Transarterial and transvenous pial arteriovenous Fistula embolization: A video case report.

Cerebral pial arteriovenous fistulas (pAVFs) are rare and complex high-flow vascular malformations found in pediatric and adolescent populations. They are often divided into two groups based on the pattern of venous drainage, galenic or nongalenic. Nongalenic pAVFs are typically supratentorial and carry a high risk of rupture. Their angioarchitecture is very complex with various patterns of feeding arteries and draining veins not originating from dural vessels or the vein of Galen. The natural history has not been well established; however, mortality estimates range as high 63%. Presentations include hemorrhage, seizure, congestive heart failure, and elevated intracranial pressure. We describe the case of an adolescent girl with acute onset of headaches that led to the discovery of an occipital, nongalenic pAVF. Transarterial and transvenous embolizations performed during a single procedure resulted in complete obliteration of the fistula. No complications arose, and the patient remained at her neurological baseline.