Microsurgical Treatment of a High-Grade Ethmoidal Dural Arteriovenous Fistula via the Pterional Approach

Background: Ethmoidal dural arteriovenous fistulas (dAVF) may demonstrate aggressive clinical behavior due to retrograde cortical venous reflux and venous hypertension and require treatment in such instances. Microsurgical treatment remains the preferred modality due to technical challenges with endovascular treatment and importantly, the risk of blindness with transarterial embolization. Objective: This video presents a step-by-step demonstration of the pterional approach for a Cognard type 4 ethmoidal dAVF with a comparative summary of pros and cons across different treatment modalities. Surgical Procedure: Pterional craniotomy was performed on the side of the dominant venous drainage. The principal draining vein was identified via the sub-frontal corridor and disconnected. Dura at the site of the fistula was coagulated. Postoperative angiogram showed complete fistula occlusion. Results: Patient recovered well with resolution of symptoms at two-week follow-up. Conclusion: Microsurgical treatment via pterional approach remains a safe and effective modality for occlusion of ethmoidal dAVFs.