{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T22:36:01Z","timestamp":1769726161245,"version":"3.49.0"},"reference-count":48,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"24","license":[{"start":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T00:00:00Z","timestamp":1765756800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2025,12,15]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Pial arteriovenous fistulas (pAVFs) are rare vascular abnormalities in the subpial space, characterized by high-flow connections between pial arteries and draining veins, without an intervening nidus. This case report describes a left parietal pAVF feeding from the angular branch (M4) of the left middle cerebral artery, which presented as an acute subdural hematoma (SDH).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>The authors present the case of a 68-year-old neurologically intact male with 1-week history of progressive holocranial headache. Initial noncontrast CT imaging of the head revealed a left-sided SDH. Subsequent CTA confirmed the SDH with a spot sign in the posterior part of the SDH. Digital subtraction angiography identified a left parietal pAVF with an associated saccular aneurysm. The patient underwent successful microsurgical ligation and hematoma evacuation, with no residual fistula or vascular abnormality on follow-up angiography.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>This case highlights the importance of a lower threshold for advanced imaging in acute SDH with no known predisposing factors. It also focuses on the complexity of managing pAVFs with associated aneurysms, along with the importance of individualized treatment strategies integrating advanced imaging and microsurgical techniques.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE25605\">https:\/\/thejns.org\/doi\/10.3171\/CASE25605<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25605","type":"journal-article","created":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T11:59:46Z","timestamp":1769083186000},"source":"Crossref","is-referenced-by-count":0,"title":["Pial arteriovenous fistula fed by an angular branch of the left middle cerebral artery with associated aneurysm and subdural hematoma: illustrative case"],"prefix":"10.3171","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-6166-8106","authenticated-orcid":true,"given":"Vanessa Y.","family":"Ruiz","sequence":"first","affiliation":[{"name":"Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adisson N.","family":"Fortunel","sequence":"additional","affiliation":[{"name":"Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ki Chang","family":"Kang","sequence":"additional","affiliation":[{"name":"Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Benjamin T.","family":"Himes","sequence":"additional","affiliation":[{"name":"Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1902-9623","authenticated-orcid":true,"given":"Deepak","family":"Khatri","sequence":"additional","affiliation":[{"name":"Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"10","key":"bib1","series-title":"Childs Nerv Syst","first-page":"1345","article-title":"Endovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children","volume":"26","author":"Berenstein","year":"2010","unstructured":"Berenstein AOrtiz RNiimi YEndovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children. Childs Nerv Syst. 2010;26(10):1345-1358."},{"issue":"6","key":"bib2","series-title":"Neurosurgery","first-page":"1351","article-title":"Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae","volume":"49","author":"Hoh","year":"2001","unstructured":"Hoh BLPutman CMBudzik RFOgilvy CS.Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae. Neurosurgery. 2001;49(6):1351-1364."},{"issue":"5","key":"bib3","series-title":"Br J Neurosurg","first-page":"580","article-title":"Pial arteriovenous fistula: a review of literature","volume":"25","author":"Yang","year":"2011","unstructured":"Yang WHLu MSCheng YKWang TC.Pial arteriovenous fistula: a review of literature. Br J Neurosurg. 2011;25(5):580-585."},{"issue":"4","key":"bib4","series-title":"Neurosurg Rev","first-page":"253","article-title":"Angiographic architecture of intracranial vascular malformations and fistulas\u2014pretherapeutic aspects","volume":"9","author":"Lasjaunias","year":"1986","unstructured":"Lasjaunias PManelfe CChiu M.Angiographic architecture of intracranial vascular malformations and fistulas\u2014pretherapeutic aspects. Neurosurg Rev. 1986;9(4):253-263."},{"issue":"2","key":"bib5","series-title":"J Korean Neurosurg Soc","first-page":"101","article-title":"Intracranial pial arteriovenous fistulas","volume":"44","author":"Lee","year":"2008","unstructured":"Lee JYSon YJKim JE.Intracranial pial arteriovenous fistulas. J Korean Neurosurg Soc. 2008;44(2):101-104."},{"issue":"2","key":"bib6","series-title":"Radiographics","first-page":"483","article-title":"Radiologic assessment of brain arteriovenous malformations: what clinicians need to know","volume":"30","author":"Geibprasert","year":"2010","unstructured":"Geibprasert SPongpech SJiarakongmun PShroff MMArmstrong DCKrings T.Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. Radiographics. 2010;30(2):483-501."},{"issue":"2","key":"bib7","series-title":"AJNR Am J Neuroradiol","first-page":"377","article-title":"Transvenous embolization of dural fistulas involving the cavernous sinus","volume":"10","author":"Halbach","year":"1989","unstructured":"Halbach VVHigashida RTHieshima GBHardin CWPribram H.Transvenous embolization of dural fistulas involving the cavernous sinus. AJNR Am J Neuroradiol. 1989;10(2):377-383."},{"issue":"5","key":"bib8","series-title":"Interv Neuroradiol","first-page":"548","article-title":"Therapeutic progress in pediatric intracranial dural arteriovenous shunts: a review","volume":"22","author":"Yu","year":"2016","unstructured":"Yu JLv XLi YWu Z.Therapeutic progress in pediatric intracranial dural arteriovenous shunts: a review. Interv Neuroradiol. 2016;22(5):548-556."},{"issue":"2","key":"bib9","series-title":"J Neurosurg","first-page":"198","article-title":"Giant intracranial varices secondary to high-flow arteriovenous fistulae","volume":"66","author":"Vi\u00f1uela","year":"1987","unstructured":"Vi\u00f1uela FDrake CGFox AJPelz DM.Giant intracranial varices secondary to high-flow arteriovenous fistulae. J Neurosurg. 1987;66(2):198-203."},{"issue":"1","key":"bib10","series-title":"Childs Nerv Syst","first-page":"48","article-title":"Congestive cardiac manifestations from cerebrocranial arteriovenous shunts. 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AJNR Am J Neuroradiol. 2008;29(2):235-241."},{"issue":"8","key":"bib18","series-title":"J Child Neurol","first-page":"1015","article-title":"Endovascular treatment of a pial arteriovenous fistula with occipital remodeling secondary to giant torcular dilation","volume":"26","author":"Aguilar","year":"2011","unstructured":"Aguilar MGonz\u00e1lez AL\u00f3pez AGuti\u00e9rrez IDurand FMayol A.Endovascular treatment of a pial arteriovenous fistula with occipital remodeling secondary to giant torcular dilation. J Child Neurol. 2011;26(8):1015-1020."},{"issue":"3","key":"bib19","series-title":"Arq Neuro-Psiquiatr","first-page":"463","article-title":"Endovascular treatment of intracranial pial arteriovenous fistula","volume":"68","author":"Nakiri","year":"2010","unstructured":"Nakiri GSAbud TGOliveira RSSantos ACMachado HRAbud DG.Endovascular treatment of intracranial pial arteriovenous fistula. 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World Neurosurg. 2018;110:e873-e881."},{"key":"bib22","series-title":"World Neurosurg","first-page":"954.e5","article-title":"Spontaneous resolution of cerebral pial arteriovenous fistula after angiography: report of two cases","volume":"103","author":"Satow","year":"2017","unstructured":"Satow TSuzuki MKomuro TOgawa MKobayashi ANishida S.Spontaneous resolution of cerebral pial arteriovenous fistula after angiography: report of two cases. World Neurosurg. 2017;103:954.e5-954.e10."},{"issue":"1","key":"bib23","series-title":"J Cerebrovasc Endovasc Neurosurg","first-page":"79","article-title":"Spontaneous occlusion of a pial arteriovenous fistula after angiography: the role of iodinated contrast media.","volume":"26","author":"John","year":"2024","unstructured":"John SMaiti TKKesav PArif AHussain SI.Spontaneous occlusion of a pial arteriovenous fistula after angiography: the role of iodinated contrast media. J Cerebrovasc Endovasc Neurosurg. 2024;26(1):79-84."},{"issue":"1","key":"bib24","series-title":"Neurosurgery","first-page":"122","article-title":"Intracerebral arteriovenous fistulas associated with intraparenchymal varix in childhood: case reports","volume":"26","author":"Barnwell","year":"1990","unstructured":"Barnwell SLCiricillo SFHalbach VVEdwards MSCogen PH.Intracerebral arteriovenous fistulas associated with intraparenchymal varix in childhood: case reports. Neurosurgery. 1990;26(1):122-125."},{"issue":"10","key":"bib1","series-title":"Childs Nerv Syst","first-page":"1345","article-title":"Endovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children","volume":"26","author":"Berenstein","year":"2010","unstructured":"Berenstein AOrtiz RNiimi YEndovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children. Childs Nerv Syst. 2010;26(10):1345-1358."},{"issue":"6","key":"bib2","series-title":"Neurosurgery","first-page":"1351","article-title":"Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae","volume":"49","author":"Hoh","year":"2001","unstructured":"Hoh BLPutman CMBudzik RFOgilvy CS.Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae. Neurosurgery. 2001;49(6):1351-1364."},{"issue":"5","key":"bib3","series-title":"Br J Neurosurg","first-page":"580","article-title":"Pial arteriovenous fistula: a review of literature","volume":"25","author":"Yang","year":"2011","unstructured":"Yang WHLu MSCheng YKWang TC.Pial arteriovenous fistula: a review of literature. Br J Neurosurg. 2011;25(5):580-585."},{"issue":"4","key":"bib4","series-title":"Neurosurg Rev","first-page":"253","article-title":"Angiographic architecture of intracranial vascular malformations and fistulas\u2014pretherapeutic aspects","volume":"9","author":"Lasjaunias","year":"1986","unstructured":"Lasjaunias PManelfe CChiu M.Angiographic architecture of intracranial vascular malformations and fistulas\u2014pretherapeutic aspects. Neurosurg Rev. 1986;9(4):253-263."},{"issue":"2","key":"bib5","series-title":"J Korean Neurosurg Soc","first-page":"101","article-title":"Intracranial pial arteriovenous fistulas","volume":"44","author":"Lee","year":"2008","unstructured":"Lee JYSon YJKim JE.Intracranial pial arteriovenous fistulas. J Korean Neurosurg Soc. 2008;44(2):101-104."},{"issue":"2","key":"bib6","series-title":"Radiographics","first-page":"483","article-title":"Radiologic assessment of brain arteriovenous malformations: what clinicians need to know","volume":"30","author":"Geibprasert","year":"2010","unstructured":"Geibprasert SPongpech SJiarakongmun PShroff MMArmstrong DCKrings T.Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. Radiographics. 2010;30(2):483-501."},{"issue":"2","key":"bib7","series-title":"AJNR Am J Neuroradiol","first-page":"377","article-title":"Transvenous embolization of dural fistulas involving the cavernous sinus","volume":"10","author":"Halbach","year":"1989","unstructured":"Halbach VVHigashida RTHieshima GBHardin CWPribram H.Transvenous embolization of dural fistulas involving the cavernous sinus. AJNR Am J Neuroradiol. 1989;10(2):377-383."},{"issue":"5","key":"bib8","series-title":"Interv Neuroradiol","first-page":"548","article-title":"Therapeutic progress in pediatric intracranial dural arteriovenous shunts: a review","volume":"22","author":"Yu","year":"2016","unstructured":"Yu JLv XLi YWu Z.Therapeutic progress in pediatric intracranial dural arteriovenous shunts: a review. Interv Neuroradiol. 2016;22(5):548-556."},{"issue":"2","key":"bib9","series-title":"J Neurosurg","first-page":"198","article-title":"Giant intracranial varices secondary to high-flow arteriovenous fistulae","volume":"66","author":"Vi\u00f1uela","year":"1987","unstructured":"Vi\u00f1uela FDrake CGFox AJPelz DM.Giant intracranial varices secondary to high-flow arteriovenous fistulae. J Neurosurg. 1987;66(2):198-203."},{"issue":"1","key":"bib10","series-title":"Childs Nerv Syst","first-page":"48","article-title":"Congestive cardiac manifestations from cerebrocranial arteriovenous shunts. 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Neurol India. 2006;54(4):434-436."},{"issue":"4","key":"bib12","series-title":"J Neurosurg Pediatr","first-page":"344","article-title":"An institutional series and literature review of pial arteriovenous fistulas in the pediatric population: clinical article","volume":"12","author":"Madsen","year":"2013","unstructured":"Madsen PJLang SSPisapia JMStorm PBHurst RWHeuer GG.An institutional series and literature review of pial arteriovenous fistulas in the pediatric population: clinical article. J Neurosurg Pediatr. 2013;12(4):344-350."},{"key":"bib13","series-title":"Surg Neurol Int","first-page":"102","article-title":"Surgical treatment of the intracranial pial arteriovenous fistula","volume":"6","author":"da Silva Martins","year":"2015","unstructured":"da Silva Martins WCde Albuquerque LAde Souza Filho CBDellaretti Mde Sousa AA.Surgical treatment of the intracranial pial arteriovenous fistula. 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World Neurosurg. 2019;127:245-248."},{"issue":"2","key":"bib16","series-title":"J Cerebrovasc Endovasc Neurosurg","first-page":"98","article-title":"Pial arteriovenous fistula with giant varices: report of two cases with good surgical outcome","volume":"16","author":"Jouibari","year":"2014","unstructured":"Jouibari MFZadeh MZKhadivi MKhoshnevisan AMoazzeni KAbdollahzade S.Pial arteriovenous fistula with giant varices: report of two cases with good surgical outcome. J Cerebrovasc Endovasc Neurosurg. 2014;16(2):98-103."},{"issue":"2","key":"bib17","series-title":"AJNR Am J Neuroradiol","first-page":"235","article-title":"Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx","volume":"29","author":"Cognard","year":"2008","unstructured":"Cognard CJanuel ACSilva NAJrTall P.Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx. AJNR Am J Neuroradiol. 2008;29(2):235-241."},{"issue":"8","key":"bib18","series-title":"J Child Neurol","first-page":"1015","article-title":"Endovascular treatment of a pial arteriovenous fistula with occipital remodeling secondary to giant torcular dilation","volume":"26","author":"Aguilar","year":"2011","unstructured":"Aguilar MGonz\u00e1lez AL\u00f3pez AGuti\u00e9rrez IDurand FMayol A.Endovascular treatment of a pial arteriovenous fistula with occipital remodeling secondary to giant torcular dilation. J Child Neurol. 2011;26(8):1015-1020."},{"issue":"3","key":"bib19","series-title":"Arq Neuro-Psiquiatr","first-page":"463","article-title":"Endovascular treatment of intracranial pial arteriovenous fistula","volume":"68","author":"Nakiri","year":"2010","unstructured":"Nakiri GSAbud TGOliveira RSSantos ACMachado HRAbud DG.Endovascular treatment of intracranial pial arteriovenous fistula. 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