Unilateral Frontopterional Craniotomy for Dural Arteriovenous Fistula of the Anterior Cranial Fossa: A Lateral Approach to a Midline Lesion

Objective: Dural arteriovenous fistulae of the anterior cranial fossa are supplied by the anterior ethmoidal branches of one or both ophthalmic arteries, and drain into the anteroinferior superior sagittal sinus. When present, cortical venous reflux poses a risk of intracerebral hemorrhage and warrants surgical obliteration. The commonly described surgical technique involves a bifrontal craniotomy for division of the fistulous vein at the cribriform plate. The authors propose that a unilateral frontopterional craniotomy would allow a lateral approach across the orbital roof to the fistula at the midline, and that the falx and crista galli may be divided to obliterate a fistulous vein on the contralateral side. Methods: Three patients who presented with spontaneous frontal intracerebral hemorrhage underwent angiography, revealing dural arteriovenous fistulae of the anterior cranial fossa. All three patients underwent a right frontopterional craniotomy, with a lateral approach for division of the falx, obliteration of the fistula, and evacuation of the hematoma. Results: Successful surgical treatment was performed in all three cases, with no postoperative morbidity. Postoperative angiography confirmed obliteration of the fistulae in all three cases. Conclusion: A unilateral frontopterional approach is a safe and effective treatment for a dural arteriovenous fistula at the midline, and provides access to fistulous veins on both sides of the falx. This approach is a viable alternative to the bifrontal craniotomy, and avoids the need for frontal sinus entry or frontal lobe retraction.