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Images in Neurology |

Prominent Forehead Scalp Arteries a Diagnostic Clue to Unruptured Anterior Cranial Fossa Dural Arteriovenous Fistula

Zhi Chen, MD; Hongping Miao, MD; Hua Feng, MD, PhD; Gang Zhu, MD, PhD
Arch Neurol. 2011;68(6):824-825. doi:10.1001/archneurol.2011.119.
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A 31-year-old man was referred to our neurosurgery clinic for evaluation of prominent scalp vessels in the forehead, first noted approximately 6 months prior. On admission, prominent scalp arteries with pulsation were detected in his left forehead without audible bruit (Figure 1A); neurological examination revealed no exact abnormalities. Magnetic resonance angiogram revealed dilated veins arising from the anterior cranial fossa (Figure 1B), suggesting a dural arteriovenous fistula (DAVF). Digital subtraction angiogram revealed an anterior cranial fossa DAVF that was supplied by the left anterior ethmoidal artery and the branches of the bilateral external carotid arteries and drained mainly to the superior sagittal sinus via a dilated cortical vein (Figure 2). The observable scalp arteries in his forehead were confirmed to be the dilated branches of the superficial temporal artery, which fed the fistula via the supraorbital branches of the ophthalmic artery. The patient rejected either surgical or endovascular treatment because he was neurologically asymptomatic. He was discharged with no further treatment and close follow-up.

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Figure 1.

A, Photograph shows prominent scalp arteries in the patient's forehead (arrows). B, Magnetic resonance angiogram shows dilated veins arising from the anterior cranial fossa (arrow).

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Figure 2.

Digital subtraction angiogram. A, Left internal carotid artery injection shows an anterior cranial fossa dural arteriovenous fistula (arrow). B, Left external carotid artery injection showing the fistula (large arrow) fed by the frontal branch (arrowheads) of the superficial temporal artery through the anastomoses with the supraorbital artery (small arrows). C, Right external artery injection showing the fistula (large arrow) and the cortical drainage vein (small arrows).

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