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Background: While Balloon Guide Catheters (BGC) have been shown to increase the rate of reperfusion during mechanical thrombectomy (MT), its implementation with transfemoral approach is at times limited due to unfavorable vascular anatomy. Objective: to determine safety, feasibility and performance of the transradial use of 8 F BGC Flowgate 2 during mechanical thrombectomy procedures in patients with unfavorable vascular anatomies (type 3 or bovine arch) Material/Methods: We performed a retrospective cohort study of consecutive transradial mechanical thrombectomies performed with BGC Flowgate 2 between January and December 2019. Patient demographics, procedural and radiographic metrics, and clinical data were analyzed. Results: 20 (8.7%) out of 230 overall thrombectomy procedures underwent transradial approach using an 8 F BGC Flowgate. 2 Successful approach was achieved in 17/20 cases, and in 3 cases radial was switched to femoral, after failure. TICI 2 C/3 was achieved in 18 cases (90%), followed by TICI 2 b and 2a in 1 (5%) case respectively. The average number of passes was 1.8. The average radial puncture-to-first pass time was 22 min. Radial vasospasm was observed in 3/20 cases. The Flowgate 2 was found kinked in 4/20 cases (20%), all of them during right internal carotid procedures. There were no postprocedural complications at puncture site, as hematoma, pseudoaneurysm or local ischemic events Conclusion: The use of 8 F Balloon Guide Catheter during MT via transradial approach might represent an alternative in selected cases with unfavorable vascular anatomies. Its use in right ICA catheterizations was associated with a high rate of catheter kinking. [ABSTRACT FROM AUTHOR]

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation. [ABSTRACT FROM AUTHOR]

A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed by direct internal jugular puncture or by femoral access. Although complication rates are low, there are potential life-threatening complications that should be avoided. The advantages of radial artery access have been widely proven, nevertheless the use of upper limb veins in neurointervention are rarely reported. We present five cases of the simultaneous arteriovenous approach through the radial artery and superficial veins of the forearm for the treatment of intracranial neurovascular diseases. [ABSTRACT FROM AUTHOR]

Endovascular treatment of intracranial aneurysms (IAs) has evolved considerably over the past decades. The technological advances have been driven by the experience that coils fail to completely exclude all IAs from the blood circulation, the need to treat the diseased parent vessel segment leading to the aneurysm formation, and expansion of endovascular therapy to treat more complex IAs. Stents were initially developed to support the placement of coils inside wide neck aneurysms. However, early work on stent-like tubular braided structure led to a more sophisticated construct that then later was coined as a flow diverter (FD) and found its way into clinical application. Although FDs were initially used to treat wide-neck large and giant internal carotid artery aneurysms only amenable to surgical trap with or without a bypass or endovascular vessel sacrifice, its use in other types of IAs and cerebrovascular pathology promptly followed. Lately, we have witnessed an explosion in the application of FDs and subsequently their modifications leading to their ubiquitous use in endovascular therapy. In this review we aim to compile the available FD technology, evaluate the devices' peculiarities from the authors' perspective, and analyze the current literature to support initial and expanded indications, recognizing that this may be outdated soon. [ABSTRACT FROM AUTHOR]

Background The new generation of flow diverters includes a surface modification with a synthetic biocompatible polymer, which makes the device more biocompatible and less thrombogenic. Optical coherence tomography (OCT) can be used to visualize perforators, stent wall apposition, and intra-stent thrombus. Unfortunately real world application of this technology has been limited because of the limited navigability of these devices in the intracranial vessels. In this report, we share our experience of using 3D-printed neurovascular anatomy models to simulate and test the navigability of a commercially available OCT system and to show the application of this device in a patient treated with the new generation of surface modified flow diverters. Material and methods Navigability of OCT catheters was tested in vitro using four different 3D-printed silicone replicas of the intracranial anterior circulation, after the implantation of surface modified devices. Intermediate catheters were used in different tortuous anatomies and positions. After this assessment, we describe the OCT image analysis of a Pipeline Shield for treating an unruptured posterior communicating artery (PCOM) aneurysm. Results Use of intermediate catheters in the 3D-printed replicas was associated with better navigation of the OCT catheters in favorable anatomies but did not help as much in unfavorable anatomies. OCT image analysis of a PCOM aneurysm treated with Pipeline Embolization Device Shield demonstrated areas of unsatisfactory apposition with no thrombus formation. Conclusions OCT improves the understanding of the flow diversion technology. The development of less thrombogenic devices, like the Pipeline Flex with Shield Technology, reinforces the need for intraluminal imaging for neurovascular application. [ABSTRACT FROM AUTHOR]

Purpose The Pipeline Embolization Device (PED) is a routine first-line treatment option for intracranial aneurysms (IAs). The Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is an updated version of the PED which has been modified to include a surface phosphorylcholine biocompatible polymer. Its early technical success and safety have been reported previously. Here, we assessed the long-term safety and efficacy of the Pipeline Shield for the treatment of IAs. Materials and methods The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study was a prospective, single-arm, multicenter study for the treatment of unruptured IAs using the Pipeline Shield. The primary endpoint was a major stroke in the territory supplied by the treated artery or neurologic death at 1-year post-procedure. Angiographic outcomes were also assessed by an independent radiology laboratory at 6-months and 1-year. Results Fifty patients (mean age, 53 years; 82% female) with 50 unruptured IAs were treated. Mean aneurysm diameter was 8.82±6.15-mm. Of the target aneurysms, 38/50 (76%) were small (<10-mm), 11/50 (22%) were large (≥10-and<25-mm), and 1/50 (2%) was giant (≥25-mm). Forty-seven (94%) were located in the internal carotid artery and three (6%) in the vertebral artery. At 1-year post-procedure, no major strokes or neurologic deaths were reported, and complete occlusion was achieved in 27/33 (81.8%). There were no instances of aneurysm recurrence or retreatment. Conclusions Our 1-year follow-up concerning angiographic and safety outcomes corroborate previous evidence that the Pipeline Shield is a safe and effective treatment for IAs. [ABSTRACT FROM AUTHOR]

Intracranial dural arteriovenous fi stulas with retrograde leptomeningeal or cortical drainage are considered aggressive. Conventional treatment in these cases is possible surgically or with endovascular arterial injections of Onyx or cyanoacrylate, but there are still some cases where distal navigation is not possible due to tortuosity of the arterial feeders. We present fi ve cases of direct transforaminal Onyx embolization where endovascular distal navigation could not be achieved. [ABSTRACT FROM AUTHOR]

Purely extradural lumbar spinal arteriovenous malformations (AVMs) are rare lesions that have diverse presentations and imaging features. The treatment of a symptomatic high flow paraspinal AVM with multiple feeders remains a challenge. We report the first use of an Ascent balloon (dual lumen balloon catheter) to deliver Onyx with excellent penetration to a paraspinal AVM. [ABSTRACT FROM AUTHOR]

Cerebral arteriovenous malformations (AVMs) are uncommon. Treatment options include embolization, radiosurgery and surgery, separately or combined, the final goal being complete occlusion of the malformation. We describe the case of a symptomatic small subependymal AVM with a single deep drainage vein previously treated unsuccessfully by radiosurgery and transarterial embolization. The AVM was successfully embolized transvenously using Onyx, achieving complete occlusion in a single treatment session. [ABSTRACT FROM AUTHOR]

Background and Purpose Methods Results Conclusions The influence of intracranial arteriosclerosis (ICAR) on acute ischaemic stroke (AIS) prognosis is unclear. This study explored its impact, focusing on ICAR subtypes categorized by intracranial carotid artery calcification (ICAC) patterns: intimal or atherosclerotic versus internal elastic lamina calcification or non‐atherosclerotic. The aim was to determine their effect on AIS prognosis in patients undergoing endovascular treatment (EVT).This prospective cohort study included consecutive AIS patients with anterior circulation large vessel occlusion undergoing EVT. ICAC, the hallmark of ICAR, was assessed using non‐contrast computed tomography to quantify volume and establish the predominant ICAR subtype. The primary outcome was long‐term functional outcome, measured by the 90‐day modified Rankin Scale score. Secondary outcomes included first‐pass effect, revascularization degree, symptomatic intracranial haemorrhage and 24‐h infarct volume. Multivariate‐adjusted linear and logistic regression models were used to assess the association of ICAC volume and subtype with these outcomes.From January 2021 to February 2022, 181 patients were included, of whom 172 (95%) had ICAC. Internal elastic lamina calcification was the predominant subtype in 103 (57%), intimal in 52 (29%) and mixed in 17 (9%). The intimal or atherosclerotic ICAC pattern was linked to poorer functional outcomes (adjusted odds ratio 2.12, 95% confidence interval [CI] 1.10–4.09), decreased first‐pass effect probability (adjusted odds ratio 0.42, 95% CI 0.21–0.84) and higher infarct volume (adjusted β value 22.11, 95% CI 0.55–43.67).A predominant intimal ICAC subtype, linked to underlying atherosclerosis, correlated with larger infarct volume and poorer 90‐day functional outcomes in EVT‐treated AIS patients. Intracranial atherosclerosis appears to be a relevant factor hampering clinical benefits post‐EVT. [ABSTRACT FROM AUTHOR]

Background and Purpose: Mechanical thrombectomy (MT) is effective for acute ischemic stroke, yet its indication in mild stroke remains unclear. This study evaluates MT's effectiveness and safety in low NIHSS patients and assesses different MT strategies' impact on procedural success and clinical outcomes., Materials and Methods: Data from the ASSIST Registry were analyzed, categorizing patients with large vessel occlusion of the anterior circulation into mild (NIHSS≤5) and moderate-severe (NIHSS>5) stroke groups. Baseline characteristics, procedural parameters, angiographic and imaging outcomes, clinical outcomes, and safety endpoints were compared. Within the mild stroke subgroup, outcomes were compared between different MT techniques., Results: Among 1360 patients with LVO, 122 had minor ischemic strokes (9%). Mild stroke patients had high rates of excellent functional outcomes (mRS 0-1) at 90 days (77.1%) and functional independence (mRS 0-2) (85.7%). Procedural success rates were similar between NIHSS groups, while safety outcomes, except mortality, were comparable. No statistically significant differences were observed in treatment techniques within the mild stroke subgroup. Significant predictors of early neurological deterioration (END) in mild stroke patients were the total number of passes (OR 1.49, 95% CI 1.01 - 2.19, P=.04) and total procedure time (OR 1.02, 95% CI 1.01 - 1.04, P=.01). Patients with END were more likely to have an unfavorable functional outcome (mRS 3-6) at 90 days (89% vs. 6%, P<0.001)., Conclusions: MT is effective and safe in mild stroke patients. Procedural success did not vary among MT techniques in mild stroke. The total number of passes predicts END, which suggests a causal pathway that requires further exploration., Abbreviations: AIS = acute ischemic stroke; BMT = best medical treatment; DA = direct aspiration; END = early neurological deterioration; EVT = endovascular treatment; LVO = large vessel occlusion; MT = mechanical thrombectomy; SAEs = serious adverse events; sICH = symptomatic intracranial hemorrhage; SR = stent retriever., Competing Interests: All other authors declare no conflicts of interest related to the content of this article., (© 2024 by American Journal of Neuroradiology.)

Background: Few clinical studies perform detailed analyses of subtypes of intracranial hemorrhage (ICH) after mechanical thrombectomy (MT) used to treat acute ischemic stroke. Symptomatic intracranial hemorrhage (sICH) is a formidable complication of MT and is widely used in clinical trials as a safety outcome. However, variable definitions of sICH are used across clinical studies., Objective: To radiographically subcategorize post-MT ICH development within this large cohort and examine overlap with sICH. Second, to examine the agreement of this definition of sICH with local site-reported occurrences of sICH to see how sICH rates change with modifications of the definitions used., Methods: A large cohort of patients treated with MT for acute ischemic stroke (n=1395) was analyzed to (1) radiographically characterize hemorrhagic subtypes of intracranial hemorrhage (ICH) occurring after MT; (2) examine associations of hemorrhagic subtypes with sICH; and (3) compare core laboratory-adjudicated occurrences of sICH with site-reported sICH., Results: The overall rate of ICH was 552/1395 patients (39.6%), and the overall rate of sICH was 47/1395 (3.4%). The most common type of ICH was hemorrhagic infarction type 1 (HI1), which represented 45.3% of all ICH cases- followed by HI2 (31.5%) and subarachnoid hemorrhage (SAH, 29.2%). Parenchymal hematoma 2 (PH2) represented only 3.3% of all ICH cases. Of the PH2 hemorrhages, only 33.3% were determined to be symptomatic. Of sICH cases, the most common ICH subtypes were HI2 (48.9%) and SAH (38.3%). Comparison of sICH rates as determined by core laboratory adjudication versus local site-reported results showed that only 14 patients were identified as having sICH with both definitions, with 47 patients total with sICH according to one definition, but not the other., Conclusions: Results of this analysis demonstrate the radiographic subtypes of ICH and also highlight the limitations of variable criteria used to define sICH, suggesting that it might be appropriate to revisit how sICH is defined post-MT., Trial Registration Number: Clinical trial NCT03845491., Competing Interests: Competing interests: AMS reports consulting (paid to self) for RapidAI, Terumo, and Penumbra; research support (paid to institution) from Penumbra, RapidAI, Microvention, Stryker, and Medtronic. OOZ reports a research grant from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; he is a consultant and speaker for Cerenovus, Stryker, Penumbra, and Medtronic; has ownership interest in Galaxy Therapeutics Inc; and serves on the endovascular committee as co-chair for National Institutes of Health StrokeNet Consortium and has served as an expert witness. LLP is an employee of Stryker and holds Stryker stock). RG serves as principal investigator (PI) for the ASSIST Registry (Stryker), PI for the RECCLAIM II Study (Zoll), Clinical Events Committee (CEC) for the MIND Trial (Penumbra), Data Safety Monitoring Board (DSMB) Membrane Study (Cerenovus), ELEVATE Study (Medtronic) consultant and stock options for Vesalio, Rapid Medical. MAM received research grants from Acandis, Balt, Medtronic, Microvention, Phenox, Stryker* (*industry payments are made to the research fund of the institution), receives payment or honoraria for lectures from Balt, Medtronic, Stryker* (*industry payments are made to the research fund of the institution). DSL reports a consultant as imaging core laboratory for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker, Vesalio. All other authors report no disclosures., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mechanical thrombectomy (MT) is part of the standard of care for stroke treatment, and improving its efficacy is one of the main objectives of clinical investigation. Of importance is placement of the distal end of balloon-guided catheters (BGC). We aim to determine if this influences outcomes., Methods: We analyzed data from the ASSIST Registry, an international, multicenter prospective study of 1492 patients. We divided patients treated with BGC according to the placement of the BGC: low cervical (LCG (the lower 2/3 of cervical internal carotid artery (ICA)) or high cervical (HCG (upper 1/3 of cervical ICA, petro-lacerum or higher)). We analyzed characteristics and outcomes overall and stratified on the primary MT technique: Stent-Retriever only (SR Classic), Combined use of aspiration catheter and SR (Combined), and Direct Aspiration (ADAPT)., Results: Our study included 704 subjects -323 in the low cervical and 381 in the high cervical groups. Statistical differences were seen in the proportion of females and tandem lesions (both higher for LCG). Placing the BGC in the high cervical segment is associated with better recanalization rates (expanded treatment in cerebral infarction (eTICI) score of 2c-3) at the end of the procedure (P<0.0001) and shorter procedures (P=0.0005). After stratifying on the three primary techniques (SR Classic, Combined, and ADAPT), placing the BGC in the high segment is associated with a better first-pass effect (FPE), less distal emboli, and better clinical outcomes in the SR Classic technique., Conclusions: Placing the distal end of the BGC at the high cervical segment or higher is associated with better recanalization., Competing Interests: Competing interests: Competing Interests: M. Moreu received research grants to the research fund of the institution (from Angionautix, Balt, Medtronic), receives payment or honoraria for lectures from Balt, Medtronic, Stryker, Johnson & Johnson, Accandis, iVascular and Inspire MD, works as a consultant for Stryker, Accandis, iVascular and Inspire MD, he holds stocks from Medtronic and Basecamp Vascular. A. Spiotta reports consulting (paid to self) for RapidAI, Terumo, and Penumbra; Research support (paid to institution) from Penumbra, RapidAI, Microvention, Stryker, and Medtronic. L. Price is an employee of Stryker and holds Stryker stock.Dr. Liebeskind reports having received grant funding from NINDS and consulting fees as an imaging core laboratory from Cerenovus, Genentech, Medtronic, Stryker and Rapid Medical. M. Möhlenbruch received research grants from Acandis, Balt, Medtronic, Microvention, Phenox, Stryker* (*industry payments are made to the research fund of the institution), receives payment or honoraria for lectures from Balt, Medtronic, Stryker* (*industry payments are made to the research fund of the institution). R. Gupta serves as Principal Investigator (PI) for the ASSIST Registry (Stryker), PI for the RECCLAIM II Study (Zoll), Clinical Events Committee (CEC) for the MIND Trial (Penumbra), Data Safety Monitoring Board (DSMB) Membrane Study (Cerenovus), ELEVATE Study (Medtronic) consultant and stock options for Vesalio, Rapid Medical. All other authors report no disclosures., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Intrasaccular devices have become increasingly popular in the treatment of cerebral aneurysms, particularly at the bifurcation. Here we evaluate the Contour Neurovascular System, an intrasaccular device for the endovascular treatment of cerebral aneurysms, in a multicenter cohort study, the largest to the best of our knowledge., Methods: Consecutive patients with intracranial aneurysms treated with the Contour Neurovascular System between February 2017 and October 2022 at 10 European neurovascular centers were prospectively collected and retrospectively reviewed. Patient and aneurysm characteristics, procedural details, and angiographic and clinical outcomes were evaluated., Results: During the study period, 279 aneurysms (median age of patients 60 years, IQR 52-68) were treated with Contour. In 83.2% of patients the device was placed electively, whereas the remaining patients were treated in the setting of acute subarachnoid hemorrhage. The most common locations were the middle cerebral artery (26.5%) followed by the anterior communicating region (26.2%). Median aneurysm dome and neck size were 5.2 mm (IQR 4.2-7) and 3.9 mm (IQR 3-5). Contour size 7 (39%) and 9 (25%) were most used. Thromboembolic and hemorrhagic complications occurred in 6.8% and 0.4% of aneurysms, respectively. Raymond-Roy 1 and 2 occlusions at last follow-up were achieved in 63.2% and 28.3%, respectively, resulting in adequate occlusion of 91.5% of aneurysms., Conclusion: This is the largest multicenter study reporting the outcome on the Contour Neurovascular System. At 1 year, the self-evaluated data on safety and efficacy are comparable to data of existing intrasaccular devices. Contour is a promising technology in the treatment of cerebral aneurysms., Competing Interests: Competing interests: Please see uploaded ICMJE forms from co-authors., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Flow diverters are the first-line treatment for specific intracranial aneurysms (iA). Surpass Evolve (SE) is a new-generation 64-wire flow diverter with a high braid angle. Current literature on the SE is limited. We aimed to report the first international real-world experience evaluating the safety and effectiveness of the SE., Methods: The Safety and Effectiveness Assessment of the Surpass Evolve (SEASE) was a multicenter retrospective international post-marketing cohort study including consecutive patients treated with SE for iAs between 2020 and 2022. Demographic, clinical, and angiographic data were collected. Primary effectiveness was independent core lab adjudicated complete occlusion rates (Raymond-Roy Class 1) at last follow-up. Primary safety were major ischemic/hemorrhagic events and mortality., Results: In total, 305 patients with 332 aneurysms underwent SE implantation. The patients had a median age of 59 [50-67] years, and 256 (83.9%) were female. The baseline modified Rankin scale score was 0-2 in 291 patients (96.7%). Most aneurysms were unruptured (285, 93.4%) and saccular (309, 93.1%). Previous treatment was present in 76 (22.9%) patients. The median aneurysm size was 5.1 [3.4-9.0] mm, and the median neck width was 3.6 [2.7-5.1] mm. Most aneurysms were in the internal carotid artery C6 ophthalmic segment (126, 38.0%), followed by the communicating segment (58, 17.5%). At median 10.2 [6.4-12.9] months follow-up, 233 (73.0%) aneurysms achieved complete occlusion. After adjusting for confounders, complete occlusion remained consistent. Major stroke and procedure-related mortality were reported in 6 (2%) and 2 (0.7%) cases, respectively., Conclusion: These results demonstrate that SE has a consistently high effectiveness and favorable safety for the treatment of iAs., Competing Interests: Competing interests: Vivanco-Suarez – None; Dibas – None; Klee Lopes – Consultant: Asahi, Stryker, Corindus, Siemens, and Medtronic. Honoraria: Cerenovus, Medtronic, and Stryker. Advisory Board: INFINITY [trial]. Grants: Mentice. Leadership role: WLNC and Advocate Health. Stock: Syncron, Three Rivers Inc., Q’apel, VIZ.AI, Methinks, Vastrax, Borvo, BendIT, Collavidence, NDI, Prometheus, NextGen, Galaxy, Global Intervention, and Sim&Cure. Hanel – Consultant: Medtronic, Stryker, Cerenovous, Microvention, Balt, Phenox, Rapid Medical, and Q’Apel. Advisory board: MiVI, eLum, Three Rivers Medical Inc., Shape Medical, and Corindus. Grants: from NIH, Interline Endowment, Microvention, Stryker, and CNX. Investor/Stoker: InNeuroCo, Cerebrotech, eLum, Endostream, Three Rivers Medical Inc., Scientia, RisT, BlinkTBI, and Corindus. Martinez-Galdamez – Consultant: Medtronic. Rodriguez-Calienes – None; Cortez – None; Fifi – Consultant: Penumbra, Stryker, Microvention, and Cerenovus. Grants: Viz. Investor/Stoker: Imperative care and Cerebrotech. Devarajan – None; Toth – Consultant: Medtronic and Dynamed. Patterson – None; Altschul – Consultant: Microvention, Stryker, and Von Vascular Inc. Pereira – Consultant: Stryker, Medtronic, Penumbra, Neurovasc, and Balt. Liu – None; Puri – Consultant: Medtronic, Stryker, Cerenovus, Microvention, Agile, Merit, Corindus, Q’apel, Arsenal, and Imperative Care. Grants: Medtronic, Stryker, and Cerenovus. Kühn – None; Guerrero – None; Khandelwal – Consultant: Stryker and Medtronic. Bach – None; Kan – Consultant: Stryker, Imperative Care, Cerenovus, and Microvention. Grants: NIH, Siemens, Joe Niekro, and Medtronic. Editorial board: Journal of NeuroInterventional Surgery. Edhayan – None; Given – Consultant: Stryker and Medtronic. Gross – Consultant: Medtronic, Microvention, and Stryker. Farooqui – None; Galecio-Castillo – None; Derakhshani – None; Ortega-Gutierrez – Grants: NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker, Medtronic, Microvention, Methinks, Viz.ai. Consulting fees: Medtronic, Stryker Neurovascular., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Spontaneous cerebrospinal fluid (CSF) fistula, of unknown origin, is a rare condition whose aetiology is increasingly related to idiopathic intracranial hypertension (IIH). This study tries to raise awareness that they should not be considered as two different processes, but that fistulas can be a form of debut, requiring a study and subsequent treatment. Repair techniques are described, as well as the study of HII., Results: We treated 8 patients, 5 women and three men, aged between 46 and 72 years, with a diagnosis of spontaneous CSF fistula, four nasal and four otics who underwent surgical treatment. After repair, a diagnostic study was performed for IIH by MRI and Angio-MRI, presenting in all cases a transverse venous sinus stenosis. The intracranial pressure values obtained by lumbar puncture showed values of 20mm Hg or higher. All patients were diagnosed with HII. The one-year follow-up did not reveal any recurrence of the fistulas, maintaining a control of the HII., Conclusion: Despite their low frequency of both cranial CSF fistula and IIH, an association of both conditions should be considered by continuing the study and surveillance of these patients after fistula closure., (Copyright © 2023 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.)

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort ( P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.