PMC8769432_01
Preoperative Angio-CT scan (A: axial view; B: sagittal view) shows ACF DAVF involving ectatic VFC and its origin at fistular point in correspondence of the FC (red circle in A and * in B). Arrow: crista galli. ACF DAVF: anterior cranial fossa dural arteriovenous fistula, CT: computed tomography, FC: foramen caecum, VFC: foramen caecum vein.
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F1
Second level diagnostic investigations with digital subtraction angiography (DSA) showed a DAVF fed mainly by SPAs bilaterally and, to a lesser extent, by left superficial temporal artery (STA) branches (Figs. 1 and 2). The feeders converged in front of the Crista Galli, in correspondence of the FC, in the VFC (Fig. 1).
Preoperative DSA, arterial phase, lateral views of bone subtraction (A) and without bone subtraction view (B) of ACF DAVF involving VFC (arrow) and its origin at fistular point (*). ACF DAVF: anterior cranial fossa dural arteriovenous fistula, DSA: digital subtraction angiography, F: frontal sinus, IMA: internal maxillary artery, SPA: sphenopalatine artery branches from internal maxillary artery (main feeders), STA: superficial temporal artery, VFC: foramen caecum vein.
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F2
Second level diagnostic investigations with digital subtraction angiography (DSA) showed a DAVF fed mainly by SPAs bilaterally and, to a lesser extent, by left superficial temporal artery (STA) branches (Figs. 1 and 2).
Preoperative DSA shows ACF DAVF involving VFC (arrow) and its origin at fistular point (*). Anteroposterior view, arterial phase from right (A) and left (B) ECA, P (venous pseudoaneurysm). VFC (C) preoperative DSA, sagittal view showing ACF DAVF and its main drainage in SSS. The first portion of SSS seems to be hypoplastic and not homogeneously filled as possible result of previous sinus thrombosis; it is possible to identify posterior drainage via Labbe vein. ACF DAVF: anterior cranial fossa dural arteriovenous fistula, DSA: digital subtraction angiography, ECA: external carotid artery, IMA: internal maxillary artery, SPA sphenopalatine artery branches from IMA (main feeders), SSS: superior sagittal sinus, STA: superficial temporal artery, VFC: foramen caecum vein.
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F3
It presented a venous pseudoaneurysm (Figs. 3A and 3B) while collateral left frontal vein branches complete the anterior DAVF drainage into the anterior one-third of the SSS, distally to the VFC. The DAVF also presented a posterior venous drainage into the left transverse sinus (TS) via Labbe vein (Fig. 3C) and was classified in DAVF type IV according to Cognard Classification.
Intraoperative pictures showing fistular point exposure (*) and pseudoaneurysm (A) and draining vein clipping (B).
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F4
The fistular point and the draining vein were checked with microscopic indocyanine green (ICG) angiography and closed with a vascular straight clip (Fig. 4).
(A) Postoperative DSA, lateral view, arterial phase, from left ECA; F: frontal sinus; (*): fistular point is not visible anymore. (B) Preoperative post contrast MRI, sagittal view. The first portion of SSS (Square brackets) seems to be extremely hypoplastic and not regularly perfused as result of previous thrombosis. DSA: digital subtraction angiography, ECA: external carotid artery, IMA: internal maxillary artery, MRI: magnetic resonance imaging, SSS: superior sagittal sinus, STA: superficial temporal artery.
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F5
The postoperative DSA showed the complete DAVF closure (Fig. 5A), and patient was discharged after 4 days.