Ethmoidal dural arteriovenous fistulae: An assessment of surgical and endovascular management

OBJECTIVE: Endovascular treatment of ethmoidal dural arteriovenous fistulae (DAVFs) has become technically feasible, but its relative risks and benefi ts have not justified its use. We present a series of patients with ethmoid al DAVFs treated almost exclusively with surgery at an institution where ex pert endovascular therapy was available. Surgical risks, treatment efficacy , and patient outcomes were determined for comparison with published endova scular data. METHODS: Sixteen patients with ethmoidal DAVFs were treated during a 17-yea r period from 1982 to 1999. In three patients, feeding arteries from the in ternal maxillary artery were embolized; no ophthalmic artery embolizations were performed. A low bifrontal surgical approach was used in most patients to expose, coagulate, and divide the fistulous site. RESULTS: Ethmoidal DAVFs were occluded grossly and angiographically in all 16 patients. There was no treatment-associated neurological morbidity, and clinical outcomes were good in all but one patient who was comatose initial ly. CONCLUSION: Review of our surgical experience with ethmoidal DAVFs as well as published endovascular results for these lesions suggests that endovascu lar management of ethmoidal DAVFs has a small but clinically significant ri sk to vision, is rarely effective in curing the fistula, and does not elimi nate the need for surgery. In contrast, surgical management has no associat ed risk to vision, is highly effective at obliterating the fistula, and can contribute to good clinical outcomes in most patients. For these reasons, surgical management of ethmoidal DAVFs remains the treatment of choice.