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Bilateral ethmoidal dural arteriovenous fistulae: a previously unreported entity: case report
Vivek R Deshmukh1, Steve Chang, Felipe C Albuquerque
1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Objective And Importance:
Ethmoidal dural arteriovenous fistulas (AVFs) are rare intracranial lesions associated with a high risk of intracranial hemorrhage. Reported hemorrhage rates have ranged from 62 to 91%, and an aggressive clinical course is more likely than a benign clinical course. We describe the first case of a patient with bilateral ethmoidal dural AVFs.
Clinical Presentation:
A 50-year-old man presented with posterior fossa subarachnoid hemorrhage and cerebellar intraparenchymal hemorrhage. Angiography revealed a tentorial AVF and a complex anterior ethmoidal dural AVF.
Intervention:
The tentorial AVF was treated with preoperative embolization and surgical obliteration. On follow-up angiography, the ethmoidal dural AVF was not considered amenable to embolization. A right modified orbitozygomatic approach was performed and the right-sided fistula was interrupted. Intraoperative angiography revealed obliteration of the right-sided fistula, but a persistent fistula on the left. Further surgical exploration revealed this contralateral anterior ethmoidal dural AVF, which was clip ligated. No residual fistula was noted on intraoperative angiography.
Conclusion:
Anterior ethmoidal dural AVFs may occur bilaterally. Given their complex angiographic appearance, their presence bilaterally may not be readily apparent on preoperative angiography. Intraoperative angiography is crucial to identify a contralateral fistula and to verify that ligation has been curative.
