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OBJECTIVE Anterior cranial fossa dural arteriovenous fistulas (DAVFs) have been almost exclusively considered as surgical lesions. However, new advances in endovascular technology have made the endovascular treatment (EVT) of ethmoidal DAVFs feasible. The aim of this study was to report the clinical and angiographic outcomes of patients harboring DAVFs of the anterior cranial fossa who had undergone EVT as a first-line approach. METHODS This was a retrospective study of a consecutive series of patients harboring anterior cranial base DAVFs who had undergone EVT as a first-line approach at four institutions. Angiographic follow-up was performed at 6 months. Immediate and late serious clinical events were assessed during follow-up, including death and stroke. Special emphasis was given to visual status before and after the treatment. RESULTS Between 2008 and 2020, 37 patients with ethmoidal DAVFs were admitted to the participating centers. In 2 patients, EVT was not attempted; therefore, 35 patients underwent EVT as a first-line procedure. An isolated transarterial approach was performed in 19 (54.3%) patients. The transvenous approach was performed exclusively in 12 (34.3%) patients, and combined access was used in 4 (11.4%) patients. The most frequently used arterial access route was the ophthalmic artery in 82.6% of the patients. Immediately, complete angiographic occlusion was achieved in 31 (91.2%) of 34 patients whose treatment was accomplished. Six-month control angiography revealed that 30 (88.2%) DAVFs were totally occluded. Complications occurred in 3 (8.8%) patients, including 1 (2.9%) patient who had central retinal artery occlusion. No significant difference in complications or occlusion rates was noted between the transarterial and transvenous approaches. CONCLUSIONS Most anterior cranial base DAVFs can be successfully treated via an endovascular approach. Neurological and visual complications are rare, even if the ophthalmic artery is used as the primary access route. Efforts should be focused on prospectively comparing the results of EVT and surgical management.

Randomized trials involving patients with stroke have established that outcomes are improved with the use of thrombectomy for large-vessel occlusion. These trials were performed in high-resource countries and have had limited effects on medical practice in low- and middle-income countries.We studied the safety and efficacy of thrombectomy in the public health system of Brazil. In 12 public hospitals, patients with a proximal intracranial occlusion in the anterior circulation that could be treated within 8 hours after the onset of stroke symptoms were randomly assigned in a 1:1 ratio to receive standard care plus mechanical thrombectomy (thrombectomy group) or standard care alone (control group). The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days.A total of 300 patients were enrolled, including 79 who had undergone thrombectomy during an open-label roll-in period. Approximately 70% in the two groups received intravenous alteplase. The trial was stopped early because of efficacy when 221 of a planned 690 patients had undergone randomization (111 to the thrombectomy group and 110 to the control group). The common odds ratio for a better distribution of scores on the modified Rankin scale at 90 days was 2.28 (95% confidence interval [CI], 1.41 to 3.69; P = 0.001), favoring thrombectomy. The percentage of patients with a score on the modified Rankin scale of 0 to 2, signifying an absence of or minor neurologic deficit, was 35.1% in the thrombectomy group and 20.0% in the control group (difference, 15.1 percentage points; 95% CI, 2.6 to 27.6). Asymptomatic intracranial hemorrhage occurred in 51.4% of the patients in the thrombectomy group and 24.5% of those in the control group; symptomatic intracranial hemorrhage occurred in 4.5% of the patients in each group.In this randomized trial conducted in the public health care system of Brazil, endovascular treatment within 8 hours after the onset of stroke symptoms in conjunction with standard care resulted in better functional outcomes at 90 days than standard care alone. (Funded by the Brazilian Ministry of Health; RESILIENT ClinicalTrials.gov number, NCT02216643.).

Introduction Thrombectomy is the standard treatment for anterior circulation stroke due to large vessel occlusions in a late time window (6 to 24 hours) for patients selected based on perfusion imaging. Most patients treated in late time window studies presented as unwitnessed or wake-up strokes. Whether patients presenting with unwitnessed stroke have an actual time window greater than 6 hours is unclear. The aim of this study was to assess the outcomes of thrombectomy in the treatment of patients presenting with anterior circulation large vessel stroke in an actual late time window of more than 6 hours. Methods This single-center registry of thrombectomy in the treatment of stroke caused by anterior circulation large vessel occlusions (LVOs) included 430 patients treated between 2011 and 2019. Patients were divided into 2 groups: an early time window (≤ 6 hours) group and a late time window group (> 6 hours). Results Outcomes of the early and the late time window groups, respectively, were recanalization of 86.8% vs 82.7% ( P = .29), symptomatic intracranial hemorrhage of 8.2% vs 5.7% ( P = .40), good clinical outcome of 45.4% vs 41.3% ( P = .46), and mortality of 20.2% vs 25% ( P = .30) at 3 months. Conclusions Thrombectomy for anterior circulation large vessel occlusions after 6 hours of symptoms onset seems to be as safe and effective as the standard thrombectomy within 6 hours from symptoms onset, even without perfusion analysis. Randomized trials are needed to confirm these findings.

Introduction: Transcranial Color-Coded Sonography (TCCS) including B-mode imaging and color-coded Duplex is non-invasive, bedside and inexpensive tool for the assessment of the intracranial circulation. TCCS can be used to assess intracranial stenosis but its accuracy has not been systematically compared to CT angiography in acute stroke patients. Hypothesis: TCCS has high accuracy when compared to CT angiography for the detection and measurement of intracranial arterial stenosis in patients with acute ischemic stroke. Methods: In this prospective study 43 patients (67% male; mean age: 59.8 ± 11 years) with acute ischemic stroke or Transient Ischemic Accident (TIA) underwent examinations of the intracranial arteries by TCCS and CT angiography. Different examiners that were blinded to test results performed the exams. TCCS and CT angiography were performed during the hospital stay. All stenotic segments of intracranial vessels were classified into 4 groups: normal or mild ( Results: 580 of 645 arterial segments in 43 patients were evaluated. The sensitivity, specificity, positive predictive value, and negative predictive value of TCCD in comparison with CT angiography for the detection of moderate to severe intracranial stenosis (≥50%) were 81.5%, 100%, 100%, and 76% respectively. The Cohen’s kappa between TCCS and CT angiography was 0.76 (p Conclusions: TCCS is a bedside non-invasive tool that can be used to evaluate intracranial arteries with high accuracy for moderate to severe stenosis when compared to CT angiography. Moderate agreement was found between TCCS and CT angiography for the evaluation of intracranial stenosis in patients with acute ischemic stroke or TIA.

Introduction: After the results of the new endovascular trials that demonstrated a robust effect of endovascular treatment for acute ischemic stroke (AIS), early detection of proximal artery occlusion (PAO) has become a fundamental task during the initial assessment of acute stroke patients at the emergency department. Nevertheless, an accurate identification of PAO may be particularly challenging in smaller hospitals and in developing countries, areas with restricted assess to vascular neuroimaging modalities such as CTA and MRA. Hypothesis: Algorithms based on NIHSS and non-contrasted CT (NCCT) findings can be accurately used to detect PAO in patients with AIS of the anterior circulation. Method: We retrospectively evaluated 194 consecutive patients with AIS of the anterior circulation from a prospective stroke registry of patients admitted to an academic tertiary emergency unit in Brazil during 2014 that had a NCCT and a CTA at admission. NIHSS scores and attenuation of major intracranial arteries of the anterior circulation on NCCT were collected by two experienced investigators that were blind to the CT angiography findings. We used a ratio between two ROIs (rVA) that were drawn on NCCT blinded to CT angiography: (i) on the region of highest vessel attenuation ipsilateral to the involved hemisphere and (ii) mirror ROI on the corresponding vessel segment of the contralateral hemisphere. We used ROC curve analysis and C-statistics to predict CT angiography PAO. Results: NIHSS and vessel attenuation values were highly associated with the PAO with an area under the curve (AUC) of 0.88 (p < 0,001) and 0.83 (p < 0,001), respectively. An NIHSS of 10 at admission had a sensitivity, and negative predictive value of 97% and 97%, respectively. The rVA ≥ 1.50 had a specificity and positive predictive value 96% and 85%, respectively. The POA score was then built by logistic regression from NIHSS and rVA and showed even higher accuracy for the presence of POA on CTA, with an AUC of 0.93 (p < 0,001). Conclusion: The PAO score based on admission NIHSS and proximal vessel attenuation on NCCT can be accurately used to detect PAO in patients with AIS of the anterior circulation. Further studies are necessary to validate this score in a multicenter setting.

Introduction: Patent Foramen Ovale (PFO) is the most common right-to-left shunt (RLS) and is often found in young patients with stroke related to paradoxical embolism. Contrast-Enhanced Transesophageal Echocardiography (TEE) is considered a gold standard to visualize PFO. Transcranial Doppler (TCD) with bubble test is often used to detect RLS with good correlation to TEE for the diagnostic of PFO. More recently, Transcranial Color Coded Sonography (TCCS) which included B-mode and color coded imaging has overcome TCD in many clinical applications but the accuracy of TCCS for detection of RLS and PFO has not been systematically evaluated. Hypothesis: To determine if the TCCS is an accurate tool to identify both PFO and RLS. Methods: We investigate 106 patients with ischemic stroke under 55 years-old admitted from 2012 to 2014 in a tertiary academic hospital. Patients were evaluated with TEE, TCD and TCCS, and all exams included a saline bubble test. The examiners were blinded for the other tests results. Kappa agreement was calculated inter-examiners for TCCS and TCD. Accuracy of TCCS was calculated in comparison to TEE. Results: We detected a RLS in 54 (50.9%) patients (age mean 43.9 ± 8.2) with kappa agreement 0.92 (95%CI 0.78-1.0) when performed TCCS and TCD. TEE and TCSS were positive in 23/98 (23.4%) and TEE did not reveal contrast in 20/98 (20.4%). In 30 (28.3%) patients only TEE revealed a PFO. TCSS had a sensitivity of 88.4% (95%CI 0.68-0.97), specificity of 72.2% (95%CI 0.60-0.81) and positive likelihood ratio of 3.18 (2.14-4.73) of the diagnosis of PFO. Conclusion: TCCS and TCD had an excellent agreement. TCCS has a good accuracy for the detection of PFO and RLS in young patients with stroke.

Background: Cerebrovascular reactivity (CVR) has been suggested as an independent predictor of stroke in patients with severe carotid stenosis. Functional-MRI (fMRI) can be used to assess CVR by comparing latency parameters of the neurovascular coupling, i.e. BOLD response at baseline and during hypercarbic challenge. We aim to compare BOLD amplitude and latency parameters in the ipsilateral (IH) and contralateral hemispheres (CH) induced by auditory stimulus, under different hypercapnia levels in diabetic and non-diabetic patients with symptomatic carotid stenosis, before and after carotid stenting. Methods: seven diabetic and eight non-diabetic patients with unilateral severe symptomatic carotid stenosis and similar clinical characteristics were evaluated. The protocol was undertaken one week before and three months after the endovascular intervention. Subjects were submitted to auditory stimulus (3s) under normocapnia and EtCO2 increase of 5 and 10mmHg. The images were acquired with a 3T MRI-scanner, preprocessed and BOLD response amplitude and latency parameters were analyzed. Results: We observed decreased BOLD amplitude in the IH compared to the CH (p Conclusions: diabetic patients have diffuse baseline compromise of CVR and their cerebrovascular reactivity measured on BOLD fMRI does not respond to carotid stenting as non-diabetic patients.