Bifrontal craniotomy and venous ligation of inferior sagittal sinus dural arteriovenous fistula

In cases of persistent filling despite embolization, inferior sagittal sinus (ISS) dural arteriovenous fistulas (dAVFs) can be surgically ligated via an anterior interhemispheric approach. A man in his late 60s presented with persistent filling of a dAVF from external carotid artery branches after embolization. The falx and ISS were exposed, allowing dissection of the anterior cerebral artery branches adjacent to the venous varix and cauterization of the inferior falx to detach the venous complex. The patient recovered well and was discharged home. ISS dAVFs are rare and require a deeper approach than the more common superior sagittal sinus dAVFs.