- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan USA
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan USA
Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan USA
DOI:10.4103/2152-7806.145669Copyright: © 2014 Reinard K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Reinard K, Basheer A, Pabaney A, Marin H, Malik G. Spontaneous resolution of a flow-related ophthalmic-segment aneurysm after treatment of anterior cranial fossa dural arteriovenous fistula. Surg Neurol Int 28-Nov-2014;5:
How to cite this URL: Reinard K, Basheer A, Pabaney A, Marin H, Malik G. Spontaneous resolution of a flow-related ophthalmic-segment aneurysm after treatment of anterior cranial fossa dural arteriovenous fistula. Surg Neurol Int 28-Nov-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/spontaneous-resolution-flow%e2%80%91related-ophthalmic%e2%80%91segment-aneurysm-treatment-anterior-cranial-fossa-dural-arteriovenous-fistula/
Background:The natural history of proximal, feeding-artery aneurysms after successful obliteration of high-grade, anterior cranial fossa dural arteriovenous fistulas (dAVFs) has not been well documented.
Case Description:A 52-year-old Caucasian male presented with an unruptured anterior cranial fossa (dAVF) and an associated aneurysm. Cerebral angiography revealed a large, contralateral, carotid-ophthalmic segment aneurysm, enlarged feeding ophthalmic arteries, as well as cortical venous drainage. Successful surgical obliteration of the dAVF was undertaken to eliminate the risk of hemorrhage.
Conclusion:The carotid-ophthalmic aneurysm regressed significantly after surgical obliteration of the dAVF and a follow-up, planned coiling procedure to address the carotid-ophthalmic aneurysm was abandoned. This represents the first reported case of a near complete, spontaneous resolution of an unruptured carotid-ophthalmic aneurysm associated with a high-grade anterior cranial fossa dAVF.
Keywords: Anterior cranial fossa, cortical venous drainage, dural arteriovenous fistula, flow-related aneurysms
Dural arteriovenous fistulas (dAVFs) comprise 10-15% of all arteriovenous malformations (AVMs)[
Given the variable complexity of dAVFs with concomitant aneurysms and their high propensity to hemorrhage, expeditious, multi-disciplinary management of these unique vascular lesions is advisable to prevent significant neurologic morbidity and mortality. No consensus guidelines for treatment of dAVFs and concomitant aneurysms exist,[
A 52-year-old, right-handed, Caucasian male was referred to our outpatient neurosurgery clinic for evaluation of progressively worsening headaches over a 2-week period. On examination, the patient did not have exophthalmoses, chemosis, or bruit, and was otherwise neurologically intact. There was, however, a prominent right superficial temporal artery that engorged with valsalva-type maneuvers.
Cerebral angiography revealed a dAVF in the anterior cranial fossa. The fistula was fed by bilateral ophthalmic arteries via the anterior ethmoidal branches [Figure
The patient's dAVF was successfully obliterated using standard microsurgical techniques through a right pterional craniotomy. Clipping of the contralateral carotid-ophthalmic aneurysm was attempted but since it required significant brain retraction, an intraoperative decision was made to abandon aneurysm clipping with the understanding that the patient could undergo coiling of the aneurysm shortly after surgery. Obliteration of the AV fistula was confirmed intraoperatively by fluorescein angiography. The patient was discharged home after an uneventful hospital course and a short-term, follow-up visit revealed resolution of the patient's headaches.
The scheduled postoperative cerebral angiography with intent to coil the carotid-ophthalmic aneurysm a mere 28 days following surgery revealed no fistulous connection, return of bilateral ophthalmic arteries to their normal caliber, and an 85% reduction in size of the aneurysm. The small, residual aneurysm appeared round with a smooth, regular outline [
Recent reports have demonstrated that 13-21% of dAVFs harbor associated aneurysms[
Cortical venous hypertension and resultant intracranial hemorrhage is the major cause of morbidity and mortality associated with most dAVFs.[
Patients with concurrent pial AVMs and flow-related aneurysms have an annual hemorrhage risk of approximately 7-20%.[
Only one report exists in the literature describing an anterior cranial fossa dAVF associated with a ruptured ophthalmic artery aneurysm. The authors treated the aneurysm by endovascular means followed by gamma knife radiosurgery of the AV fistula.[
We report the case of a 52-year-old Caucasian male with headaches and prominent scalp vasculature who was found to have a large, unruptured left carotid-ophthalmic aneurysm in addition to a high-grade anterior cranial fossa dAVF. Although studies have demonstrated that safe embolization of vascular lesions supplied by ophthalmic arteries can be achieved,[
Anterior cranial base dAVFs associated with flow-related aneurysms carry a high morbidity and mortality risk due to their high propensity to hemorrhage and, as such, require aggressive, multidisciplinary treatment. While no consensus guidelines exist on the management of high-grade dAVFs associated with feeding artery aneurysms, successful microsurgical obliteration of anterior cranial fossa dAVFs may result in near complete resolution of parent artery aneurysms.
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