• Vivek R Deshmukh, Steve Chang, Felipe C Albuquerque, Cameron G McDougall, and Robert F Spetzler.
• Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
• Neurosurgery. 2005 Oct 1; 57 (4): E809.

Objective And ImportanceEthmoidal dural arteriovenous fistulas (AVFs) are rare intracranial lesions associated with a high risk of intracranial hemorrhage. Reported hemorrhage rates have ranged from 62 to 91%, and an aggressive clinical course is more likely than a benign clinical course. We describe the first case of a patient with bilateral ethmoidal dural AVFs.Clinical PresentationA 50-year-old man presented with posterior fossa subarachnoid hemorrhage and cerebellar intraparenchymal hemorrhage. Angiography revealed a tentorial AVF and a complex anterior ethmoidal dural AVF.InterventionThe tentorial AVF was treated with preoperative embolization and surgical obliteration. On follow-up angiography, the ethmoidal dural AVF was not considered amenable to embolization. A right modified orbitozygomatic approach was performed and the right-sided fistula was interrupted. Intraoperative angiography revealed obliteration of the right-sided fistula, but a persistent fistula on the left. Further surgical exploration revealed this contralateral anterior ethmoidal dural AVF, which was clip ligated. No residual fistula was noted on intraoperative angiography.ConclusionAnterior ethmoidal dural AVFs may occur bilaterally. Given their complex angiographic appearance, their presence bilaterally may not be readily apparent on preoperative angiography. Intraoperative angiography is crucial to identify a contralateral fistula and to verify that ligation has been curative.

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