Pial arteriovenous fistula following aneurysm clipping: a case report of a rare complication

Craniotomy is a potential predisposing factor for iatrogenic pial arteriovenous fistula (PAVF), yet cases complicated by PAVF following aneurysm clipping are extremely rare. Given the high risk of hemorrhage associated with PAVF, timely diagnosis and treatment are crucial. This study investigates the clinical characteristics and treatment strategies through the analysis of two cases of PAVF occurring after aneurysm clipping. A systematic literature review following PRISMA guidelines identified four previously reported cases, which together with the two current cases were analyzed for clinical presentation, management, and outcomes. In the first case, as the venous approach was inaccessible to the fistulous point, transarterial coil embolization was alternatively employed to occlude partial feeding arteries, thereby reducing blood flow and the risk of hemorrhage. The long-term efficacy of this approach requires further follow-up observation. The second patient achieved immediate fistula occlusion successfully via venous embolization. The systematic review and case analysis confirm that post-clipping PAVF is a rare complication most often discovered incidentally, with transvenous embolization and microsurgical disconnection being effective treatment options. This report aims to emphasize the importance of clinicians' vigilance regarding PAVF following aneurysm clipping and to highlight the significance of early diagnosis and intervention. In the first case, as the venous approach was inaccessible to the fistulous point, transarterial coil embolization was alternatively employed to occlude partial feeding arteries, thereby reducing blood flow and the risk of hemorrhage. The long-term efficacy of this approach requires further follow-up observation. The second patient achieved immediate fistula occlusion successfully via venous embolization. This report aims to emphasize the importance of clinicians' vigilance regarding PAVF following aneurysm clipping and to highlight the significance of early diagnosis and intervention.