Ethmoidal Dural Arteriovenous Fistula: Massive Intracerebral Hemorrhage, Delayed Diagnosis; Transarterial nBCA Embolization and Transvenous Coil Occlusion, with Complete Obliteration of the Fistula and Good Clinical Outcome

Abstract

A 55-year-old man suddenly lost consciousness and was brought to a hospital. CT revealed a large intracerebral hemorrhage (ICH) in the right frontal lobe. Anisocoria with a mydriatic right pupil prompted a craniotomy with evacuation of the hematoma and clipping of a suspected but not unambiguously identified “aneurysm” of the right anterior cerebral artery. Within 3 weeks of hemorrhage and surgery, the patient regained consciousness. A DSA examination 4 weeks after the hemorrhage revealed an arteriovenous shunt supplied by both ophthalmic arteries, which was drained through a frontal vein to the superior sagittal sinus. This ethmoidal DAVF was identified as the source of the ICH, and endovascular treatment was offered. When the subsequent rehabilitation treatment began, a left-hand hemiparesis with an inability to stand and walk was noted. Cognitive and mnestic functions were impaired. During the following 4 weeks, the hemiparesis resolved, and cognition and memory improved. The first endovascular treatment was carried out 2 months after the ICH. Both ophthalmic arteries were supplying an ethmoidal DAVF. The left ophthalmic artery was catheterized, and the distal, ethmoidal branch was occluded with nBCA/ethiodized oil. DSA 1 week later showed a reduced arteriovenous shunt. The DAVF had only been partially occluded. The draining frontal vein was then catheterized in a retrograde direction. Three detachable coils were implanted at the origin of the draining vein, which successfully blocked the arteriovenous connection. Follow-up DSA examinations 3 and 16 months later confirmed the persistent occlusion of the DAVF. Transvenous coil occlusion of ethmoidal DAVFs is the main topic of this chapter.