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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">S. Bracco</span> and <span class="highwire-citation-author" data-delta="1">E. Bertelli</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">November 2016,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">37 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(11) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E73; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A4910 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-26--62098078879" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">S. Bracco </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Unit of Neuroimaging and Neurointervention
Azienda Ospedaliera Universitaria Senese
University of Siena, Policlinico “Santa Maria alle Scotte”
Siena, Italy</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.%2BBracco%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bracco%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AS.%2BBracco%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-4721-1425" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for S. Bracco</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">E. Bertelli </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Department of Molecular and Developmental Medicine
University of Siena
Siena, Italy</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=E.%2BBertelli%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bertelli%20E&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AE.%2BBertelli%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-9681-4556" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for E. Bertelli</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">We thank Drs Paruthi, Gupta, and Khandelwal for drawing our attention to the issue of the rare embryologic variations one can encounter performing intra-arterial chemotherapy. Indeed, they can represent challenging scenarios for the neurovascular interventionalist. In our series of eyes treated for intraocular retinoblastoma, we did not face rare variants such as those encountered by Paruthi et al and, therefore, did not discuss the subject. Nevertheless, we believe that the case reported by Paruthi et al illustrating a combination of very unfortunate events (a too-angulated ophthalmic artery stemming and a type 1 persistent trigeminal artery) strengthens the concept that the neurovascular interventionalist must be prepared to adapt the technical approach on the basis of the circumstances.<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup></p><p id="p-2">Anatomic and hemodynamic variations may require the exploration of several possible alternative pathways of intra-arterial drug delivery from the external carotid artery (ECA)<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> or the use of the balloon technique occluding the ICA or the ECA.<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a>,<a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> In the specific case addressed by Paruthi et al, we agree that the disappearance of the ophthalmic artery (OA) after ICA occlusion was due to hemodynamic alterations of the blood flow, but we suggest a different interpretation of such changes. In our opinion, the missing OA opacification could likely be the result of a reversal of flow in the OA related to the occlusion of the ICA rather than to the preferential retrograde flow to the posterior circulation through the primitive trigeminal artery. Thus, we believe that the authors would have to verify with the microcatheter the possible reformation of the OA by branches of the ECA during occlusion of the ICA before giving up on the procedure. On the other hand, we agree with Paruthi et al that the use of 2 balloons in a single artery of an infant would have been an unsafe procedure.</p><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-37.11.E73.1" data-doi="10.3174/ajnr.A4741"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Bertelli</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Leonini</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Galimberti</span>  <span class="cit-name-given-names">D</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Hemodynamic and anatomic variations require an adaptable approach during intra-arterial chemotherapy for intraocular retinoblastoma: alternative routes, strategies and follow-up</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2016</span>;<span class="cit-vol">37</span>:<span class="cit-fpage">1289</span>–<span class="cit-lpage">95</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A4741</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>26915566</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo5OiIzNy83LzEyODkiO3M6NDoiYXRvbSI7czoyMDoiL2FqbnIvMzcvMTEvRTczLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-37.11.E73.2" data-doi="10.1007/s00276-015-1519-3"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Bracco</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Venturi</span>  <span class="cit-name-given-names">C</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Leonini</span>  <span class="cit-name-given-names">S</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Transorbital anastomotic pathways between the external and internal carotid systems in children affected by intraocular retinoblastoma</span>. <abbr class="cit-jnl-abbrev">Surg Radiol Anat</abbr> <span class="cit-pub-date">2016</span>;<span class="cit-vol">38</span>:<span class="cit-fpage">79</span>–<span class="cit-lpage">87</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1007/s00276-015-1519-3</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>26198114</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1007/s00276-015-1519-3&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=26198114&amp;link_type=MED&amp;atom=%2Fajnr%2F37%2F11%2FE73.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a><div class="cit ref-cit ref-journal" id="cit-37.11.E73.3" data-doi="10.1016/j.ophtha.2011.03.013"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Suzuki</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Yamane</span>  <span class="cit-name-given-names">T</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Mohri</span>  <span class="cit-name-given-names">M</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Selective ophthalmic arterial injection therapy for intraocular retinoblastoma: the long-term prognosis</span>. <abbr class="cit-jnl-abbrev">Ophthalmology</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">118</span>:<span class="cit-fpage">2081</span>–<span class="cit-lpage">87</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1016/j.ophtha.2011.03.013</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>21715012</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1016/j.ophtha.2011.03.013&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=21715012&amp;link_type=MED&amp;atom=%2Fajnr%2F37%2F11%2FE73.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a><div class="cit ref-cit ref-journal" id="cit-37.11.E73.4" data-doi="10.1136/neurintsurg-2014-011295"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Abruzzo</span>  <span class="cit-name-given-names">TA</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Geller</span>  <span class="cit-name-given-names">JI</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Kimbrough</span>  <span class="cit-name-given-names">DA</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Adjunctive techniques for optimization of ocular hemodynamics in children undergoing ophthalmic artery infusion chemotherapy</span>. <abbr class="cit-jnl-abbrev">J Neurointerv Surg</abbr> <span class="cit-pub-date">2015</span>;<span class="cit-vol">7</span>:<span class="cit-fpage">770</span>–<span class="cit-lpage">76</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1136/neurintsurg-2014-011295</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>25179634</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTE6Im5ldXJpbnRzdXJnIjtzOjU6InJlc2lkIjtzOjg6IjcvMTAvNzcwIjtzOjQ6ImF0b20iO3M6MjA6Ii9ham5yLzM3LzExL0U3My5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2016 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 37</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 11 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Nov 2016 </div></div>
      
      
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