Transarterial N-butyl Cyanoacrylate Embolization of a Pediatric Pial Arteriovenous Fistula Using a Distal Access...

Pial arteriovenous fistulas (pAVFs) are rare, high-flow cerebrovascular malformations characterized by direct arteriovenous shunting without an intervening nidus, and treatment selection depends on angioarchitecture, clinical severity, and institutional expertise. A seven-year-old boy presented with intracerebral hemorrhage caused by a right temporal pAVF supplied by the superior trunk of the middle cerebral artery, with cortical venous drainage into a vein anatomically consistent with the vein of Labbé. Hematoma evacuation and decompressive craniectomy were performed, followed by elective transarterial embolization. A distal access intermediate catheter was advanced to provide distal support and to allow contrast injection while a microcatheter was in place, and n-butyl cyanoacrylate (NBCA) was injected through the microcatheter positioned adjacent to the fistulous point. Final angiography demonstrated complete shunt disconnection with preservation of the cortical venous drainage pathway. This case describes a catheter support strategy facilitating microcatheter-based NBCA delivery without adjunctive balloon or coil assistance in a pediatric high-flow pAVF.