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.

Stent assisted coil embolization of wide-necked bilobed anterior inferior cerebellar artery aneurysm with incorporated artery arising from the dome: a technical note.

BACKGROUND: A technique for stent-assisted coil embolization of a bilobed wide-necked saccular aneurysm of the anterior inferior cerebellar artery (AICA) with the AICA arising from the dome of the aneurysm is described. CLINICAL PRESENTATION: A middle-aged patient was referred for treatment of a bilobed saccular aneurysm identified on a CT angiogram performed for a subarachnoid hemorrhage which occurred 20 days prior to presentation. A diagnostic angiogram showed a bilobed wide-necked saccular aneurysm at the AICA origin with the AICA arising from the dome of the aneurysm and also supplying the territory of the posterior inferior cerebellar artery. The therapeutic procedure involved trans-aneurysmal cannulation of the AICA with the microcatheter left in situ. Another microcatheter was maneuvered into the larger dome of the aneurysm. A stent was then deployed in the basilar artery, jailing the previous microcatheter in the aneurysm. Helical Guglielmi detachable coils were deployed in the aneurysm resulting in complete occlusion of the aneurysm with preservation of the AICA. CONCLUSIONS: It is important to preserve a normal branch arising from the dome of an aneurysm although it is technically demanding and a relative limitation. This case report describes a technique of coiling a bilobed aneurysm with a vital branch arising from the dome, with preservation of the branch and complete occlusion of the aneurysm using two microcatheters and a stent. This expands the repertoire of endovascular treatment of complex aneurysms.