Dominant Orbitofrontal Pial Supply in Anterior Cranial Fossa Dural Arteriovenous Fistula: Angiographic Differentiation from Mixed Pial-Dural Arteriovenous Malformation and Anatomy-Based Treatment Selection.
前颅窝硬脑膜动静脉瘘（ACF DAVFs）通常由筛动脉供血。软脑膜动脉供血已在颅内硬脑膜动静脉瘘（包括前颅窝硬脑膜动静脉瘘）中有过描述，但以眶额软脑膜动脉为主要供血动脉时，可与混合性软脑膜-硬脑膜动静脉畸形产生诊断重叠，并使血管内治疗变得危险。一名75岁男性房颤患者因右侧大脑中动脉闭塞就诊，接受静脉溶栓后行机械取栓。在右侧颈内动脉造影过程中，通过前交通动脉出现对侧额部引流静脉的一过性动脉期显影，促使在血管再通后再次行造影检查。诊断为左侧高级别前颅窝硬脑膜动静脉瘘，以左侧眶额动脉为主要供血动脉，少量前筛动脉供血，两条静脉引流途径，伴皮质静脉反流及静脉瘤。尽管该硬脑膜动静脉瘘为缺血表现之外的偶然发现，但因其血管构筑高危——包括Borden III型/Cognard IV型引流、皮质静脉反流及静脉扩张——被认为需要治疗。未发现脑实质内畸形团，反流静脉亦无正常静脉期使用。由于经软脑膜动脉途径及完全经静脉闭塞被认为不安全或不确定，遂行显微外科引流静脉离断术。术后造影证实完全闭塞。本病例中，显微外科离断实现了造影治愈，患者改良Rankin量表评分为1分，转至康复治疗。以软脑膜动脉供血为主的前颅窝硬脑膜动静脉瘘，其核心诊断和治疗问题不仅在于其罕见性，更在于与混合性软脑膜-硬脑膜动静脉畸形的造影鉴别，以及评估能否在不损害正常软脑膜动脉或静脉引流的情况下闭合分流。取栓时的造影提供了诊断途径，而软脑膜动脉优势供血及分离的静脉引流决定了治愈策略。
Anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) usually receive ethmoidal dural supply. Pial arterial supply has been described in intracranial DAVFs, including ACF DAVFs, but a dominant orbitofrontal pial feeder can create diagnostic overlap with mixed pial-dural arteriovenous malformation and make endovascular treatment hazardous. A 75-year-old man with atrial fibrillation presented with right middle cerebral artery occlusion and underwent intravenous thrombolysis followed by mechanical thrombectomy. During right internal carotid angiography, transient arterial-phase opacification of a contralateral frontal draining vein through the anterior communicating artery prompted post-recanalization angiography. A high-grade left ACF DAVF was diagnosed, with dominant supply from the left orbitofrontal artery, minor anterior ethmoidal supply, two venous drainage routes, cortical venous reflux, and a varix. Although the DAVF was incidental to the ischemic presentation, it was considered to require treatment because of high-risk angioarchitecture, including Borden type III/Cognard type IV drainage, cortical venous reflux, and venous ectasia. No intraparenchymal nidus or normal venous-phase use of the refluxing veins was identified. Because pial transarterial access and complete transvenous closure were considered unsafe or uncertain, microsurgical draining-vein disconnection was performed. Postoperative angiography confirmed complete obliteration. In this case, microsurgical disconnection achieved angiographic cure, and the patient was transferred for rehabilitation with a modified Rankin Scale score of 1. The central diagnostic and therapeutic issue in pial-feeder-dominant ACF DAVF is not rarity alone, but angiographic differentiation from mixed pial-dural arteriovenous malformation and assessment of whether the shunt can be closed without compromising normal pial arteries or venous outflow. The thrombectomy angiogram provided the route to diagnosis, whereas pial arterial dominance and divided venous drainage determined the curative strategy.
Kosei Goto, Nobuo Kutsuna, Takuto Nishihara, Kotaro Makita. Dominant Orbitofrontal Pial Supply in Anterior Cranial Fossa Dural Arteriovenous Fistula: Angiographic Differentiation from Mixed Pial-Dural Arteriovenous Malformation and Anatomy-Based Treatment Selection.. Brain sciences. 2026; doi:10.3390/brainsci16050534.
Kosei Goto, Nobuo Kutsuna, Takuto Nishihara, Kotaro Makita (2026). Dominant Orbitofrontal Pial Supply in Anterior Cranial Fossa Dural Arteriovenous Fistula: Angiographic Differentiation from Mixed Pial-Dural Arteriovenous Malformation and Anatomy-Based Treatment Selection.. Brain sciences. https://doi.org/10.3390/brainsci16050534
Kosei Goto, Nobuo Kutsuna, Takuto Nishihara, Kotaro Makita. Dominant Orbitofrontal Pial Supply in Anterior Cranial Fossa Dural Arteriovenous Fistula: Angiographic Differentiation from Mixed Pial-Dural Arteriovenous Malformation and Anatomy-Based Treatment Selection.[J]. Brain sciences, 2026 doi:10.3390/brainsci16050534.
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