Combined Surgery for Pial Arteriovenous Fistula with Giant Varix: A Case Report

Abstract

Intracranial pial arteriovenous fistula (pAVF) is uncommon, accounting for approximately 1.6% of all intracranial vascular malformations. High flow pressure renders varices and AVF highly susceptible to rupture and life-threatening hemorrhage.A 15-year-old girl who presented with headache and visual disturbance was diagnosed with an intracranial pAVF associated with a giant varix in the right occipital lobe. Imaging studies showed anomalous dilatation of the right posterior cerebral artery, a 53 mm thrombosed and calcified varix in the right occipital lobe, and drainage into the transverse sinus. We planned a combined surgery with the goal of reducing the mass and curing the pAVF. The patient underwent coil embolization for the obliteration of an angiographic shunt point; however, shunt flow appeared from the new feeders. We resected the giant varix with an angiographic shunt point completely and safely, with embolization the following day. The patient was discharged without any postoperative intracranial complications. The pathological shunt point was confirmed.Recently, reports on endovascular surgery for pAVF have increased. Combined surgery that includes safe excision, particularly in cases with mass effects, is required.