Interhemispheric approach for endoscopic ligation of an anterior cranial fossa dural arteriovenous fistula.

We describe the endoscopic ligation of an anterior cranial fossa (ACF) dural arteriovenous fistula (DAVF) through an interhemispheric approach. Intracranial DAVF of the ACF are rare and associated with an aggressive natural history, due to their ubiquitous direct cortical venous drainage and frequent coincidence of venous ectasia. Although surgical ligation is the preferred treatment for ACF DAVF, the role of endoscopy in the surgical management of DAVF is undefined. A 53-year-old woman was incidentally diagnosed with an ACF DAVF. Cerebral angiography showed a Borden type III, Cognard type IV left sided ACF DAVF, supplied by ethmoidal branches of the bilateral ophthalmic arteries and draining directly into an enlarged and ectatic left inferior frontal cortical vein, with a venous varix distal to the point of fistulization. An initial attempt at endovascular treatment from a transvenous approach was unsuccessful, due to significant stenosis of the left cavernous sinus. Therefore, we elected to proceed with surgical ligation. From an interhemispheric approach and under the guidance of frameless stereotactic neuronavigation, a 0° endoscope was advanced into the interhemispheric fissure until the arterialized draining vein was visualized. After dissecting along the draining vein to the point of fistulization, the proximal portion of the draining vein was ligated. Intraoperative angiography confirmed complete obliteration of the DAVF, and the patient was asymptomatic at the 6 week postoperative follow-up. Endoscopy provides excellent visualization of ACF DAVF and can safely facilitate surgical treatment in appropriately selected patients with these lesions.