This is a video presentation of a complex tentorial arteriovenous fistula that required multimodal treatment with preoperative embolization followed by craniotomy for clip ligation with several teaching points. A Cognard type IV fistula has multiple arterial feeders and direct cortical venous drainage with venous ectasia. A multimodal approach was required, consisting of endovascular embolization of occipital feeders followed by tailored craniotomy for clip ligation of the venous outflow of the fistula. The video discusses important nuances for the successful treatment of complex arteriovenous fistulas while minimizing morbidity. The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2597
Nguyen et al. (Wed,) studied this question.