Posterior Fossa Dural Arteriovenous Fistulas with Subarachnoid Venous Drainage: Outcomes of Endovascular Treatment

Abstract

BACKGROUND AND PURPOSE: Dural AVFs located in the posterior fossa are a rare entity. The objectives of the study were to analyze the anatomy of dural AVFs, their endovascular treatment strategies, and clinical outcomes. MATERIALS AND METHODS: Two centers retrospectively selected patients treated between January 2009 and June 2018 having posterior fossa dural AVFs. We collected patient demographics, clinical presentation, arterial and venous outflow anatomy of the dural AVFs, and treatment outcomes. RESULTS: Twenty-six patients treated endovascularly for posterior fossa dural AVFs, type III, IV, or V, were included. One hundred percent of the dural AVFs were occluded. A transarterial approach was performed in 23 dural AVFs (88.5%); a combined transarterial and transvenous approach, for 2 dural AVFs (7.7%); and a transvenous approach alone, for 1 dural AVF (3.8%). The middle meningeal artery was the most common artery chosen to inject embolic liquid (46%, 12/26). Procedure-related morbidity was 15.4% at 24 hours, 7.7% at discharge, and 0% at 6 months. Procedure-related mortality was 0%. CONCLUSIONS: Endovascular treatment offers high occlusion rates for posterior fossa dural AVFs with low morbidity and mortality rates. The arterial approach is the first-line preferred approach, even if a transvenous or combined approach would be a safe and effective option for patients with favorable anatomy. ABBREVIATIONS: APA ϭ ascending pharyngeal artery; dAVF ϭ dural AVF; MHT ϭ meningohypophyseal trunk; MMA ϭ middle meningeal artery; NAEL ϭ nonadhesive embolic liquid; PMA ϭ posterior meningeal artery

Role of surgery in management of intracranial dural arteriovenous fistulas

“…DAVFs in the posterior fossa are mostly fed by the vertebral (25%) and occipital arteries (20.5%), followed by branches of the meningohypophyseal trunk (15.9%) and ascending pharyngeal arteries (13.6%). 18) Because there is no unified nomenclature for intracranial DAVFs, they can have several names. Most of them are based on anatomical locations of the dural layer where the fistula is situated, such as CS DAVFs and primary treatment option because endovascular intervention is not feasible in certain cases.…”

“…Ethmoidal branches of the ophthalmic arteries are the main feeding arteries of anterior cranial fossa DAVFs. DAVFs in the posterior fossa are mostly fed by the vertebral (25%) and occipital arteries (20.5%), followed by branches of the meningohypophyseal trunk (15.9%) and ascending pharyngeal arteries (13.6%) [ 18 ].…”

Management and Outcome of Intracranial Dural Arteriovenous Fistulas That Have Caused a Hemorrhage in the Posterior Fossa : A Clinical Study

“…Because of the rarity of dAVFs that have caused bleeding in the posterior fossa, their endovascular treatment is less well-defined [ 6 , 18 ]. In our series and EVT approach preference was determined according to fistula localization and venous outflow.…”

“…Recurrence was observed in one patient, while mRS at first year (0–2) was 64.2%. Bleeding due to dAVFs appears to have a more benign clinical course compared with bleeding from an aneurysm [ 6 ]. Our clinical results lagged behind two other similar studies, the fact that our series consisted of only bleeding patients and can be attributed to the natural course of posterior fossa hemorrhages, which already have high morbidity and mortality rates.…”

“…The treatment of intracranial dAVFs becomes very difficult when the complex vascular nutrition originating from the external carotid artery (ECA), the internal carotid artery (ICA), and the vertebrobasilar system, as well as the frequent cerebellar cortical venous drainage, are added together with the bleeding presentation. This increases the importance of performing stepwise procedures with a multidisciplinary approach [ 4 , 6 , 15 , 18 , 24 ]. With the development of endovascular techniques, the anatomical and pathophysiological features of the fistula have been better understood, and it has been possible to perform patient-based treatment with the highest closure rates and low risk.…”