Cranial Fossa Dural Arteriovenous Fistula Research Articles

Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx.

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT's role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger's test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

Microsurgical Management of a Middle Cranial Fossa Dural Arteriovenous Fistula After Failed Embolization: 2-Dimensional Operative Video.

Dural arteriovenous fistulas (DAVFs) are intracranial vascular lesions with abnormal communication between the dural arteries and dural and/or cortical venous systems. While benign DAVFs, like Cognard I and IIa/Borden I, can be observed, higher-grade DAVFs, such as Cognard IIb-V/Borden II and III, should be treated.1,2 This video article depicts the microsurgical management after embolization of a middle cranial fossa Cognard IV DAVF with venous varices causing mass effect in the right thalamus, basal ganglia, and posterior limb of the right internal capsule. Initial attempts at embolization showed persistent arterial supply from the right ophthalmic artery and distal right internal maxillary artery, with sustaining cortical venous reflux. Microsurgical clipping was chosen because of venous congestion, associated risk of hemorrhage, and corresponding neurological symptoms. The patient consented to the procedure. Intraoperative angiography revealed successful obliteration of the fistula, and postoperative imaging displayed no residual DAVF and thrombosed venous varices without complications. The patient showed remarkable improvement, with a resolution of neurological deficits on discharge to rehabilitation. This case highlights the potential efficacy of direct clipping after unsuccessful endovascular intervention for DAVFs. Understanding the angioarchitecture with identification of the fistulous point, using intraoperative imaging modalities, and ensuring comprehensive exposure are crucial steps in such microsurgical interventions.

Trans-Arterial Embolization of Anterior Cranial Fossa Dural Arteriovenous Fistulas via the Sphenopalatine Artery: A Technique Report

BackgroundTrans-arterial embolization (TAE) via the ophthalmic artery and middle meningeal arterial are the common arterial routes for anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs). However, TAE via the sphenopalatine artery (SPA) to treat ACF DAVFs is rarely reported. Here, we describe 14 cases of ACF DAVFs that were either treated solely or in conjunction with other arterial routes via the SPA. A total of 15 embolization attempts were performed via the SPA. Method14 patients were treated with TAE via the SPA over a 20-year period. There were 13 males and 1 female in total, with a mean age of 57.4 (57.4±6.0) years. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were all documented. Results14 patients with ACF DAVFs underwent TAE via the SPA. Complete immediate angiographic occlusion was achieved in 78.6% of the fistulas (11/14). Complete embolization via the SPA alone was achieved in 63.6% (7/11) of the fistulas. A total of 15 embolization attempts were performed via the SPA, with a 46.7% (7/15) success rate. After TAE via the SPA, no complications were found. 42.9% (6/14) of the patients had DSA or MRA follow-up. There was no recurrence of the fistulas. ConclusionsThe SPA may be as an alternative arterial route if other appropriate arterial routes are unavailable. However, its safety and efficiency need to be confirmed further.

Transarterial embolization for anterior cranial fossa dural arteriovenous fistulas: a retrospective single-center study

BackgroundClip ligation of anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) is the traditionally accepted first-line treatment. Endovascular treatment for ACF DAVFs may achieve good outcomes as endovascular techniques advance....

Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas

BackgroundAnterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous...

Anterior cranial fossa osseous arteriovenous fistula of the crista galli with bone erosion: patient series

BACKGROUNDAlthough an anterior cranial fossa dural arteriovenous fistula (ACFdAVF) is thought to have a fistula on the dura near the olfactory groove, the detailed angioarchitecture remains unreported.OBSERVATIONSIn case 1, a 65-year-old man was found to have an asymptomatic ACFAVF. His computed tomography angiography (CTA)-maximum intensity projection (MIP) showed the shunt point in the crista galli (CG), with the intradural drainer penetrating the destroyed bone of the CG. In case 2, a 78-year-old man had a past history of intracerebral hemorrhage and was found to have an ACFAVF. The rotational angiography (RA)-MIP showed the intraosseous fistula in the CG with the drainer passing through a tiny bone defect of the CG. In case 3, a 35-year-old man was investigated for epilepsy. The RA-MIP showed an osseous arteriovenous fistula (AVF) in the anterior cranial base, with the drainer penetrating the skull osteolytic site. In case 4, a 73-year-old woman was found to have an asymptomatic ACFAVF. Her RA-MIP showed the osseous AVF with the drainer penetrating the CG with bone erosion.LESSSONSAll patients were diagnosed with anterior cranial fossa osseous AVF rather than dAVF, with bone erosion in the CG. These findings should be noted at the time of diagnosis and treatment.

Foramen Caecum Vein Involved in Dural Arteriovenous Fistula Fed by Sphenopalatine Arteries: A Case Report

Anterior cranial fossa (ACF) dural arteriovenous fistulas (ACF DAVFs) are an infrequent subtype of cranial DAVFs that are usually fed by the anterior ethmoidal artery (AEA) and ophthalmic artery (OA) branches. Due to the lack of dural venous sinus in the ACF, they directly drain into cortical veins, resulting in high bleeding tendency. For this reason, ACF DAVFs have to be treated regardless of whether they are symptomatic or not. A 74-year-old man, with hypertension history, came to our attention because of ear pain, dizziness, and impaired hearing for 2 months. No other pathological conditions have been found in his medical history. The patient underwent brain magnetic resonance imaging (MRI) scan and subsequently second level diagnostic investigations with digital subtraction angiography (DSA), showing a foramen caecum (FC) patency and a persistent, enlarged, arterialized FC vein (FCV) involved in an incidental ACF DAVF (Cognard IV), fed mainly by sphenopalatine arteries (SPAs) branches bilaterally. The patient underwent open surgery performed by small high frontal craniotomy with DAVFs complete closure and without any complications. To the best of our knowledge, this is the first case ever described of FCV persistence with involvement in an intracranial vascular malformation. It has been managed by surgical intervention that can be considered, despite the large skin incision, a minimally invasive approach with an excellent cosmetic result and minimal risk of complications.

Endovascular treatment of anterior cranial fossa dural arteriovenous fistula: a multicenter series.

We report a multicenter experience using endovascular embolization as the first line approach for treatment of anterior cranial fossa (ACF) dural arteriovenous fistula (DAVF). All patients with DAVFs located in the anterior cranial fossa who were treated with endovascular technique as a first line approach were included. Demographics, clinical presentation, angioarchitecture, strategy, complications, immediate angiographic, and follow-up results were included in the analysis. Twenty-three patients met the inclusion criteria (18 male and 5 female). Age ranged from 14 to 79years (mean 53years). Twelve patients presented with hemorrhage. Twenty-eight endovascular procedures were performed. The overall immediate angiographic cure rate after endovascular treatment was 82.6% (19/23 patients). The angiographic cure rate of the transvenous strategy was significantly superior to the transarterial strategy (p ≤ 0.001). There was 1 complication in 28 total procedures (3.6%). Angiographic follow-up was available in 21 out of the 23 patients with a mean of 25months (range 2 to 108months). In these 21 patients, the DAVF was completely cured in 20 (95%). At last follow-up, all patients had a modified Rankin scale (mRS) 0 to 2. Our experience suggests that endovascular treatment for ACF DAVFs has an acceptable safety profile with high rates of complete occlusion, particularly with transvenous approach. Whenever possible, transvenous approach should be preferred over transarterial approach as first line strategy.

Frontal Ethmoidal Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Anterior cranial fossa dural arteriovenous fistulas (DAVFs) are an infrequent subtype of cranial DAVFs. These lesions are most commonly derived from the ophthalmic artery. These lesions are often best treated utilizing endovascular embolization; however, this modality can be challenging because of the difficulty in catheterizing the ophthalmic or ethmoidal arteries. Surgical intervention is therefore indicated and requires approaching the proximal portion of the drainage vein to appropriately obliterate the fistulous point. For ethmoidal DAVFs, this is frequently along the dura of the cranial base adjacent to the cribriform plate. This patient had a right frontal hematoma with a typical ethmoidal DAVF. The fistula was exposed through a frontal craniotomy, and the ethmoidal branch was identified at the fistulous point. Intraoperative angiography was used to test for obliteration, which revealed a contralateral DAVF. The contralateral fistula was then obliterated in a similar manner, demonstrated on a second intraoperative angiogram. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Anterior cranial fossa dural arteriovenous fistula with pial arterial supply

Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) are mainly fed by the ethmoidal arteries and sometimes have pial arterial feeders. DAVFs with pial arterial supply in ACF are extremely rare because most of the reported cases of DAVFs with pial arterial supply are located at the transverse sigmoid sinus and tentorium. A 68-year-old male presented with dizziness. Angiography showed cortical venous reflex (CVR) through an ACF DAVF fed by both bilateral ethmoidal arteries and by the right orbitofrontal artery as a pial feeder. The ethmoidal feeders were disconnected by craniotomy. The pial arterial feeder from the anterior cerebral artery was not found during surgery, and disconnection of the draining vein was not performed. CVR showed a significant reduction after the surgery. After 2 years of follow-up, angiography revealed an increased shunt flow from the pial feeder. Endovascular treatment using n-butyl-2-cyanoacrylate was performed, resulting in the complete occlusion of the fistula. DAVFs with pial supply are reported to carry a high risk of perioperative complications because of the restriction of the venous outflow and retrograde thrombosis of the pial artery. Endovascular pial feeder occlusion after surgical dural arterial feeder disconnection might achieve a safe and effective outcome. With close follow-up, the recurrence of increased shunt flow may be an appropriate timing for additional treatment. This rare condition may offer a new insight into the mechanisms of pial feeder development.

Clinical Characteristics and Microsurgery Treatment of Anterior Cranial Fossa Dural Arteriovenous Fistula.

Anterior cranial fossa dural arteriovenous fistulas (DAVFs) represent 6% of all intracranial DAVFs and have a high risk of intracranial hemorrhage. To analyze the clinical characteristics and microsurgery treatment of anterior cranial fossa DAVFs, a retrospective review of 21 patients with anterior cranial fossa DAVFs undergoing microsurgery was performed, including 8 bleeding patients and 13 non-bleeding patients. The Glasgow coma scale (GCS) scores were used to evaluate the conscious states of 8 bleeding patients before and after operation. All patients had no obvious complications and the clinical symptoms were improved after operation. No abnormal fistulas and drainage veins were detected by digital subtraction angiography postoperatively. The GCS scores of 8 bleeding patients showed that the conscious states became better than pre-operation. Of the 21 patients, 9 patients were followed up without recurrence. Taken together, microsurgery is an effective method for the treatment of anterior cranial fossa DAVFs and it is very important for the improvement of bleeding patients' conscious states.

Surgical Obliteration of Anterior Cranial Fossa Dural Arteriovenous Fistulas via Unilateral High Frontal Craniotomy

Surgical obliteration is generally recommended for anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) because of a high risk of bleeding and the difficulty of endovascular approaches. Surgical obliteration is generally performed via a frontobasal craniotomy; however, it is slightly excessive over the target fistula. Here, we present 2 cases of ACF DAVFs treated with small craniotomy without frontal sinus involvement and a review of the related literature. We present 2 cases including a 63-year-old woman who presented with a right-sided ACF DAVF that was fed by both ethmoidal arteries and drained into the right cortical veins (case 1) and a 59-year-old man with right-sided unruptured multiple aneurysms and a left-sided ACF DAVF that was fed by the right ethmoidal artery and drained into the left cortical veins (case 2). Case 1 underwent surgical obliteration via a right high frontal craniotomy. Case 2 was simultaneously treated with surgical clipping of the multiple aneurysms via a right lateral supraorbital craniotomy and surgical obliteration of the ACF DAVF via a left high frontal craniotomy. These 2 patients had no neurologic deficits, and complete obliteration of all the lesions was confirmed on cerebral angiography. Constructing a small corridor and a deep working distance in unilateral small high frontal craniotomy may be a slightly unusual approach; however, it is thought to provide sufficient space and a range of microscopic views that facilitate surgical manipulation without requiring extensive bone work.

Anterior cranial fossa dural arteriovenous fistula: Transarterial embolization from the ophthalmic artery as first-line treatment

ObjectiveTo retrospectively review the outcome of patients with dural arteriovenous fistula of the anterior cranial fossa (afDAVF) treated by transarterial embolization. Material and methodsSix consecutive patients were referred to our hospital for afDAVF treatment. After a multidisciplinary discussion, they underwent endovascular embolization with Onyx injection through the ophthalmic artery. Their clinical presentation, management and outcomes were retrospectively assessed. ResultsAll interventions were performed with the liquid embolic agent Onyx through the transarterial route from the ophthalmic artery to access the fistulous point. All patients showed a good outcome with complete afDAVF obliteration. ConclusionThis study demonstrates that afDAVFs can be safely and completely obliterated by transarterial embolization via the ophthalmic artery.

Surgical treatment of anterior cranial fossa dural arterio-venous fistulas (DAVFs): a two-centre experience.

Anterior cranial fossa dural arterio-venous fistulas (DAVFs) represent 6% of all intracranial DAVFs; characteristically they show an aggressive behaviour with high risk of intracranial haemorrhage. Peculiar anatomical features, such as feeding by the ethmoidal arteries and the pattern of venous drainage (frequently with varices that mimic aneurysmal dilatation), can be evaluated in detail only by digital subtraction angiography (DSA), which represents the "gold standard" in the diagnosis of such cranial fistulas. Recent technological developments in endovascular management of this type of DAVF have partially reduced the morbidity risk related to this modality of treatment. Our purpose is to present our experience in the surgical management of 14 patients with anterior cranial fossa DAVFs, with attention paid to the possible role of preoperative embolisation in these cases and to the surgical technique. Between 1999 and 2015, 14 patients with anterior cranial fossa DAVFs were submitted to surgery in two neurosurgical departments; the mean age was 63years old; nine DAVFs caused intracranial haemorrhage (subarachnoid haemorrhage in three cases, intracerebral haemorrhage in six cases). Pre-operative embolisation was attempted in an early case and was successfully done in one recent case. In all patients, the surgical approach chosen was a pterional craniotomy with a low margin on the frontal bone in order to gain the exposure of the anterior cranial fossa and especially of the olphactory groove region; the resection of the falx at its insertion on the crista galli was needed in five cases in order to get access to the contralateral afferent vessels. Cauterisation of all the dural feeders on and around the lamina cribrosa was needed in all cases; venous dilatations were evident in eight patients (in seven out of nine patients with ruptured DAVF and in one out of five patients with unruptured DAVF) and were removed in all cases. One patient harboured an ophthalmic artery aneurysm, which was excluded by clipping. One patient died 5days after surgery due to the severity of the pre-operative haemorrhage. Postoperative DSA showed the disappearance of the DAVF and of the venous pseudo-aneurysms in all cases. Clinical outcome was favourable (without neurological deficits) in 11 patients; three patients presented an unfavourable clinical outcome, due to the severity of the initial haemorrhage. Surgical exclusion of the anterior cranial fossa DAVFs still represents the gold standard for such lesions, due to low post-operative morbidity and to complete protection against future rebleedings; endovascular techniques may help the surgeon in complex cases.

Interhemispheric approach for endoscopic ligation of an anterior cranial fossa dural arteriovenous fistula

We describe the endoscopic ligation of an anterior cranial fossa (ACF) dural arteriovenous fistula (DAVF) through an interhemispheric approach. Intracranial DAVF of the ACF are rare and associated with an aggressive natural history, due to their ubiquitous direct cortical venous drainage and frequent coincidence of venous ectasia. Although surgical ligation is the preferred treatment for ACF DAVF, the role of endoscopy in the surgical management of DAVF is undefined. A 53-year-old woman was incidentally diagnosed with an ACF DAVF. Cerebral angiography showed a Borden type III, Cognard type IV left sided ACF DAVF, supplied by ethmoidal branches of the bilateral ophthalmic arteries and draining directly into an enlarged and ectatic left inferior frontal cortical vein, with a venous varix distal to the point of fistulization. An initial attempt at endovascular treatment from a transvenous approach was unsuccessful, due to significant stenosis of the left cavernous sinus. Therefore, we elected to proceed with surgical ligation. From an interhemispheric approach and under the guidance of frameless stereotactic neuronavigation, a 0° endoscope was advanced into the interhemispheric fissure until the arterialized draining vein was visualized. After dissecting along the draining vein to the point of fistulization, the proximal portion of the draining vein was ligated. Intraoperative angiography confirmed complete obliteration of the DAVF, and the patient was asymptomatic at the 6week postoperative follow-up. Endoscopy provides excellent visualization of ACF DAVF and can safely facilitate surgical treatment in appropriately selected patients with these lesions.

Endovascular Approach for Treatment of Frontal Dural Arteriovenous Fistula through the Ophthalmic Arteries using Glue: A Case Presentation with Review of Literature

A rare case of right frontal bleed in elderly gentleman secondary to anterior cranial fossa dural arteriovenous fistula was detected on computed tomography angiogram, and complete endovascular embolization was achieved through ophthalmic arteries using glue as embolic material. Successful endovascular treatment along with surgical evacuation of subdural hematoma resulted in excellent recovery of the patient. Quick in-and-out approach using flow directed microcatheters and fast embolizing potential of glue may allow for rapid, safe, and successful embolization of such fistulas. The rarity of the location and the transarterial glue embolization of the nidus by micro catheter through both ophthalmic arteries makes this an interesting case for discussion.

Undiagnosed Anterior Cranial Fossa Dural Arteriovenous Fistula with Intracranial Hematoma: Case Report and Review of the Literature about Its Natural History

Dural arteriovenous fistulas (dAVFs) of an anterior cranial fossa are rare. Because of the high risk of intracranial hemorrhage and relatively easy access for direct surgery, aggressive treatment has been recommended. The natural history of anterior cranial fossa dAVFs (ACF dAVFs) is unclear in spite of many reports for the natural history of general dAVFs. To treat ACF dAVFs, direct surgery has traditionally been performed and endovascular surgery has recently been introduced. A 74-year-old man was transferred with severe consciousness disturbance and presented with devastating intracerebral hemorrhage on the CT scan. Digital subtraction angiography revealed the ACF dAVFs with a large venous pouch. The patient received direct surgery, nevertheless he became vegetative state. Later on, a smaller venous pouch was recognized on the CT scan when he had suffered from the thalamic hemorrhage sixteen months before. There are twelve cases including our case which was treated for a certain period and documented in detail. Eleven of twelve cases were asymptomatic. Three of the six cases with a venous pouch had some events possibly related to the disease, though none of the six cases without a venous pouch had any events during observation. In conclusion, an ACF dAVF with a venous pouch should be treated by direct surgery or endovascular surgery even if it is incidentally found. By contrast, careful observation might be a possible therapeutic option for an ACF dAVF without a venous pouch if there is mild reflux flow.

Aneurysmal Dilatation of Anterior Cranial Fossa Dural Arteriovenous Fistula: Three Cases

Aneurysmal dilatation of anterior cranial fossa dural arteriovenous fistula is a rare malformation with a unique and complex angio-architecture profile. Clinical manifestations, diagnosis and treatment management of three patients with the malformation were retrospectively analyzed. Preoperative examinations revealed all three patients suffered from aneurysmal dilatation; two of them were treated with surgical clipping of the fistula as well as removing of the aneurysm, and cured; one patient died of delayed surgical operation and other complications in two weeks. MRI examination could be used for early diagnosis and cerebral angiography could further confirm the diagnosis. To achieve a favorable outcome for patients the malformation has to be treated as early as possible by surgery or interventional therapy. doi: http://dx.doi.org/10.4021/jnr230e

Transarterial treatment with Onyx of Cognard type IV anterior cranial fossa dural arteriovenous fistulas

Background and purposeCognard type IV anterior cranial fossa dural arteriovenous fistulas (DAVFs) are rare lesions with a high risk of intracranial hemorrhage. We present our experience with the use of...

Aneurysmal Dilatation of Anterior Cranial Fossa Dural Arteriovenous Fistula: Three Cases

Aneurysmal dilatation of anterior cranial fossa dural arteriovenous fistula is a rare malformation with a unique and complex angio-architecture profile. Clinical manifestations, diagnosis and treatment management of three patients with the malformation were retrospectively analyzed. Preoperative examinations revealed all three patients suffered from aneurysmal dilatation; two of them were treated with surgical clipping of the fistula as well as removing of the aneurysm, and cured; one patient died of delayed surgical operation and other complications in two weeks. MRI examination could be used for early diagnosis and cerebral angiography could further confirm the diagnosis. To achieve a favorable outcome for patients the malformation has to be treated as early as possible by surgery or interventional therapy. J Neurol Res. 2013;3(5):159-162 doi: https://doi.org/10.4021/jnr230e