Cooling, rescue stenting and difficult fistula access: Biplane Weekly No. 2

ReCCLAIM II tested intravascular cooling during mechanical thrombectomy for proximal MCA or ICA occlusion, ASPECTS 6–10, within 24 hours. Of 95 enrolled patients, 29 entered a roll-in phase and 66 were randomised, with 33 per arm. In the cooling arm, 30/33 reached below 34°C within an hour of arterial puncture. Median door-to-reperfusion times were 95 versus 94 minutes (P=0.70).

These results establish operational feasibility in the trial setting. They do not establish neuroprotective efficacy: median final infarct volumes were 11 versus 30 cm³ (P=0.13). Serious adverse events occurred in 45.5% versus 24.2% (P=0.12), while haemorrhagic conversion and pneumonia did not differ significantly. The trial was not powered for clinical efficacy or serious adverse events, so the nonsignificant comparisons cannot establish safety equivalence.

The practical milestone is timing. Twenty-three of 33 cooled patients reached the target before reperfusion, showing that systemic hypothermia can be incorporated into the thrombectomy workflow rather than delivered only after the vessel has reopened.

A German registry analysis of MCA occlusions matched 218 rescue-stented patients with 218 patients who had failed reperfusion and no further intervention. Stenting was associated with better 90-day disability distribution: adjusted common OR for worse mRS 0.41 (95% CI 0.29–0.59). Mortality was 26% versus 37%; symptomatic intracranial haemorrhage was 4% versus 5%. Missing covariates, unrecorded indications and antiplatelets, and injuries excluded from controls limit causal interpretation.

ANGEL-REBOOT included failed recanalisation or high-grade residual stenosis. In 348 randomised patients, it found no 90-day disability benefit and more haemorrhagic and dissection complications. Among 326 completing one-year follow-up, disability distribution favoured intervention (generalised OR 1.34, 95% CI 1.05–1.73), with treated-artery stroke recurrence in 7/166 versus 21/160.

The registry adds a favourable association against failed reperfusion; the randomised evidence describes different outcomes over time. One-year follow-up extends the original trial rather than independently replicating it or reversing its 90-day safety findings.

Delayed headache, seizures or focal deficits after flow diversion may reflect a foreign-body inflammatory reaction rather than a new infarct. A systematic review identified 40 unique patients with non-ischaemic cerebral enhancing lesions across 22 reports. Median onset was 73 days. The flow-diverter-specific denominator was 12 cases among 1,201 treated aneurysms; that 1.0% proportion is not a reliable general incidence estimate.

Biopsy identified polymer or other foreign material in four of six sampled patients, supporting an inflammatory mechanism in some cases. Attribution to a particular component remained uncertain: the implanted device, delivery wire and access catheters belong to the same construct. Device-family comparisons were at critical risk of bias.

Steroids were used in 22/24 cases with treatment details, while recurrent or fluctuating activity occurred in 11/25 with relevant follow-up. These observations cannot establish a treatment effect. The review makes the delayed clinical and imaging phenotype more recognisable and gives a concrete reason to document the entire device construct when investigating it.

Functionally isolated sinus segments lack antegrade or retrograde venous sinus outflow, making access central to fistula treatment. A retrospective 20-year single-centre series included 35 such patients among 425 treated intracranial dural fistulas, with 43 treatment sessions.

Initial transarterial embolisation achieved immediate single-session occlusion in 17/23 patients and final single-session occlusion in 18/23 after spontaneous thrombosis of one residual fistula. Corresponding transvenous results were 8/10 and 9/10. These selected groups describe treatment experience, rather than establish superiority of one route.

Three burr-hole-assisted transvenous procedures and two surgical disconnections achieved complete occlusion, including primary and salvage treatments. Five of 35 patients required multiple sessions, and three major complications occurred across 43 sessions. No residual fistula was found at last available imaging follow-up; the abstract does not provide the follow-up distribution. The series documents several successful ways to reach the endpoint in this anatomy. Assisted venous access and surgical disconnection were part of the treatment inventory when standard endovascular routes were insufficient.

Subdural collections accompanying spontaneous intracranial hypotension pose a different question from ordinary chronic subdural haematoma: does middle meningeal artery embolisation add benefit when a CSF-venous fistula is treated?

A single-centre retrospective cohort compared 18 patients receiving combined MMA and CSF-venous fistula embolisation with 22 receiving fistula embolisation alone. Complete or significant symptom improvement occurred in 15/18 (83%) versus 19/22 (86%). Repeat subdural collections occurred in one versus three patients; no procedural complications were reported in either group. Patients considered nonsurgical candidates were excluded.

The study documents improvement in both treatment groups and experience delivering the combined procedure. Similar observed symptom proportions do not establish equivalence, and the small, nonrandom groups cannot attribute the difference in repeat collections to MMA embolisation. The clinically useful finding is that substantial symptom improvement was also observed after fistula embolisation alone. This keeps treatment of the underlying CSF leak central to interpreting the adjunctive procedure.

A retrospective 21-patient series describes outpatient treatment of 25 aneurysms using preprocedural 3D DSA selection, anaesthetic assessment, transradial access, strictly intrasaccular treatment and a dedicated surveillance facility. Treatment comprised coiling, with or without balloon remodelling, or an intrasaccular flow disruptor.

No early significant clinical events were observed, although two asymptomatic radial occlusions occurred. Mean hospital stay was 11 hours 27 minutes. Adequate occlusion was reported in 16/17 assessed cases at six months and 12/12 at one year. These follow-up denominators are smaller than the number of treated aneurysms, and the small selected cohort cannot define an event-free discharge threshold.

The report documents an outpatient pathway delivered with short hospital stays and favourable occlusion findings among assessed cases. Its procedural scope was intrasaccular treatment, so it provides no evidence for extending the pathway to flow diversion or stent-assisted treatment. The selection process and dedicated surveillance facility are concrete parts of the reported service model.