Staged transarterial and transvenous embolization of a high-grade ruptured tentorial dural arteriovenous fistula

Tentorial dural arteriovenous fistulas (TDAVFs) are rare but high-risk lesions due to frequent deep venous drainage. A 77-year-old woman presented with a ruptured, high-grade (Borden III, Cognard IV, Zipfel 3S) TDAVF at the pontomesencephalic junction. Angiography revealed feeders from the left middle meningeal artery, occipital artery, and meningohypophyseal trunk with tortuous venous drainage into a partially thrombosed varix. Initial transarterial N -butyl cyanoacrylate ( N -BCA) embolization was incomplete. Definitive cure was achieved with transvenous coiling. Postoperatively, the patient was neurologically stable, and follow-up angiography revealed no further arteriovenous shunting, demonstrating how staged embolization can lead to curing TDAVFs with complex angioarchitecture. The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2593