Anterior Cranial Fossa Dural Arteriovenous Fistula With Bilateral Cortical Drainers

A 58-year-old man presented with sudden onset of severe headache. Computed tomography demonstrated subarachnoid hemorrhage and right acute subdural hematoma. He had no neurological deficits. Cerebral angiography showed an anterior cranial fossa dural arteriovenous fistula (AVF) supplied by the bilateral ethmoidal arteries. A fistula was suggested on the right side, and the dural AVF drained into the superior sagittal sinus via the bilateral frontal cortical veins. Venous varix was observed at both drainage sites. Bifrontal craniotomy with right-side dural incision was performed and the fistula was interrupted. Postoperative angiography demonstrated a persistent fistula draining into the left cortical vein. Nineteen days later, bifrontal craniotomy with left-side dural incision was performed and the draining vein was completely coagulated with the aid of intraoperative angiography. Postoperatively, there was no detectable residual fistula. He was discharged without neurological deficits 2 weeks after surgery. The present case of anterior cranial fossa dural AVF with bilateral cortical drainers shows that drainer occlusion at two points may be needed for complete obliteration of the drainers because the fistulous connection may not be simple.