Surgical Treatment of a Dural Arteriovenous Fistula in the Sphenoid Wing with a Unique Drainage Pattern through the Basal Vein of Rosenthal

Abstract

A 69-year-old man consulted our department regarding further examination because abnormal venous ectasia of the basal vein of Rosenthal (BVR) was accidentally found on magnetic resonance imaging. Angiography revealed a dural arteriovenous fistula (DAVF) in the left sphenoid wing; the fistula was supplied by the ophthalmic artery and the middle meningeal artery. Venous drainage from the fistula consisted of a large collector vein located in the temporal tip, which drained into the BVR. We selected open surgery because this lesion may be difficult to access and is associated with significant risks through an endovascular approach. After temporal clip ligation of the drainer, the superficial middle cerebral vein became the main drainage route directly in connection with the fistula. Therefore, both were ligated, after coagulation of feeding arterial networks on the dura around the sphenoid wing. The patient experienced no complications from the surgical procedure, and postoperative angiography demonstrated obliteration of the fistula. DAVF in the sphenoid wing with deep drainage is believed to carry a high risk of hemorrhage or venous infarction because of the presence of Galenic drainage, varix, and cortical venous reflux. Treatment is strongly recommended even if the symptoms are minimal. Open surgery appears to be safe and often the best therapeutic option.

Keywords: basal vein of Rosenthal; dural arteriovenous fistula; sphenoid wing; surgery.

Fig. 1

Preoperative T₂-weighted magnetic resonance imaging revealing aberrant venous ectasia of the basal vein of Rosenthal.

Fig. 2

Angiographic images (lateral view). A: Preoperative left internal carotid angiography (ICAG) showing the dural arteriovenous fistula (DAVF; in the left sphenoid wing) fed by ethmoidal branches of the ophthalmic artery (OA). B: Preoperative left external carotid angiography (ECAG) showing DAVF fed by the middle meningeal artery (MMA). The main drainer of DAVF is the bridging anterior temporal vein (BATV) draining in an anterograde manner into basal vein of Rosenthal (BVR) and subsequently into the vein of Galen. C: Preoperative left ICAG in the venous phase demonstrating the superficial middle cerebral vein (SMCV, black arrows), deep middle cerebral vein (DMCV; white arrows), and cavernous sinus (CS, arrowheads). There is a retrograde flow into SMCV through DMCV. SMCV drains into the CS.

Fig. 3

A: An intraoperative photograph of a fistula location in the sphenoid wing (arrow) and the ectatic arterialized bridging anterior temporal vein (BATV; arrowheads). B: An intraoperative photograph showing clip ligation of BATV. Superficial middle cerebral vein (SMCV; arrows) expanded and turned red. C: A photograph after surgical obliteration of dural arteriovenous fistula (DAVF) demonstrated the disconnected BATV (arrowhead) and SMCV (arrows). Feeding arterial networks on the dura around the sphenoid wing are coagulated. SMCV returned to normal color.

Fig. 4

A, B: Angiographic images (lateral view). Postoperative internal carotid angiography (ICAG; panel A) and external carotid angiography (ECAG; panel B) revealing disappearance of the dural arteriovenous fistula (DAVF). C: Postoperative ICAG in the venous phase showing the superficial middle cerebral vein (SMCV; black arrows), deep middle cerebral vein (DMCV; white arrows), and the basal vein of Rosenthal (BVR; arrowheads). The drainage flow of SMCV is diverted from cavernous sinus to DMCV, subsequently flowing into BVR.

Fig. 5

A: Diagram of the venous drainage pattern of our case. B: Diagrammatic representation after the temporal clip ligation of the bridging anterior temporal vein (BATV) showing the secondary superficial middle cerebral vein (SMCV) route. C: Diagrammatic representation after ligation of both the BATV and SMCV routes following coagulation of feeding arterial network demonstrating the final drainage pattern. Red and blue arrow indicates arterial and venous flow, respectively. LSS: lesser sphenoid sinus.