Pais, Alexander

In this video, the authors present the microsurgical treatment of a superior petrosal dural arteriovenous fistula (dAVF) associated with a symptomatic hemorrhagic brainstem cavernous malformation in a 38-year-old male. The patient underwent a retrosigmoid craniotomy for cavernoma evacuation and fistula disconnection. Intraoperative indocyanine green angiography revealed cortical venous reflux not evident on catheter angiography, prompting reclassification to a higher-grade fistula. Postoperatively, the patient returned to neurological baseline, and follow-up imaging confirmed complete fistula obliteration, cavernoma resection, and new appearance of a developmental venous anomaly (DVA). This case highlights the dynamic nature of dAVF venous drainage and illustrates the rare co-occurrence of dAVF, DVA, and brainstem cavernoma. The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2553