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Introduction: The endovascular modality of treatment is the preferred treatment modality for DAVF.
All presenting symptoms not related to presenting hemorrhage resolved after surgical obliteration. DISCUSSIONDural arteriovenous fistulae have a variable natural history that ranges from benign to aggressively life-threatening.
In some circumstances, successful obliteration may not be possible by endovascular means, and such cases may require a direct surgical treatment.
Four patients had intracerebral hemorrhages; two in the temporal lobe and two in the cerebellum. Intracranial dural arteriovenous malformations: Factors predisposing to an aggressive neurological course.
A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage. Treatment of cranial dural arteriovenous fistulae by interruption of leptomeningeal venous drainage.
Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: Report of four technical cases. Complex dural arteriovenous fistulas: Results of combined endovascular and neurosurgical treatment in 16 patients.
Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space: Report of four cases. Management of tentorial dural arteriovenous malformations: Transarterial embolization combined with stereotactic radiation or surgery. The role of radiosurgery and particulate embolization in the treatment of dural arteriovenous fistulas. Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: Results for 31 patients and review of the literature. Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse-sigmoid sinus. The surgical approach to arteriovenous malformations of the lateral and sigmoid dural sinuses.
Combining endovascular and neurosurgical treatments of high-risk dural arteriovenous fistulas in the lateral sinus and the confluence of the sinuses. Direct packing of the isolated sinus in patients with dural arteriovenous fistulas of the transverse-sigmoid sinus. The authors report on their experience with the use of cranial base approaches in the treatment of deep and complex DAVF. The choice of treatment depends on the clinical presentation, anatomical location, arterial supply, and venous drainage pattern. No seizures have been reported in the one patient who presented with intractable chronic epilepsy secondary to a tentorial dural fistula. Awad et al[1] observed that a DAVF with leptomeningeal drainage had a much more aggressive natural course.
Advances in endovascular techniques allow for a successful obliteration in a majority of these lesions. Two patients experienced rapidly progressive myelopathy, and one patient experienced 13 years of incapacitating seizures. The two patients presenting with rapidly progressive brainstem dysfunction from venous hypertension had complete reversal of their symptoms after surgery. However, in some instances endovascular obliteration is not possible and surgical intervention is required. One patient had immediate improvement of her myelopathy.One patient with a tentorial dural fistula developed a temporal lobe hematoma. Four patients presented with intracerebral hemorrhage, two with progressive myelopathy, two with tinnitus, and one with incapacitating chronic seizures.
In both patients, bruits were auscultated on the mastoid process.All nine patients underwent six-vessel cerebral angiography. Type II fistulae drain into a major sinus but create a retrograde flow into other veins that also drain into the same sinus.
Four DAVF were tentorial, two transverse sigmoid, one craniocervical, one straight sinus, and one sphenoparietal.
Deep-seated or complex DAVF require skull base techniques to provide the necessary exposure of the involved sinus.
In these cases neurological deterioration and hemorrhage results from the venous retrograde hypertension occurring within these veins. Endovascular embolization was attempted and unsuccessful in four cases, and was successful only as an adjunct to surgery in four others. In the current study, the authors report on their experience with the use of cranial base approaches in the treatment of these difficult DAVF.Materials and MethodsThe clinical findings, angiographic characteristics, and surgical outcomes of nine patients treated through cranial base techniques were retrospectively reviewed. Type III fistulae do not have any communication with a sinus and drain only into the leptomeningeal vein. All patients required the use of cranial base approaches to disconnect the fistula or resect the nidus. Many Type III DAVF are in close anatomical proximity to a large draining sinus but do not communicate with it.The goal of treatment should be complete and permanent elimination of the arteriovenous shunt. All other DAVF had either pure leptomeningeal drainage or retrograde reflux from the involved sinus.TreatmentThe craniocervical DAVF was treated through a transcondylar craniotomy. Several options are available for the treatment of DAVF, including arterial embolization, transvenous occlusion, stereotactic radiosurgery, and direct surgical obliteration.[1],[7],[8],[9],[10],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]Endovascular TreatmentEndovascular treatment should be considered as the first choice in the treatment of DAVF. Six-month follow-up results were obtained on seven patients where there was no evidence of recurrence.
The angiogram showed a single feeding vessel arising from the meningeal branch of the vertebral artery.
The patient was surgically treated employing a far lateral approach with removal of one-third of the right condyle.
Conclusion: This retrospective study demonstrates that complex DAVF can be successfully treated with the assistance of cranial base techniques. The draining vein was identified and cut near the surface of the medullary spinal junction.Four cases of tentorial DAVF were treated employing an anterior petrosectomy approach. Three cases were noted to have isolated SPS.Patient #2 was initially noted to have feeding vessels from the right MMA and MHPA. The ten patients treated had complete obliteration and there was no permanent morbidity.Transarterial embolization has been suggested as an initial treatment. However, only one patient underwent an angiogram after six months; therefore, long-term recurrence cannot be assessed. Seven patients were treated through a combination of embolization and radiosurgery (800-2000 cGy).
Link et al[20] also reported 29 patients treated with radiosurgery (1800-2000 cGy) followed by particulate embolization. A variety of fistulae were presented, with the majority being transverse or cavernous sinus (18 patients).
The greater superficial petrosal nerve (GSPN) was cut to avoid facial nerve damage from retraction. Angiography obtained at one to three years following treatment showed complete obliteration in 72% of the fistulae treated. Removal of the bone posterior to the trigeminal nerve in Glasscock′s triangle exposed the petrous portion of the carotid artery. The bone in the Kawase′s triangle, posterior to the carotid artery, was removed up to the SPS. The dura was then opened in a linear fashion from the inferior lateral temporal lobe to the SPS.
Skeletalization of the transverse-sigmoid junction was performed, followed by resection of the involved sinus with its arteriovenous malformation. The drainage vein was then identified and cut.The cranial base procedures for Patients 3 and 4 were performed in the same fashion. Three tentorial and one inferior petrosal DAVF were treated through either anterior, posterior, or combined petrosectomy. In this case, the entire medial half of the SPS was removed.Patient #5, who also had a tentorial DAVF with an isolated SPS, required an orbitozygomatic osteotomy.
After the sectioning of the SPS, the draining veins were identified in the posterior fossa. If the craniotomy is supplemented with an orbitozygomatic osteotomy, less temporal lobe retraction is required.
Resection of the sinus may not be necessary and the fistula can be treated by disconnecting the draining vein.
Tinnitus resolved following treatment; however, her symptoms of tinnitus returned 6 months later. Access to the vertebral artery as it penetrates the dura is necessary to expose a fistula in this location. The authors utilized this approach in a straight sinus fistula to reduce bleeding before the suboccipital craniotomy was performed.Disconnection of the sphenoparietal fistula required exposure by extensive removal of the lesser sphenoid wing. The resection of the extradural bone to the meningo-orbital band exposed the abnormal vessel.
The proximal exposure of the superior petrosal sinus can be achieved through a partial posterior petrosectomy. The jugular bulb was exposed by transcondylar removal of bone, including the jugular tubercle. Complete removal of the TSS from the vein of Labbé to the jugular bulb was achieved.
Five mm of the lateral SPS was also removed with the TSS.Patient #7 also presented with a TSS-DAVF. In some cases, surgical exposure of the sinus is required because the sinus is either isolated or obstructed. Multiple ipsilateral feeding vessels were noted on the left MHPA, MMA, AMA, STA, OA, PICA, PMA, and VMA. Houdart et al[25] also had successful obliteration of five cases of TSS-fistulae utilizing direct packing through a small craniectomy.However, even in completely obliterated TSS-fistulae, direct packing is not always successful. Goto et al[27] reported that surgical resection of the TSS was necessary in 4 of 17 cases treated with direct packing. This could not be performed safely because of the proximity of the feeding vessels to the antegrade draining vein of Labbé.
Based on these reports, it is relevant to include sinus resection as a form of treatment.CONCLUSIONDural arteriovenous fistulae have a variable clinical history.
However, in some circumstances this may not be the optimal treatment for complete and permanent obliteration.
Jugular bulb exposure was not required in this case; therefore, a transcondylar approach was not necessary. Standard surgical techniques may not be successful in gaining good exposure to the arteriovenous fistula or nidus. The sinus was resected from the vein of Labbé to the lower portion of the sigmoid sinus. By utilizing cranial base techniques, DAVF can be successfully treated with minimal morbidity and mortality.
The SPS was also cut in the medial portion.One case of an isolated straight sinus was treated.
Instead of draining into the straight sinus, a large vein drained the fistula onto the superior surface of the right cerebellar hemisphere.
The draining vein was accessed through inferior retraction of the right cerebellar hemisphere. The vein was coagulated and cut where it bridged from the tentorium to the superior surface of the cerebellum.Patient #9 presented with a rare sphenoparietal DAVF. A single feeding vessel arose from the ophthalmic artery and drained directly into the sphenoparietal sinus.



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