Background: The Surpass Elite (Stryker Neurovascular) is a third-generation flow diverter featuring modified braid architecture with increased braid angle and novel surface charge neutralization treatment. This study presents the first clinical experience with the Surpass Elite globally. Methods: A retrospective analysis of 81 consecutive cases (78 unique patients) treated with the Surpass Elite across four centers by two operators from January to July 2025 was performed. Data collected included patient demographics, aneurysm characteristics, procedural details, technical success, complications, and angiographic/clinical outcomes. Primary endpoints were technical success rate, perioperative safety profile, and aneurysm occlusion rates at approximately 6-month follow-up. Results: The cohort comprised 78 unique patients (76.9% female, mean age 59.2 ± 14.5 years) with 81 aneurysms treated using 112 total devices (mean 1.38 devices per case). Aneurysms were predominantly located in the internal carotid artery (75.3%). Technical success was achieved in 100% of cases regardless of access site. Balloon angioplasty was required in only 13.6% of cases. Among 61 aneurysms with complete angiographic follow-up at a mean of 6 months, complete occlusion (RROC Class I or OKM Grade D) was achieved in 78.7%. In-stent stenosis (< 50%) was observed in only 3.3% of cases with follow-up imaging, suggesting favorable vessel remodeling with minimal intimal hyperplasia. The immediate intraprocedural complication rate was 2.5% (2/81), including one device-related microperforation (complete recovery) and one intraoperative thrombosis (managed successfully intraprocedurally; delayed stroke from subsequent medication noncompliance). Delayed complications within 30 days included one stroke from antiplatelet noncompliance (fatal) and one access-site hematoma (recovered). One delayed adverse event beyond 30 days (delayed right temporal intraparenchymal hemorrhage at 10 months) was observed in a patient on dual antiplatelet therapy plus apixaban and was attributed to cerebral amyloid angiopathy; this event was not considered device- or procedure-related. Overall mortality was 7.4% (6/81): one death (1.2%) was procedure-related (stroke from medication noncompliance), one death occurred within 30 days from post-SAH vasospasm in a ruptured aneurysm case, and four deaths occurred after 30 days (recurrent ICH at 3 weeks, acute respiratory failure with acute on chronic heart failure at 5 months, homicide at approximately 6 months, and one of unknown cause), none of which were device- or procedure-related. Conclusion: This first published clinical experience with Surpass Elite flow diverter demonstrates reliable technical deliverability, favorable early occlusion rates comparable to established flow diverters, and a satisfactory safety profile. The low rates of required balloon angioplasty support the clinical benefit of the modified braid architecture. These preliminary findings support the continued clinical evaluation of the Surpass Elite in larger prospective cohorts.

The discovery of the glymphatic system (GS) transformed understanding of central nervous system homeostasis by revealing a brain-wide network that facilitates cerebrospinal and interstitial fluid exchange along perivascular pathways. This system clears metabolic waste and maintains the precise ionic environment required for neuronal function through the coordinated action of astrocytic aquaporin-4 channels and intact perivascular architecture. Glioblastoma multiforme (GBM), the most aggressive primary brain tumor in adults, alters physiological barriers through pathological angiogenesis, compression of perivascular spaces, depolarization of aquaporin-4 at astrocytic endfeet, and obstruction of venous and lymphatic drainage. This narrative review synthesizes current experimental and clinical literature identified through targeted searches of PubMed and Scopus to examine interactions between glioblastoma, glymphatic system dysfunction, and tumor microenvironmental changes. To minimize selection bias, studies were categorized according to evidence source and experimental design. Evidence from rodent models and advanced imaging demonstrates as tumor growth impairs glymphatic function, the resulting dysfunction promotes tumor progression by enabling accumulation of pro-tumorigenic growth factors, inflammatory mediators, and acidic metabolites, while elevated interstitial fluid pressure limits drug delivery. Impaired antigen drainage further diminishes immune surveillance, contributing to the immunosuppressive microenvironment that limits immunotherapy efficacy. A critical evaluation of these mechanisms highlights how the glymphatic system influences disease progression and suggests novel avenues for diagnostic imaging and therapeutic intervention. Although significant challenges remain in modeling human fluid dynamics, understanding these hidden networks offers a promising frontier for strategies aimed at restoring cerebral clearance and improving clinical outcomes.

Purpose: During diagnostic cerebral angiography, catheter navigation requires manual contrast “puff” injections, while subsequent 2D/3D runs often use automated power injectors. Using power injectors for navigation puffs has not been described. We present a closed-circuit dual-port injector system (Nemoto Press Duo Elite) that integrates both navigation puff delivery and diagnostic run injection into a single automated platform, eliminating all manual tableside contrast handling. A foot pedal interface enables operator-controlled puff timing, potentially reducing contrast waste and air embolism risk while improving single-operator ergonomics with future remote robotic implications.Materials and Methods: This retrospective comparative cohort study compared 19 consecutive patients undergoing diagnostic cerebral angiography with foot pedal-controlled puff injections (June–July 2023) to 19 historical controls using manual hand injections (May 2021). Both groups used 90% contrast concentration. Fluoroscopy time, radiation dose, contrast utilization, and safety outcomes were compared.Results: Groups were demographically matched (mean age 52.1±14.2 vs. 50.2±12.9 years; 73.7% female). All 38 procedures achieved diagnostic adequacy with no complications. The foot pedal group demonstrated significantly shorter procedure time per vessel (11.5±4.4 vs. 18.9±10.5 min/vessel, P=0.010) with no significant differences in fluoroscopy time (P=0.171), radiation dose (P=0.690), or contrast delivered (88.7±30.9 vs. 88.2±42.5 mL, P=0.966). A trend toward improved contrast efficiency was observed (23.4±9.4 vs. 27.4±10.4 mL/vessel, P=0.226). Despite undergoing significantly more 3D rotational runs (1.3±1.0 vs. 0.6±0.7, P=0.030), the foot pedal group maintained comparable safety metrics, strengthening the non-inferiority findings.Conclusion: A closed-circuit dual-port injector system integrating automated navigation puff delivery with diagnostic run injection demonstrates non-inferiority to manual injection for diagnostic cerebral angiography, with shorter procedure time per vessel (39% reduction, P=0.010), though interpretation is limited by differences in indication distribution. By eliminating manual tableside contrast handling, this approach enables precise digital contrast accounting and reduces air embolism risk, establishing a foundation for remote and robotic angiography applications.

Bow Hunter's syndrome (BHS) causes vertebrobasilar insufficiency when head rotation compresses the vertebral artery (VA).^1,2 Although classically craniocervical, subaxial cases from osteophytic V2 compression lack standardized management with treatments ranging from decompression to stenting.^3-5Table 1 presents a summary of previously reported subaxial BHS cases. During decompression, intraoperative VA patency confirmation is essential because static postoperative imaging cannot reliably exclude residual dynamic compression, and delayed confirmation may necessitate reoperation.^6,7 We present 2 cases of subaxial rotational occlusion syndrome (subaxial BHS) treated with anterior cervical decompression and intraoperative angiography in a hybrid operating suite (Video 1). Case 1 is an 80-year-old woman with neck pain, dizziness, tinnitus, near-syncope, and ocular symptoms on leftward head rotation; computed tomography/dynamic angiography showed left VA narrowing at C4-5 from spondylotic compression. Case 2 is a 57-year-old woman with prior Eagle syndrome with vertigo, nausea, and blurred vision on left neck rotation; magnetic resonance angiography demonstrated focal left V2 stenosis at C5-6 from uncovertebral osteophytes and incidental distal VA fenestration. Both underwent anterior V2 exposure, ultrasonic drilling of osteophytes, Gore-Tex/fibrin glue reinforcement, and anterior cervical discectomy and fusion (C4-5 and C5-6) to eliminate residual rotational motion at the decompressed segment. Intraoperative biplane angiography via left radial access (Isovue-300; 6 mL at 6 mL/s per 2-dimensional run; 18 mL at 3 mL/s for 3-dimensional acquisition) with simulated head turning, performed 10-15 minutes after hemostasis under general anesthesia, supplemented by 3-dimensional rotational angiography in case 2 to characterize the VA fenestration, showed no head-turning compression and confirmed complete VA patency.^8,9 Both were discharged on postoperative day 3, and complete symptom resolution was confirmed at 6 weeks.

Superior hypophyseal artery (SHA) aneurysms are occasionally associated with infraoptic anterior cerebral artery (ACA) variants, characterized by the A1 segment coursing beneath the optic nerve.^1,2 A 69-year-old female presented with an 8 mm right SHA aneurysm, and subsequent angiography demonstrated a Wong Type I infraoptic ACA, resulting in a dual arterial supply to the aneurysm.³ Due to this anatomy, dual overlapping Pipeline Shield flow diverters were deployed. However, one-year follow-up demonstrated persistent aneurysm flowing from continued infraoptic ACA inflow. Microsurgical clipping via supraorbital eyebrow craniotomy was performed, placing two mini-clips at the aneurysm-infraoptic ACA junction to eliminate anterograde filling while preserving retrograde perfusion. Complete exclusion with normal A1 patency was confirmed with intraoperative ICG angiography, fluorescein angiography, and formal cerebral angiography. Six-month imaging demonstrated persistent occlusion. Infraoptic ACA variants resulting in dual blood supply may necessitate combined embolization and flow diversion or microsurgical approaches when flow diversion alone proves inadequate. Institutional review board (IRB) approval was obtained and written informed consent was obtained from the patient for publication of this case video and accompanying images.

Background/Objectives: The blood–brain barrier (BBB) remains a major obstacle to effective gene therapy for neurological disorders by limiting delivery of viral vectors, nanoparticles, and biologics to the central nervous system. Multiple strategies have been developed to transiently disrupt or bypass the BBB, including focused ultrasound (FUS) with microbubbles, osmotic agents, biochemical modulators, and receptor-mediated transport systems. Among these approaches, FUS-mediated BBB opening has emerged as the most spatially precise and clinically advanced strategy. Methods: This narrative review synthesizes recent preclinical and clinical literature on BBB microdisruption technologies for central nervous system gene therapy, with primary emphasis on FUS combined with microbubbles. We review BBB physiology, gene delivery platforms, the development of FUS technologies, optimization parameters, and translational evidence across neurological diseases from animal models through early-phase human studies. Results: FUS-mediated BBB opening has emerged as the leading method for transient barrier modulation. Preclinical studies in Parkinson’s disease, Alzheimer’s disease, Huntington’s disease, glioblastoma, amyotrophic lateral sclerosis, and lysosomal storage disorders demonstrate enhanced gene delivery, increased transgene expression, and improved functional outcomes. Large-animal studies and early clinical trials indicate that BBB opening is reversible, spatially controlled, and generally well tolerated. Clinical investigations have demonstrated successful delivery of therapeutic agents across neurological indications, with preliminary efficacy signals including improved drug penetration, metabolic changes, and potential survival benefits. Optimization of acoustic parameters, microbubble characteristics, and real-time cavitation monitoring remains critical for maximizing safety and therapeutic efficacy. Conclusions: BBB microdisruption, particularly through FUS with microbubbles, represents a transformative platform for central nervous system gene therapy. Continued research is needed to standardize treatment protocols, characterize long-term safety, and facilitate broader clinical translation.