Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment

Clinical article

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Object

Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare lesions that can cause intracranial hemorrhage. Authors of previous reports mostly have described open surgical treatment for this fistula type. The authors' purpose in the present study was to describe their experience with anterior cranial fossa DAVFs, including their endovascular treatment.

Methods

All patients with anterior cranial fossa DAVFs diagnosed and treated in 3 separate institutions during the last 23 years were retrospectively identified. Clinical charts, imaging studies, and procedural notes were evaluated.

Results

Twenty-four patients (22 males and 2 females), ranging in age from 3 to 77 years, harbored 24 DAVFs in the anterior cranial fossa. Eleven patients were primarily treated with surgical disconnection and 2 with radiosurgery. Eleven patients were treated endovascularly; 7 of these patients (63.6%) were cured. In 4 cases of failed embolization, final disconnection was achieved through surgery. In fact, surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures consisted of transarterial injections of diluted glue (N-butyl cyanoacrylate [NBCA]), and there were no complications. Brain edema developed around the venous pouch and confusion was apparent after venous disconnection in 1 surgically treated patient. No patient suffered a hemorrhage during the follow-up period.

Conclusions

Disconnection of an anterior cranial fossa DAVF by using transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and low risk for complications. In patients with good vascular access this procedure could be the treatment of choice, to be followed by open surgery in cases of embolization failure.

Abbreviations used in this paper: AVM = arteriovenous malformation; DAVF = dural arteriovenous fistula; DS = digital subtraction; ECA = external carotid artery; ICA = internal carotid artery; ICH = intracerebral hematoma; NBCA = N-butyl cyanoacrylate; OphA = ophthalmic artery; PVA = polyvinyl alcohol; SSS = superior sagittal sinus.

Article Information

Address correspondence to: Ronit Agid, M.D., Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, 399 Bathurst Street, 3 McLaughling Wing, Room #425, Toronto, Ontario, M5T 2S8 Canada. email: ronit.agid@uhn.on.ca.

Please include this information when citing this paper: published online October 10, 2008; DOI: 10.3171/2008.6.17601.

© AANS, except where prohibited by US copyright law.

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    Images obtained in a 55-year-old man with a 1-week history of severe headaches, nausea, vomiting, and confusion. A: Axial unenhanced CT showing an intraparenchymal hematoma in the right frontal lobe. B: Diagnostic right ICA angiogram, lateral view, demonstrating an anterior cranial fossa DAVF. The main supply to this fistula is from the right OphA via the right ethmoidal artery. Venous drainage is into an olfactory vein and via a frontal cortical vein into the SSS (arrows in B). C: Angiogram revealing contribution from the right ECA. Relatively minor supply is also noted from the left ICA (not shown). D: Angiogram, lateral view, obtained after a microcatheter was advanced into the right OphA and selective injections were performed, verifying that the microcatheter tip is located beyond the origin of the central retinal artery. The whole nidus and the proximal part of the draining vein were embolized using 50% NBCA. E: Angiogram, same lateral view as in panel D, demonstrating the radiopaque glue cast formed during embolization (arrow). F: Postembolization right ICA angiogram, lateral projection, confirming complete cure of the fistula. Injection of the left ICA and ECA also showed no residual fistula.

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