Anterior Cranial Fossa Dural Arteriovenous Fistulae - Angioarchitecture and Intervention

Purpose: Anterior cranial fossa (ACF) dural arteriovenous fistulae (DAVF) are rare, unique, and ominous. While surgical disconnection is considered as the favored management option, endovascular treatment has lately gained importance. We present a single institution experience of seven cases.

Method: A retrospective analysis was performed on the institutional patient database. Features analyzed were demographic details, symptoms, angioarchitecture, treatment course, angiographic results, procedural complications, and follow-up.

Results: This study included seven patients. The age at presentation ranged from 5-67 years. Clinical symptomatology was as intracranial hemorrhage in 4 patients and headache, chemosis and seizures in one patient each. The fistulae were paramedian at the ACF base. All DAVFs were Cognard type 4. The arterial feeders were from the anterior ethmoidal branches of the ophthalmic artery in all cases (bilateral in n = 5), frontal branches of the middle meningeal artery (MMA) (n = 6), and multiple ECA branches. The arterial route was the choice for access. Complete fistula obliteration was achieved in all but one patient. A traversed vein underwent rupture in one patient. One patient suffered postsurgical hemorrhage. No clinical or angiographic recurrence was noted.

Conclusion: The DAVFs of the ACF are inherently high-grade lesions. Transorbital ECA-ICA branch anastomoses may be recruited as feeders. They may be best managed by multidisciplinary means personalized on an angioarchitectural basis. Endovascular embolization is safe and efficacious when performed through a navigable feeder from the frontal division of the MMA, which according to our interpretation is in anastomosis with the anterior falcine branch of the anterior ethmoidal artery.