Mini-Pterional Craniotomy for Microsurgical Ligation of a Sylvian Fissure Arteriovenous Fistula

Pial arteriovenous fistulae (pAVF) are rare lesions, arising from direct fistulation between an artery and vein, with absence of a nidus. We present the surgical treatment of a 22-year-old female found to have a right middle cerebral artery (MCA) pAVF in the Sylvian fissure. The patient underwent a right mini-pterional approach, and careful dissection of the arterial feeder, venous varix and fistulation point. The fistulation point was tested with a temporary clip and intra-operative indocyanine green (ICG) videoangiography. All arterial feeders were identified and ligated. Complete obliteration was confirmed using ICG and post-operative digital subtraction angiography (DSA). The patient made a good recovery with no neurological deficits, and her pulsatile tinnitus stopped. Pial arteriovenous fistulae are rare lesions amenable for a surgical cure in the appropriate context.