We report a case of adult pial arteriovenous fistula (AVF) with unfavorable angioarchitecture treated by staged hybrid approach. A 62-year-old man had high-flow pial AVF supplied by the superior trunk of the left middle cerebral artery with multiple venous pouches and a flow-related aneurysm. Three-dimensional rotational angiography demonstrated an extremely short arterial segment between the fistulous point and an adjacent normal arterial branch, precluding safe selective occlusion. Coil embolization of the venous pouch reduced flow, enabling next-day microsurgical disconnection. The shunt was completely obliterated without ischemic complications, and follow-up imaging showed aneurysm regression.
Korai et al. (Fri,) studied this question.