ABSTRACT Introduction: Intracranial pial fistulas are an extremely uncommon type of vascular pathology consisting of one or multiple arterial connections to a single venous drainage channel without the presence of an intervening nidus. Due to its typical location and high-flow dynamics, its management is diffi cult and options include endovascular treatment and open surgical treatment. The arterial supply of these lesions is usually derived from pial or cortical vessels, and commonly such lesions are not localized in the dura mater. Materials and Methods: Authors report the experience of consecutive ten cases managed at the Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” of México extending from 2007 to 2012 with endovascular technique, constituting one of the largest series in the Western literature. Discussion: Pial fistulas are associated with a poor natural history, and the selection of individualized therapeutic strategies can provide good outcomes. Conclusion: The neuroendovascular intervention is currently considered as safe, low cost, and effective management modality for such lesions.