{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T17:32:07Z","timestamp":1787506327209,"version":"build-2736575974"},"reference-count":32,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"22","license":[{"start":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T00:00:00Z","timestamp":1780272000000},"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":[[2026,6,1]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Pedicled nasoseptal flap (NSF) is the gold-standard skull base reconstruction method in endoscopic endonasal surgery (EES). Although vascular complications, such as internal carotid artery injury or carotid-cavernous fistula (CCF), are well documented, dural arteriovenous fistula (dAVF) originating from the vascular network of an NSF is exceedingly rare. Herein, the authors report the first case of a cavernous sinus (CS) dAVF supplied by an NSF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 50-year-old woman underwent EES with NSF reconstruction for tuberculum sellae meningioma. She experienced delayed hemorrhage from the sphenoid sinus on postoperative day 21, requiring bipolar coagulation and packing. Five months later, she developed right-sided pulsatile tinnitus. MRI and digital subtraction angiography revealed a CS dAVF (Borden type I). The primary feeder was the sphenopalatine artery (SPA), which supplies the CS through the vascular network of the transposed NSF. The patient is currently under conservative management, with stable symptoms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>Pathophysiology likely involved postoperative inflammation and angiogenesis triggered by delayed hemorrhage and subsequent healing. The proximity of the NSF to the medial CS wall may have facilitated abnormal shunting between the SPA-supplied flap and venous sinus. Despite the efficacy of NSF, clinicians must recognize its potential as a vascular source of dAVF.<\/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\/CASE26300\">https:\/\/thejns.org\/doi\/10.3171\/CASE26300<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case26300","type":"journal-article","created":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T00:00:56Z","timestamp":1779840056000},"source":"Crossref","is-referenced-by-count":1,"title":["Delayed-onset cavernous sinus dural arteriovenous fistula after nasoseptal flap reconstruction: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-6191-8217","authenticated-orcid":true,"given":"Toshiki","family":"Ishikura","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4400-3006","authenticated-orcid":true,"given":"Kentaro","family":"Horiguchi","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katsuya","family":"Hayashi","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tatsuma","family":"Matsuda","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9160-945X","authenticated-orcid":true,"given":"Masaaki","family":"Kubota","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6224-819X","authenticated-orcid":true,"given":"Yosuke","family":"Tajima","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshinori","family":"Higuchi","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"10","key":"bib1","series-title":"Laryngoscope","first-page":"1882","article-title":"A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap","volume":"116","author":"Hadad","year":"2006","unstructured":"Hadad GBassagasteguy LCarrau RLA novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882-1886. doi:10.1097\/01.mlg.0000234933.37779.e4"},{"issue":"1","key":"bib2","series-title":"Neurosurgery","first-page":"ONS44","article-title":"Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap","volume":"63","author":"Kassam","year":"2008","unstructured":"Kassam ABThomas ACarrau RLEndoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery. 2008;63(1)(suppl 1):ONS44-ONS52. doi:10.1227\/01.neu.0000297074.13423.f5"},{"issue":"2","key":"bib3","series-title":"Laryngoscope","first-page":"452","article-title":"Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence","volume":"122","author":"Harvey","year":"2012","unstructured":"Harvey RJParmar PSacks RZanation AM.Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope. 2012;122(2):452-459. doi:10.1002\/lary.22475"},{"issue":"2","key":"bib4","series-title":"Neurosurg Rev","first-page":"235","article-title":"Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions","volume":"33","author":"Horiguchi","year":"2010","unstructured":"Horiguchi KMurai HHasegawa YHanazawa TYamakami ISaeki N.Endoscopic endonasal skull base reconstruction using a nasal septal flap: surgical results and comparison with previous reconstructions. Neurosurg Rev. 2010;33(2):235-241. doi:10.1007\/s10143-010-0247-8"},{"key":"bib5","series-title":"J Clin Neurosci","first-page":"266","article-title":"Rupture from cavernous internal carotid artery pseudoaneurysm 11 years after transsphenoidal surgery","volume":"79","author":"Morrison","year":"2020","unstructured":"Morrison TJukes AWong J.Rupture from cavernous internal carotid artery pseudoaneurysm 11 years after transsphenoidal surgery. J Clin Neurosci. 2020;79:266-268. doi:10.1016\/j.jocn.2020.06.018"},{"key":"bib6","series-title":"World Neurosurg","first-page":"221","article-title":"Carotid-cavernous fistula after transsphenoidal surgery: a rare but challenging complication","volume":"134","author":"Cossu","year":"2020","unstructured":"Cossu GAl-Taha KHajdu SDDaniel RTMesserer M.Carotid-cavernous fistula after transsphenoidal surgery: a rare but challenging complication. World Neurosurg. 2020;134:221-227. doi:10.1016\/j.wneu.2019.10.194"},{"issue":"2","key":"bib7","series-title":"J Craniofac Surg","first-page":"556","article-title":"Carotid-cavernous fistula after functional endoscopic sinus surgery","volume":"20","author":"Karaman","year":"2009","unstructured":"Karaman EIsildak HHaciyev YKaytaz AEnver O.Carotid-cavernous fistula after functional endoscopic sinus surgery. J Craniofac Surg. 2009;20(2):556-558. doi:10.1097\/SCS.0b013e31819ba1e8"},{"issue":"4","key":"bib8","series-title":"Br J Neurosurg","first-page":"836","article-title":"Mixed pial and dural arteriovenous fistula after craniotomy: case report and literature review","volume":"37","author":"Doi","year":"2019","unstructured":"Doi KOtani NHayashi MMixed pial and dural arteriovenous fistula after craniotomy: case report and literature review. Br J Neurosurg. 2019;37(4):836-839. doi:10.1080\/02688697.2019.1672860"},{"issue":"6","key":"bib9","series-title":"Acta Radiol","first-page":"582","article-title":"Classification of spontaneous dural arteriovenous fistulas with regard to their pathogenesis","volume":"36","author":"Mironov","year":"1995","unstructured":"Mironov A.Classification of spontaneous dural arteriovenous fistulas with regard to their pathogenesis. 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Acta Radiol Suppl. 1975;16(suppl 347):63-69. doi:10.1177\/0284185175016s34709"},{"issue":"1","key":"bib14","series-title":"Neurosurg Clin N Am","first-page":"179","article-title":"Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management","volume":"23","author":"Miller","year":"2012","unstructured":"Miller NR.Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management. Neurosurg Clin N Am. 2012;23(1):179-192. doi:10.1016\/j.nec.2011.09.008"},{"issue":"4","key":"bib15","series-title":"J Reconstr Microsurg","first-page":"227","article-title":"Arteriovenous fistula complicating an inferior gluteal artery perforator flap donor site","volume":"24","author":"Lannon","year":"2008","unstructured":"Lannon DANovak CBNeligan PC.Arteriovenous fistula complicating an inferior gluteal artery perforator flap donor site. J Reconstr Microsurg. 2008;24(4):227-229. doi:10.1055\/s-2008-1076095"},{"issue":"3","key":"bib16","series-title":"J Craniofac Surg","first-page":"e216","article-title":"Arteriovenous fistula occurring after alveolar arch repair with free medial femoral condyle flap","volume":"30","author":"Akdag","year":"2019","unstructured":"Akdag OGuray Evin SSutcu M.Arteriovenous fistula occurring after alveolar arch repair with free medial femoral condyle flap. J Craniofac Surg. 2019;30(3):e216-e218. doi:10.1097\/SCS.0000000000005176"},{"issue":"10","key":"bib1","series-title":"Laryngoscope","first-page":"1882","article-title":"A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap","volume":"116","author":"Hadad","year":"2006","unstructured":"Hadad GBassagasteguy LCarrau RLA novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882-1886. doi:10.1097\/01.mlg.0000234933.37779.e4"},{"issue":"1","key":"bib2","series-title":"Neurosurgery","first-page":"ONS44","article-title":"Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap","volume":"63","author":"Kassam","year":"2008","unstructured":"Kassam ABThomas ACarrau RLEndoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery. 2008;63(1)(suppl 1):ONS44-ONS52. doi:10.1227\/01.neu.0000297074.13423.f5"},{"issue":"2","key":"bib3","series-title":"Laryngoscope","first-page":"452","article-title":"Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence","volume":"122","author":"Harvey","year":"2012","unstructured":"Harvey RJParmar PSacks RZanation AM.Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. 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J Clin Neurosci. 2020;79:266-268. doi:10.1016\/j.jocn.2020.06.018"},{"key":"bib6","series-title":"World Neurosurg","first-page":"221","article-title":"Carotid-cavernous fistula after transsphenoidal surgery: a rare but challenging complication","volume":"134","author":"Cossu","year":"2020","unstructured":"Cossu GAl-Taha KHajdu SDDaniel RTMesserer M.Carotid-cavernous fistula after transsphenoidal surgery: a rare but challenging complication. World Neurosurg. 2020;134:221-227. doi:10.1016\/j.wneu.2019.10.194"},{"issue":"2","key":"bib7","series-title":"J Craniofac Surg","first-page":"556","article-title":"Carotid-cavernous fistula after functional endoscopic sinus surgery","volume":"20","author":"Karaman","year":"2009","unstructured":"Karaman EIsildak HHaciyev YKaytaz AEnver O.Carotid-cavernous fistula after functional endoscopic sinus surgery. J Craniofac Surg. 2009;20(2):556-558. doi:10.1097\/SCS.0b013e31819ba1e8"},{"issue":"4","key":"bib8","series-title":"Br J Neurosurg","first-page":"836","article-title":"Mixed pial and dural arteriovenous fistula after craniotomy: case report and literature review","volume":"37","author":"Doi","year":"2019","unstructured":"Doi KOtani NHayashi MMixed pial and dural arteriovenous fistula after craniotomy: case report and literature review. Br J Neurosurg. 2019;37(4):836-839. doi:10.1080\/02688697.2019.1672860"},{"issue":"6","key":"bib9","series-title":"Acta Radiol","first-page":"582","article-title":"Classification of spontaneous dural arteriovenous fistulas with regard to their pathogenesis","volume":"36","author":"Mironov","year":"1995","unstructured":"Mironov A.Classification of spontaneous dural arteriovenous fistulas with regard to their pathogenesis. Acta Radiol. 1995;36(6):582-592. doi:10.1177\/028418519503600457"},{"issue":"5","key":"bib10","series-title":"J Neurointerv Surg","first-page":"516","article-title":"Standard and guidelines: intracranial dural arteriovenous shunts","volume":"9","author":"Lee","year":"2017","unstructured":"Lee SKHetts SWHalbach VStandard and guidelines: intracranial dural arteriovenous shunts. J Neurointerv Surg. 2017;9(5):516-523. doi:10.1136\/neurintsurg-2015-012116"},{"issue":"7","key":"bib11","series-title":"Neurol Res","first-page":"727","article-title":"Expression of angiogenic growth factor in the rat DAVF model","volume":"29","author":"Shin","year":"2007","unstructured":"Shin YNakase HNakamura MShimada KKonishi NSakaki T.Expression of angiogenic growth factor in the rat DAVF model. Neurol Res. 2007;29(7):727-733. doi:10.1179\/016164107X208077"},{"issue":"1","key":"bib12","series-title":"Rhinology","first-page":"82","article-title":"Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery","volume":"56","author":"Eordogh","year":"2018","unstructured":"Eordogh MGrimm AGawish IAnatomy of the sphenopalatine artery and its implications for transnasal neurosurgery. Rhinology. 2018;56(1):82-88. doi:10.4193\/Rhin17.181"},{"issue":"suppl 347","key":"bib13","series-title":"Acta Radiol Suppl","first-page":"63","article-title":"Accessory meningeal artery","volume":"16","author":"Dilenge","year":"1975","unstructured":"Dilenge DG\u00e9raud G.Accessory meningeal artery. Acta Radiol Suppl. 1975;16(suppl 347):63-69. doi:10.1177\/0284185175016s34709"},{"issue":"1","key":"bib14","series-title":"Neurosurg Clin N Am","first-page":"179","article-title":"Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management","volume":"23","author":"Miller","year":"2012","unstructured":"Miller NR.Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management. Neurosurg Clin N Am. 2012;23(1):179-192. doi:10.1016\/j.nec.2011.09.008"},{"issue":"4","key":"bib15","series-title":"J Reconstr Microsurg","first-page":"227","article-title":"Arteriovenous fistula complicating an inferior gluteal artery perforator flap donor site","volume":"24","author":"Lannon","year":"2008","unstructured":"Lannon DANovak CBNeligan PC.Arteriovenous fistula complicating an inferior gluteal artery perforator flap donor site. J Reconstr Microsurg. 2008;24(4):227-229. doi:10.1055\/s-2008-1076095"},{"issue":"3","key":"bib16","series-title":"J Craniofac Surg","first-page":"e216","article-title":"Arteriovenous fistula occurring after alveolar arch repair with free medial femoral condyle flap","volume":"30","author":"Akdag","year":"2019","unstructured":"Akdag OGuray Evin SSutcu M.Arteriovenous fistula occurring after alveolar arch repair with free medial femoral condyle flap. 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