2018 and September 2024. Demographics, clinical presentation and follow-up, angiographic findings, procedural details, and complications were collected. Outcomes included procedural success, periprocedural stroke, and in-stent restenosis (ISR) requiring reintervention. Results: 84 Onyx DES were deployed in 63 patients (33% female). Procedural success was achieved in all cases. Stent locations included the basilar artery (21.4%), middle cerebral artery (20%), cervical internal carotid artery (ICA) (2.4%), petrous ICA (4.8%), cavernous ICA (8.3%), supraclinoid ICA (10.7%), V1 (10.7%), V3 (1.2%), and V4 (19%). Three patients (4.8%) developed iatrogenic carotid-cavernous fistulae, all successfully treated. Postprocedural stroke rate was 4.8%. During a mean follow-up of 20.6 months, three patients (4.8%) required angioplasty for ISR. Independent predictors of complications included posterior circulation stenting (OR 13.8, p = .005), smaller stent diameter (OR 0.17, p = .03), and higher stent number (OR 14.7, p < .0001). Conclusion: Onyx DES demonstrated excellent navigability, high technical success, and favorable long-term outcomes in patients with neurovascular atherosclerotic lesions. Together with growing comparative evidence, these findings suggest newer-generation DES may overcome limitations of earlier stent systems and merit further prospective evaluation.

Endoscopic third ventriculostomy (ETV) is an effective cerebrospinal fluid diversion procedure but can be complicated by the presence of a high-riding basilar artery (BA). A 70-year-old female presented with obstructive hydrocephalus caused by melanoma metastatic to the brainstem in the setting of a high-riding BA. ETV was successfully performed using the Penumbra Artemis™ Neuro evacuation device (Artemis; Penumbra Inc, Alameda, CA, USA) to minimize the risk of injury to the BA. This is to our knowledge the first known Artemis-assisted ETV reported in the English literature, which may reduce the risk of BA injury in selected patients. Further characterization of the benefits and limitations of this procedure is needed.

Purpose: Flow diverting stents are a mainstay treatment of intracranial aneurysms (IA). They rely on reduction of intra-aneurysmal blood flow velocity along with endothelialization to induce thrombus formation and promote occlusion. Patients with hematologic disorders (HDs) can have abnormal fluid dynamics and blood cell/metal interactions that can affect the mechanism of action of flow diversion (FD). We sought to determine the outcomes of patients with various HD after receiving FD treatment for IA.Materials and Methods: This retrospective chart review examined 11 patients with various HD who received FD for their IAs. HD were classified as either coagulopathies (e.g., factor deficiencies, von Willebrand disease) or hemoglobinopathies (e.g., sickle cell disease [SCD]). Patient outcomes were assessed clinically and radiographically, with radiographic outcomes based on O’Kelly-Marotta (OKM) scores from follow-up angiograms.Results: The total sample included 11 patients with 29 IAs. The median age was 50 years and 81.8% were female. All patients were on pre-procedural dual antiplatelet therapy. Out of the 29 total aneurysms, 17 were treated with FD and 15 originated from the paraophthalmic segment. Seven patients received surface modified stents. The median number of deployed stents during initial treatment was 2. The average aneurysm diameter was 5.03 mm (standard deviation: 3.88 mm). Patients with SCD were the only group to experience complications, with 2 out of 3 patients suffering a post-operative stroke. Seven patients with 8 treated aneurysms experienced complete occlusion at last follow-up with a mean time to OKMD score of 16.8 months.Conclusion: Despite a small sample size, this series raises concern for the use of FD in patients with SCD. While FD still resulted in adequate rates of aneurysm occlusion, treatment methodology must be tailored for patients with HD.