Pial arterial venous fistulas (PAVFs) are rare vascular entities that occur with direct high-flow connections between pial arterial feeders and large veins without an intervening nidus.1-5 These vascular abnormalities can present in the pediatric population with high output heart failure.1 PAVFs can be treated with endovascular intervention, microvascular ligation, or a combination depending on the clinical scenario.4 Here, we present a case in which a newborn presented in high output heart failure because of a large left-sided middle cerebral artery fed PAVF. We performed a craniotomy for ligation of the PAVF to obliterate the arteriovenous shunting to improve her cardiac status and diminish her intracranial venous hypertension. Throughout the ligation, we used indocyanine green to localize the next appropriate vessels to ligate, allowing us to safely obliterate the anomalous vasculature and improve the patient's cardiac function. Postoperatively, the patient did well neurologically with improvements in cardiac function and near normalization of intracranial vasculature. The patient's guardians consented to the procedure and to the publication of her image.
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