• Francesco Calvanese, Anna Maria Auricchio, Rahul Raj, and Martin Lehecka.
• Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
• World Neurosurg. 2025 Feb 10: 123750123750.

AbstractSphenoid dural arterio-venous fistulas (DAVFs) located on the greater sphenoid wing (GSW) carry a notable risk of intracranial hemorrhage due to the frequent presence of cortical venous reflux. Because of the challenging embolization procedure, microsurgery still remains a valuable option in these cases. While in most cases, the fistula is located in the anterolateral endocranial surface of the middle cranial fossa (MCF) just below the sphenoid ridge, in a small subset of cases, the fistula is positioned posteriorly and medially in the region between the foramen ovale and rotundum. The former region can be reached using various frontolateral approaches, while the latter region can be accessed through a subtemporal trajectory, minimizing temporal lobe retraction. Exoscope has been gaining popularity for improved magnification, visualization and surgeon ergonomics expanding possible surgeon trajectory in skull base surgery. We present a targeted subtemporal approach using the exoscope for selective occlusion of an unruptured greater sphenoid wing DAVF. With proper brain relaxation a small temporobasal craniotomy opens a direct corridor to the middle cranial fossa. Exoscopic-assisted surgery could improve dissection of middle cranial base, dynamic temporal lobe retraction and expand the range of antero-medial subtemporal trajectories providing angles that may be challenging to achieve using the operative microscope, as well as improve the surgeon's ergonomy. Thus, exoscopic-assisted subtemporal approach is a feasible, safe and a minimally invasive approach to treat unruptured greater sphenoid wing DAVFs and could be considered an alternative to the endovascular treatment.Copyright © 2025 The Author(s). Published by Elsevier Inc. All rights reserved.

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