BACKGROUND AND IMPORTANCE The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) have long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage. The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products, and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device. CLINICAL PRESENTATION A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery. CONCLUSION Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial.

In the brain, vascular endothelial cells conserve blood viscosity, control blood flow, and form the interface between central nervous system and circulating blood. Clinical outcome after aneurysmal subarachnoid hemorrhage is linked to early brain injury, cerebral vasospasm, and other causes of delayed cerebral ischemia. The cerebral vasculature remains a unique target for therapies since it becomes rapidly disrupted after subarachnoid hemorrhage, and damage to the blood vessels continues into the delayed injury phase. The current failure of therapies to improve clinical outcome warrants a re-evaluation of current therapeutic approaches. The mechanisms of endothelial cell injury and blood–brain barrier breakdown are critical to the pathway of cerebral injury, and an improved understanding of these mechanisms may lead to novel therapeutic targets. This review provides an update on the current understanding of endothelial cell injury following aneurysmal subarachnoid hemorrhage, including blood–brain barrier dysfunction.

Background and Importance: The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) has long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH). The NeurapheresisTM system has been developed to filter CSF and remove blood products and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of Subarachnoid Hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device. Clinical Presentation: A 65-year-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 hours of filtration during 31 hours of catheter indwelling resulted in 309.47 mL of processed CSF without complication. CT images demonstrated an interval reduction of SAH immediately after filtration. The patient was discharged home on post-bleed day 11 and at 30 days showed good recovery. Conclusion: Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial. BACKGROUND AND IMPORTANCE Aneurysmal subarachnoid hemorrhage (aSAH) is a catastrophic result of a ruptured aneurysm. There are roughly 30,000 cases/year in the US, with worldwide incidence between 4.2-22.7 people per 100,0001. Blood and blood breakdown products (BBP) in the subarachnoid space (SAS) have long been associated with complications leading to poor outcomes after aSAH, including vasospasm, microthrombosis, and delayed cerebral ischemia (DCI)2–4. Hemolysis of red blood cells (RBCs) in the cerebrospinal fluid (CSF) results in release of hemoglobin which triggers oxidative reactions, neuroinflammation, depletion of nitric oxide, and disruption of the blood brain barrier5–8. There have been a number of studies on removal of blood and BBPs via lumbar drain (LD) 9–12. However, LDs are not broadly used in this patient population. A system that removes blood and BBPs from the CSF more quickly and efficiently may reduce delayed complications following aSAH. We introduce the NeurapheresisTM therapy system (Minnetronix, Inc., St. Paul, MN), an investigational lumbar dual lumen catheter and filtration system designed to rapidly remove blood from CSF. CSF is simultaneously removed via proximal fenestrations (lumbar cistern) and returned post-filtration into the patient through distal fenestrations (mid-thoracic). This case report represents the first in the ExtracorPoreal FILtration of Subarachnoid Hemorrhage via SpinaL CAtheteR (PILLAR) safety study. CLINICAL PRESENTATION A 65-year-old female and presented to an outside hospital after a thunderclap headache. An external ventricular drain (EVD) was placed and the patient was transferred. On admission, Glasgow Coma Scale was 14, World Federation of Neurosurgical Societies (WFNS) 2, Hunt-Hess (HH) 3. She had neither family history of aSAH or cerebral aneurysm. A brain CT showed diffuse aSAH (modified Fisher Grade 3); CTA demonstrated a left posterior communicating artery aneurysm confirmed by angiography (7.3 x 4.6 x 2.9 mm) as a wide neck aneurysm. Informed consent for PILLAR was obtained from a legally authorized representative. The aneurysm was secured via coil embolization (Raymond Class 2). Neurapheresis catheter placement began at 18 hours postbleed immediately following coiling. Entry was at L3/L4, and fluoroscopy provided visual confirmation of CSF access and spinal level. The guidewire and catheter were placed without complication, and final placement was verified on fluoroscopy with the proximal radiopaque marker bands at L2/L3 and distal marker bands at T1 (Figure 1). A successful filtration flow test

In the brain, vascular endothelial cells conserve blood viscosity, control blood flow, and form the interface between central nervous system and circulating blood. Clinical outcome after aneurysmal subarachnoid hemorrhage is linked to early brain injury, cerebral vasospasm, and other causes of delayed cerebral ischemia. The cerebral vasculature remains a unique target for therapies since it becomes rapidly disrupted after subarachnoid hemorrhage, and damage to the blood vessels continues into the delayed injury phase. The current failure of therapies to improve clinical outcome warrants a re-evaluation of current therapeutic approaches. The mechanisms of endothelial cell injury and blood–brain barrier breakdown are critical to the pathway of cerebral injury, and an improved understanding of these mechanisms may lead to novel therapeutic targets. This review provides an update on the current understanding of endothelial cell injury following aneurysmal subarachnoid hemorrhage, including blood–brain barrier dysfunction.