Recurrent epistaxis due to cribriform plate dural arteriovenous fistula: are they related? Should the treatment be from venous, pial or arterial side?

Purpose: Dural arteriovenous fistula (DAVF) of the anterior cranial fossa with cortical venous reflux is an aggressive neurovascular entity with a high rate of intracranial bleeding. Only two cases of anterior cranial fossa DAVF presenting with epistaxis alone have been reported. Endovascular approaches have emerged as the primary and safer treatment modality for most DAVFs. Certain fistulas are better treated with open surgical approaches and disconnection.
Case Description: A 55 years old male presented with the history of multiple episodes of severe epistaxis. Cerebral angiography revealed an anterior cranial fossa DAVF of the cribriform plate with cortical venous reflux and a venous varix. The patient was successfully managed with a bifrontal craniotomy and disconnection from the arterial side.
Conclusion: Atypical or severe epistaxis may arise from a DAVF. Surgical arterial disconnection my be a curative treatment option.