Emerging Biologics in Neuroendovascular Management: From Periprocedural Pharmacotherapy to Regenerative and Gene-Based Interventions

Neuroendovascular medicine is moving beyond purely mechanical treatment toward catheter-based systems that also deliver biologic therapies. In this narrative review, “biologic-enabled neurointervention” denotes three groups, distinguished throughout and grouped by route rather than regulatory class: true biologic products (recombinant proteins, monoclonal antibodies, cell therapies, extracellular vesicles and gene-transfer vectors); adjunctive small-molecule pharmacotherapy; and bioengineered device and nanocarrier platforms. We synthesize clinical, translational and preclinical evidence on periprocedural pharmacotherapy, bioactive devices, biologics for delayed cerebral ischemia, genotype-guided and anti-angiogenic therapies for arteriovenous malformations (AVMs), endovascular stem cell delivery, intra-arterial gene therapy and nanoscale delivery platforms. Superselective intra-arterial delivery may achieve higher target-site concentrations, lower systemic exposure and access to difficult-to-reach territories, although these advantages are not universal and depend on cerebral blood flow, first-pass extraction, molecular size and barrier integrity. Limitations include immunogenicity, off-target distribution, procedure-related risk, small and heterogeneous clinical datasets, and unresolved regulatory and manufacturing pathways for living and gene-based products. With the exception of adjunctive intra-arterial thrombolysis, which is supported by randomized evidence, the approaches reviewed here remain predominantly investigational, and each is assigned an explicit evidence tier. Whether biologic-enabled neurointervention becomes an integrated component of standard cerebrovascular care will depend on adequately powered multicenter trials.