Management of dural arteriovenous malformations of the anterior cranial fossa

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✓ Eight patients with dural arteriovenous malformations (AVM's) of the anterior cranial fossa are presented, and the pertinent literature is reviewed. Unlike cases of dural AVM's in other locations, sudden massive intracerebral hemorrhage was the most frequent reason for presentation. Other symptoms included tinnitus, retro-orbital headache, and a generalized seizure. The malformations were supplied consistently by the anterior ethmoidal artery, usually in combination with other less prominent feeding vessels. The lesion's venous drainage was through the superior sagittal sinus via a cortical vein; in addition, in two cases a subfrontal vein drained the AVM. A venous aneurysm was encountered near the site of anastomosis with the dural feeder in most cases, and was found in all patients who presented with hemorrhage. The AVM was obliterated surgically in six patients, with favorable results achieved in five. One patient died postoperatively from a pulmonary complication. Because of their anatomy and proclivity for hemorrhage, these vascular malformations represent a unique group of dural AVM's. Surgical management of anterior fossa dural AVM's carries low morbidity, and is indicated when the lesions have caused hemorrhage or when there is an associated venous aneurysm.

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Address reprint requests to: Neil Martin, M.D., Division of Neurosurgery, 74-140 CHS, University of California at Los Angeles Medical Center, Los Angeles, California 90024.

© AANS, except where prohibited by US copyright law.

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    Case 8. Left: Computerized tomography scan showing a large intraparenchymal hemorrhage in the left frontal lobe with mass effect and intraventricular extension. Right: Left common carotid angiogram. The venous aneurysm which was the source of hemorrhage is demonstrated (upper arrow). The two smaller arrows indicate the ophthalmic and anterior ethmoidal arteries. The nidus in the dura is located in the region of the open arrow.

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    Drawing of a typical anterior fossa dural arteriovenous malformation indicating the anterior ethmoidal artery, nidus, and venous aneurysm.

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    Left common carotid angiograms, early arterial phase, in Case 5. Left: This shows a branch of the ophthalmic artery (small arrows) feeding the dural arteriovenous malformation (AVM) nidus (large arrow). An aneurysm clip was previously used to treat a contralateral middle cerebral artery aneurysm. Right: Distal branches of the internal maxillary artery (lower arrows) have been recruited by the AVM. The supraorbital branch (arrowheads) and a transosseous branch (upper arrows) of the superficial temporal artery also supply the AVM. In this case drainage is through a subfrontal pial vein.

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    Case 4. Right common carotid angiogram showing an incidentally found anterior fossa arteriovenous malformation. The malformation drains directly into the superior sagittal sinus (large arrows). The nidus is clearly seen distal to the ophthalmic and ethmoidal arteries (small arrows).

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    Surgical drawing with the left frontal lobe elevated to reveal the arterialized vascular connection between the dura in the region of the cribriform plate and the pial venous system.

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    Internal carotid angiograms in Case 2. Left: Preoperative appearance of the lesion. Solid arrows identify the draining veins. The open arrow shows drainage into the posterosuperior compartment of the cavernous sinus. Right: Postoperative result after dividing the vascular connection between the anterior fossa dura and the frontal lobe. There is no filling of either the nidus (arrow) or the draining veins.

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