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

Abstract

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 sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.MethodsThe CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990–2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.Results60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.ConclusionMost ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.

Microsurgical versus endovascular treatment of ethmoidal dural arteriovenous fistulas: systematic review and meta-analysis with a single-center case series

“…22 In a retrospective analysis of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database by Sanchez et al, 51 of 60 (85%) patients had CVD, most commonly draining into the superior sagittal sinus (63%, 32/51), followed by the cavernous/petrous sinuses (8%, 4/51). 30 These findings in the literature are supported by our meta-analysis, with 86% of the patients in our review having bilateral ethmoidal arterial supply and 98% having CVD.…”

“…5 In ethmoidal DAVFs treated as part of the CONDOR database, it was similarly demonstrated that microsurgery (66%, 35/53) had superior obliteration rates to EVT (32%, 17/53). 30 Furthermore, a lower complication rate with microsurgery (6%, 2/35) versus EVT (12%, 2/17) was supported by the CONDOR cohort. 30 These data were substantiated by our current meta-analysis, which showed that surgery had a higher complete obliteration rate (89% vs 70%) and a slightly lower complication rate (10% vs 13%) than EVT.…”

“…29 Given that ethmoidal DAVFs by definition do not have an intervening sinus, they are anatomically confined to Borden type III and Cognard types III and IV, the higher and more malignant classifications. 30 The treatment of ethmoidal DAVFs requires an appreciation of the surrounding anatomical structures and vasculature, namely their arterial supply by the anterior ethmoidal or falcine branches of the ophthalmic artery. 22,27 Ethmoidal DAVFs typically drain directly into frontal cortical veins, and rarely may drain directly into the ophthalmic vein.…”

Development of Anterior Cranial Fossa Dural Arteriovenous Fistula and Supraclinoid Internal Carotid Artery Pseudoaneurysm Following Frontobasal Trauma: A Case Report and Literature Review

“…In this case, the patient developed an ACF-dAVF within three days of the initial encounter, which is to our knowledge the first case report of a patient presenting with this condition within one month of the initial injury. In ACF-dAVFs, the cribriform plate is commonly the fistula point, in which afferent arterial supply arises from the distal ophthalmic artery and both anterior and posterior ethmoidal arteries, and venous drainage occurs through frontal cortical veins into the superior frontal sinus or posteriorly into the cavernous sinus or basal vein of Rosenthal [ 14 , 15 ]. In the absence of a more robust dural sinus in the ACF, the fragile pial cortical veinous drainage predisposes ACF-dAVFs for rupture and intracranial hemorrhage.…”

Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes

“…High-pressure arterial reflux into cortical veins can lead to intracranial hemorrhage, the most dreaded complication of dAVFs. 1 Chronic venous hypertension can also lead to a spectrum of nonhemorrhagic neurological deficits (NHNDs). [2][3][4] Cognitive impairment mimicking a dementing process is a NHND that can be triggered by venous hypertension.…”