Management of tentorial dural arteriovenous malformations: transarterial embolization combined with stereotactic radiation or surgery

Abstract

The clinical, anatomical, and radiological features of nine cases of tentorial dural arteriovenous malformations (AVM's) are presented, and 45 reported cases are reviewed. Unlike dural AVM's of the transverse sigmoid and cavernous sinuses that usually have a benign natural history, dural AVM's of the tentorium typically present with hemorrhage or progressive neurological deficit. In this series, patients ranged in age from 52 to 72 years and included five men and four women. These patients presented with subarachnoid hemorrhage, parenchymal hemorrhage, brainstem dysfunction, cerebellar signs, and obstructive hydrocephalus. Malformations were fed principally by the meningohypophyseal trunk, branches of the middle meningeal artery, and the occipital artery. Venous drainage was uniform through the cortical veins (predominantly the mesencephalic, petrosal, and cerebellar veins). Eight of the nine patients had an associated venous aneurysm(s); two had more than one venous aneurysm, and two patients had a vein of Galen aneurysm associated with the tentorial dural AVM. Eight of nine patients improved after treatment, including four patients with complete obliteration of the dural AVM. Based on our experience, we have developed a treatment protocol for tentorial dural AVM's that uses transarterial embolization followed by direct microsurgery or stereotactic radiation. These therapies, applied in a staged manner, have proven safe and relatively effective for the treatment of dural AVM's.

Dural arteriovenous fistulas draining into the petrosal vein or bridging vein of the medulla: possible homologs of spinal dural arteriovenous fistulas

“…We excluded DAVFs located in remote regions that drained into posterior fossa veins secondary to thrombosis of their "natural" outlets, in particular cavernous sinus or transversesigmoid lesions with venous occlusions. In the previously published literature, we found 30 cases of petrosal vein DAVFs 4,5,[7][8][9]13,16,21,30,33,[36][37][38]41,45,48,52,55,56,59,60 and 35 cases of medulla bridging vein DAVFs, 1,11,14,[17][18][19][20][22][23][24][25]31,32,35,39,40,43,46,50,51,53,58,61 all of which were well described with clinical and angiographic information. These previously reported cases were analyzed together, with special attention to their clinical characteristics.…”

“…We also found 2 cases in which SRS was used. 30,33 Although SRS has the advantage of being less invasive, it takes > 1 year to obliterate the lesion. We consider SRS to be inappropriate in most cases of petrosal vein-draining DAVFs because these lesions usually demonstrate aggressive and lifethreatening manifestations that require urgent reduction of the leptomeningeal venous reflux.…”

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

“…7,12,22,23,35,39,51 Although endovascular embolization may provide immediate symptomatic relief and reduction of hemorrhage risk, the treatment may not afford longterm cure in cases of subtotal obliteration or delayed recanalization. 24 Therefore, SRS serves as a complementary treatment by potentially increasing the likelihood of permanent DAVF occlusion.…”

Arterial Onyx Embolisation of Intracranial DAVFs with Cortical Venous Drainage

“…Embolisation of particles has proven to be of limited use in reducing flow rate, but may have only a temporary result and is generally not curative. Surgery and radiotherapy have also been employed for the treatment of these lesions with varying success, with or without adjuvant arterial embolisation with nBCA [7][8][9]5 , however radiotherapy is not immediately curative, requiring a period of some months for the fistula to close after treatment, during which time it is not protected from haemorrhage.…”