Microsurgical Treatment of Ethmoidal Dural Arteriovenous Fistula

A 78-year-old male patient presented with an episode of confusion. Computed tomography angiography (CTA) revealed an abnormal collection of vessels in the basal frontal region, and diagnostic cerebral angiogram revealed an ethmoidal dural arteriovenous fistula (dAVF). dAVFs are rare intracranial vascular lesions, comprising approximately 2%-3% of all dAVFs.^1-3 These fistulas are primarily supplied by the ethmoidal branches of the ophthalmic artery.^1-3 A high-grade ethmoidal dural arteriovenous fistula characterized by cortical venous drainage or associated symptoms requires treatment.⁴ Intervention is necessary due to the potential risk of intracranial hypertension or hemorrhage,⁴ which could lead to serious neurological deficits.⁵ Endovascular treatment of ethmoidal dural arteriovenous fistulas, while possible, could lead to blindness due to ethmoidal feeders branching from ophthalmic artery and risk of retrograde embolization.⁶ Given the fistula's angioarchitecture and supply solely from ethmoidal branches, microsurgery was selected as the primary treatment to mitigate the risk of visual compromise. The patient underwent microsurgical treatment for dAVF disconnection. The surgical strategy involved subarachnoid dissection, identification of the main draining vein, identification of fistulous arteries, coagulation of the feeders, and disconnection of the main draining vein. The patient made an excellent recovery, and his confusion resolved. He was initially discharged to home on postoperative day 2 but returned due to left-sided weakness and a right convexity hygroma requiring single burr hole drainage. A 1-month follow-up in clinic revealed the patient was neurologically intact, and a CTA of the head revealed no residual fistula. At the 1-year follow-up, he was without neurological deficit. A follow-up CTA showed no evidence of recurrence. This video article aims to demonstrate the key microsurgical steps, anatomical landmarks, and the efficacy of open surgery as a primary treatment for these unique fistulas.