Intracranial Dural Arteriovenous Fistulas: Clinical Characteristics and Management Based on Location and Hemodynamics

Abstract

ObjectiveA dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period.MethodsBetween January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern.ResultsBorden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS).ConclusionThe hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

Image Diagnosis: Encephalopathy Resulting from Dural Arteriovenous Fistula

“…[2][3][4] The initiating events which lead to their development are not clear, but the literature reports association with trauma, infection, recent surgery, and dural sinus thrombosis. [2][3][4] A wide variety of signs and symptoms, which can vary because of lesion location and pattern of venous drainage, may arise from DAVFs, namely, pulsatile tinnitus, ophthalmoplegia, proptosis, chemosis, retro-orbital pain, decreased visual acuity, seizures, Parkinsonism, cerebellar symptoms, apathy, and dementia. [2][3][4] …”

“…[2][3][4] A wide variety of signs and symptoms, which can vary because of lesion location and pattern of venous drainage, may arise from DAVFs, namely, pulsatile tinnitus, ophthalmoplegia, proptosis, chemosis, retro-orbital pain, decreased visual acuity, seizures, Parkinsonism, cerebellar symptoms, apathy, and dementia. [2][3][4] …”

Cerebral Vascular Malformations and Headache

“…2 In these challenging cases, stereotactic radiosurgery sometimes is considered, despite the absence of strong evidence. 82 What is the risk of hemorrhage with dural AVFs?-Dural AVFs can either be benign or have significant risk of neurologic deficit (hemorrhagic or non-hemorrhagic). They are divided based on their arterial supply into either dural AVFs or pial AVFs.…”

Transverse and Sigmoid Sinus Dural Arteriovenous Fistula Mimicking Idiopathic Intracranial Hypertension and Carotid Cavernous Fistula

“…However, ocular symptoms and signs of both increased ICP and localised orbital venous congestion have rarely been described in a non-cavernous dAVF. In a review by Oh et al, 12 only 2 of 95 patients with dAVFs had ''ocular symptoms'' and 3 of 95 patients presented with ''visual symptoms.'' In another review of patients with multiple dAVFs not involving the cavernous sinus, one patient presented with ocular symptoms (exophthalmos).…”

“…Intracranial dAVFs are abnormal connections between dural arteries and any portion of the intracranial venous sinuses, meningeal veins, or cortical veins, 12 and represent 10-15% of all intracranial vascular abnormalities. These dAVFs most commonly occur in the transverse or cavernous sinus (i.e.…”