Clipping of bilateral supply to a midline ethmoidal dural arteriovenous fistula at the origin of the superior sagittal sinus using a bifrontal approach

Roberto Rodriguez Rubio, MD; Ricky Chae, BA; W. Caleb Rutledge, MD; Vera Vigo, MD; Ethan Winkler, MD, PhD; Ioannis Kournoutas, BS; Adib A. Abla, MD

Interdisciplinary Neurosurgery (Dec 2019)

Clipping of bilateral supply to a midline ethmoidal dural arteriovenous fistula at the origin of the superior sagittal sinus using a bifrontal approach

Roberto Rodriguez Rubio, MD,
Ricky Chae, BA,
W. Caleb Rutledge, MD,
Vera Vigo, MD,
Ethan Winkler, MD, PhD,
Ioannis Kournoutas, BS,
Adib A. Abla, MD

Affiliations

Roberto Rodriguez Rubio, MD: Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA; Department of Otolaryngology – Head and Neck Surgery, University of California, San Francisco, CA, USA
Ricky Chae, BA: Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
W. Caleb Rutledge, MD: Department of Neurological Surgery, University of California, San Francisco, CA, USA
Vera Vigo, MD: Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
Ethan Winkler, MD, PhD: Department of Neurological Surgery, University of California, San Francisco, CA, USA
Ioannis Kournoutas, BS: Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
Adib A. Abla, MD: Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA; Corresponding author at: Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave, M780, San Francisco, CA 94143, USA.

Journal volume & issue: Vol. 18

Abstract

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Dural arteriovenous fistulas (dAVFs) in the anterior cranial fossa represent only 10% of all dAVFs. Anterior fossa or ethmoidal dAVFs have a unique angioarchitecture, with cortical vein drainage, associated with a significant risk of hemorrhage. Treatment of ethmoidal dAVFs is challenging due to the ethmoidal artery origin and branch of the ophthalmic artery (OpA), which makes this lesion a difficult target for endovascular route.We present management of a 59-year-old female with a recent history of migraine. Angiography demonstrated bilateral supply with shunting directly into the superior sagittal sinus (SSS) at its origin adjacent to the crista galli via ethmoidal arteries arising from both OpA, and a 5 mm basilar tip aneurysm projecting postero-superiorly. Since the fistula had a higher risk of hemorrhage, aneurysm occlusion was deferred for treatment at a later time. Endovascular occlusion of the dAVF was not feasible due to the high risk of catherization of OpA, and the patient agreed to microsurgical treatment. A bifrontal craniotomy with ligation of SSS in its proximal third was required to allow access to the crista galli. After occlusion of the arterial feeders, clips were placed to occlude the origin of SSS and avoid fistula recurrence. The patient was discharged without complications, and post-operative angiography showed complete occlusion of the fistula and no further shunting into the SSS. This facilitated future antiplatelet therapy for endovascular treatment of the basilar aneurysm. Keywords: Dural arteriovenous fistula, Ethmoidal arteries, Bifrontal approach

Published in Interdisciplinary Neurosurgery

ISSN: 2214-7519 (Online)
Publisher: Elsevier
Country of publisher: Netherlands
LCC subjects: Medicine: Surgery; Medicine: Internal medicine: Neurosciences. Biological psychiatry. Neuropsychiatry: Neurology. Diseases of the nervous system
Website: http://www.journals.elsevier.com/interdisciplinary-neurosurgery/

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