• Mohammad Ghorbani, Christoph Wipplinger, Christoph J Griessenauer, Seyed Ebrahim Hejazian, Fatemeh Zangi Abadi, and Sina Asaadi.
• Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
• World Neurosurg. 2019 Jul 1; 127: 245-248.

BackgroundPial arteriovenous fistulas are abnormal vascular connections between arteries and the cranial venous system on the surface of the brain in the pia mater. In contrast to vein of Galen aneurysmal malformations, they lack a true vascular nidus and may only indirectly involve the vein of Galen.Case DescriptionAn 18-month-old boy was referred to us with a history of seizures, drowsiness, bulging cephalic veins, and cranial nerves palsy identified as vein of Galen aneurysmal malformation according to initial magnetic resonance imaging. Digital subtraction angiography showed a vertebrobasilar junction pial high-flow fistula between the basilar artery and anterior pontomesencephalic vein, causing retrograde flow, dilation, and tortuosity of the lateral and posterior mesencephalic vein as well as the vein of Galen. Endovascular treatment, including coil embolization of fistula site, was done successfully without complication resulting in recovery from previous symptoms and signs.ConclusionsIf cerebral venous dilations are encountered, one must keep in mind that the location of the fistula may not be in close proximity to the dilated veins, especially when there is a suspicion for vein of Galen aneurysmal malformation. Other pathologies, such as pial arteriovenous fistula, in a region away from the site of the vein of Galen must be considered.Copyright © 2019 Elsevier Inc. All rights reserved.

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