Name:
10.3171/2025.7.FOCVID25107
Description:
10.3171/2025.7.FOCVID25107
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/92191602-be64-4a53-8646-f4c7b6a2ae13/videoscrubberimages/Scrubber_249.jpg
Duration:
T00H05M57S
Embed URL:
https://stream.cadmore.media/v10.3171/2025.7.FOCVID25107
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/92191602-be64-4a53-8646-f4c7b6a2ae13/11. 25-107.mp4?sv=2019-02-02&sr=c&sig=doEw4MhUHizkaztIqj5LIcKWsILlnUOOg05w5br8CZI%3D&st=2026-04-02T05%3A00%3A15Z&se=2026-04-02T07%3A05%3A15Z&sp=r
Upload Date:
2026-04-02T05:05:15.4707511Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video presents the open surgical management of a high-flow supratentorial pial arteriovenous fistula in a pediatric patient. A 14-year-old boy presented with 4 days of persistent, intermittent frontal headaches after minor head trauma. The patient has a past medical history of hereditary hemorrhagic telangiectasia. On presentation, the patient is neurologically intact. Digital subtraction angiography confirms this vascular lesion is most consistent with a pial AV fistula, with a hypertrophied arterial feeder from the superior temporal branch of the left middle cerebral artery, which enters at the caudal aspect of the 2.3 by 4.4 by 4.2-centimeter varix, and venous drainage through a singular superficial cortical vein to the superior sagittal sinus.
SPEAKER: Given the presence of a radiographically confirmed high-flow vascular lesion with a bulky venous varix deforming the overlying skull and underlying brain parenchyma, with surrounding T2 signal changes on MRI, open surgical intervention was favored following multidisciplinary neurovascular conference and discussion with the patient and his parents. Multiple approaches were considered. While many pial AV fistula cases are amenable to endovascular management, endovascular embolization was not chosen given the high-flow lesion, large superficial varix, and the likely bulky coil/embolysate mass that may contribute to a compressive lesion in a sensorimotor anatomic location.
SPEAKER: Radiosurgery was not pursued given the large size of the venous varix with underlying mass effect on brain parenchyma, as well as the sizable arterial feeder. Medical management and/or observation is not recommended, given the high lifetime risk of rupture without definitive treatment. Open surgical treatment was ultimately chosen for this young, healthy patient, as it allows for definitive removal of the surgically accessible, superficially located vascular lesion to decrease hemorrhage risk and optimize neurocognitive development caused by varix compression.
SPEAKER: The patient was positioned in a right lateral decubitus position. The head was fixed in a Mayfield skull clamp. We used the option of neuromonitoring for the sizable high-flow lesion posterior to the sensorimotor area. Stereotactic neuronavigation was used to plan the craniotomy. A microscope, intraoperative ultrasound, and indocyanine green was used to assist with identifying the vascular anatomy and resecting the lesion.
SPEAKER: Anesthetic considerations included arterial line insertion and keeping the systolic blood pressure between 100 to 120. Given the risk of bleeding during high-flow open pial AV fistula surgical resection, a risk which is further increased in the pediatric population due to their lower circulating blood volume, appropriate preoperative labs should be obtained and blood should be available in the operating room prior to the surgery. A left posterior parietal craniotomy was performed.
SPEAKER: Preoperative CT head shows scalloping of the undersurface of the skull from the pial AV fistula venous varix, as shown by the solid arrow, and the dilated draining vein, as shown by the dashed arrow. Intraoperatively, this was seen as an indentation on the undersurface of the bone flap. Pial AV fistula in pediatric patients more commonly present with a venous varix, which can lead to calvarial remodeling due to their congenital long-standing nature.
SPEAKER: Thus, it is critical to map out the varix with relation to the planned craniotomy, and to take care when drilling due to these bony irregularities. Violation of the high-flow venous varix during the craniotomy can quickly lead to exsanguination of the patient, particularly in pediatric patients who have a lower circulating total blood volume. Baseline SSEP, MEP were obtained and monitored throughout the case.
SPEAKER: Dura was opened carefully to keep the vascular lesions safe, and the pial AV fistula was visualized. A baseline ICG run was performed and shows the arterial feeder, venous varix, and draining vein going to the sagittal sinus. Intraoperative color Doppler was used as an adjunct to confirm the exact fistulous point. The arterial feeder is dissected out and a temporary aneurysm clip is placed on the arterial feeder. The pial AV fistula is skeletonized, working caudally to cut off the arterial feeders.
SPEAKER: The arterial feeder is cauterized and divided. Further pial AV fistula dissection is performed. The venous varix appears more deflated and dark in color. The draining vein, which appears smaller and collapsed, is then dissected out. The draining vein was cauterized and divided. The venous varix is further dissected and the pial AV fistula is removed.
SPEAKER: SSEP and MEP remained at baseline at time of closing. The patient tolerated the procedure well. Postoperative angiography on postop day 1 showed complete pial AV fistula obliteration. The patient was discharged home on postop day 2. At 1-year follow-up, the patient remains neurologically intact, has returned to baseline at school, and has resumed all physical activities. His MRI/MRA brain shows no residual or recurrence of his pial AV fistula.
SPEAKER: The references for this operative video are included here.
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
