Epidural Skull Base Approach for Aggressive Dural Arterio Venous Fistulas (DAVF)

Background: Aggressive dural arterio venous fistulas (DAVF), presenting with hemorrhage or neurological deficits represent a significant source of morbidity or mortality. Even if most patients can be cured with endovascular treatment, surgery still remains the best option in some cases. Among them, when the feeders originate within the skull base, standard approaches do not often provide a safe and appropriate exposure. We used an epidural approach to skull base in two cases of complex DAVFs in the anterior and middle cranial fossa. Patients and Methods: A patient with diplopia due to an anterior cranial fossa DAVF was approached using a subfrontal epidural dissection after failure of multiple transcatheter embolizations and clinical impairment. This approach allowed the exposure and the obliteration of all ethmoidal feeders arising from the skull base. A second patient with subarachnoid hemorrhage (SAH) due to a middle cranial fossa DAVF, was unable to be treated with endovascular embolization. The surgical management was necessary. Arterial feeders originating from the petrous segment of the carotid artery were epidurally obliterated using a pretemporal transclinoidal epidural approach. In both cases, the obliteration was evaluated using intraoperative angiography. Results: Perfect hemostasis was achieved in both cases, even for multiple intrabony feeders. Intraoperative angiography confirmed the complete obliteration of the fistulas and patients showed clinical improvement. No clinical or radiological recurrences were reported during the follow-up period. Conclusion: We propose the epidural approach to achieve a less invasive circumferential exposure and the most complete treatment of complex skull base DAVFs.