Ipsilateral resection of a planum tuberculum sellae meningioma and concurrent contralateral clip ligation of an ethmoidal dural arteriovenous fistula

Background: Ethmoidal dural arteriovenous fistulas (dAVFs) account for 2–3% of all intracranial dAVFs and are associated with a significant risk of intracerebral hemorrhage and neurological deficits due to their supply by ethmoidal branches of the ophthalmic artery. Urgent surgical management is indicated for high-grade lesions presenting with high-risk characteristics, such as ectasia of the draining vein. Case Description: A man in his late 60s presented with a progressive decline in visual acuity in his left eye over several months. Magnetic resonance imaging revealed a tuberculum sellae meningioma encasing the optic nerve and distal segments of the internal carotid artery. An incidental ethmoidal dAVF with a venous varix was also identified, classified as a Borden grade III dAVF. The patient consented to surgery. To address both lesions, the patient underwent a right pterional craniotomy for meningioma resection, followed by clip ligation of the ethmoidal dAVF. Exposure of the cribriform plate allowed for identification of an arterialized vein. Indocyanine green video angiography was used to identify the fistulous point. Aneurysm clip occlusion of the fistula near the dura covering the cribriform plate resulted in darkening of the arterialized vein, confirming the absence of further arteriovenous shunting. The patient achieved a successful surgical recovery without new neurological deficits and was discharged home on postoperative day 3. Conclusion: This video demonstrates the microsurgical resection of a tuberculum sellae meningioma and clip ligation of a high-grade dAVF, highlighting surgical techniques and pearls for achieving complete fistula ligation in ethmoidal dAVFs exhibiting high-risk features.