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Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful., Competing Interests: Competing interests: GPC is a consultant for Medtronic, Stryker and MicroVention. ALC is a consultant for Medtronic, Stryker, MicroVention and InNeuroCo., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Background The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications. Case Description We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein. Conclusions We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula. [ABSTRACT FROM AUTHOR]

The authors attempted to better delineate the natural course of untreated cerebral dural arteriovenous fistulas. For a group of 295 fistulas, drainage pattern was most important in predicting the risk of future neurological events or bleeding. Moreover, presentation with a neurological event or hemorrhage was an independent risk factor for future neurological events or hemorrhage, respectively. The authors provided hemorrhage rates for various subclasses of dural arteriovenous fistulas to facilitate risk stratification, excluding partially treated lesions.

Objective: Aggressive dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) are known for their relatively high risk of recurrent neurological events or hemorrhage. However, recent natural history literature has indicated that nonaggressive dAVFs with CVD have a significantly lower prospective risk of hemorrhage. These nonaggressive dAVFs are typically diagnosed because of symptomatic headache, pulsatile tinnitus, or ocular symptoms, as in low-risk dAVFs. Therefore, the viability of stereotactic radiosurgery (SRS) as a treatment for this lesion subclass should be investigated., Methods: The authors evaluated their institutional experience with SRS for dAVFs with CVD for the period from 1991 to 2016, assessing angiographic outcomes and posttreatment hemorrhage rates. They subsequently pooled their results with those published in the literature and stratified the results based on the mode of clinical presentation., Results: In an institutional cohort of 42 dAVFs with CVD treated using SRS, there were no complications or hemorrhages after treatment in 19 patients with nonaggressive dAVFs, but there was 1 radiation-induced complication and 1 hemorrhage among the 23 patients with aggressive dAVFs. In pooling these cases with 155 additional cases from the literature, the authors found that the hemorrhage rate after SRS was significantly lower among the patients with nonaggressive dAVFs (0% vs 6.8%, p = 0.003). Similarly, the number of radiation-related complications was 0/124 in nonaggressive dAVF cases versus 6/73 in aggressive dAVF cases (p = 0.001). The annual rate of hemorrhage after SRS for aggressive fistulas was 3.0% over 164.5 patient-years, whereas none of the nonaggressive fistulas bled after radiosurgery over 279.4 patient-years of follow-up despite the presence of CVD., Conclusions: Cortical venous drainage is thought to be a significant risk factor in all dAVFs. In the institutional experience described here, SRS proved to be a low-risk strategy associated with a very low risk of subsequent hemorrhage or radiation-related complications in nonaggressive dAVFs with CVD.

Background: High-grade dural arteriovenous fistulas (dAVFs) can present shunts with very different angio-architectural characteristics. Specific hemodynamic factors may affect clinical history and determine very different clinical courses., Objectives: To evaluate the relationship between some venous angio-architectural features in high-grade dAVFs and clinical presentation. Specific indicators of moderate or severe venous hypertension were analyzed, such as altered configurations of the dural sinuses (by a single or a dual thrombosis), or overload of cortical vessels (restrictions of outflow, pseudophlebitic cortical vessels, and venous aneurysms)., Methods: The institutional series was retrospectively reviewed (49 cases), and the pattern of venous drainage was analyzed in relationship with clinical presentation (benign/aggressive/hemorrhage)., Results: Thirty-five of 49 cases displayed cortical reflux (high-grade dAVFs). This subgroup displayed a benign presentation in 31.42% of cases, an aggressive in 31.42%, and hemorrhage in 37.14%., Conclusions: Our data confirm that within high-grade dAVFs, 2 distinct subpopulations exist according to severity of clinical presentation. Some indicators we examined showed correlation with aggressive nonhemorrhagic manifestations (outflow restriction and pseudophlebitic cortical vessels), while other showed a correlation with hemorrhage (dual thrombosis and venous aneurysms). Current classifications appear insufficient to identify a wide range of conditions that ultimately determine the organization of the cortical venous drainage. Intermediate degrees of venous congestion correlate better with the clinical risk than the simple definition of cortical reflux. The angiographic aspects of venous drainage presented in this study may prove useful to assess dAVF hemodynamic characteristics and identify conditions at higher clinical risk., (Copyright © 2017 by the Congress of Neurological Surgeons)

OBJECTIVE Many small series and technical reports chronicle the evolution of endovascular techniques for cranial dural arteriovenous fistulas (dAVFs) over the past 3 decades, but reports of large patient series are lacking. The authors provide a thorough analysis of clinical and angiographic outcomes across a large patient cohort. METHODS The authors reviewed their endovascular database from January 1996 to September 2015 to identify patients harboring cranial dAVFs who were treated initially with endovascular approaches. They extracted demographic, presentation, angiographic, detailed treatment, and long-term follow-up data, and they evaluated natural history, initial angiographic occlusion, complications, recurrence, and symptomatic resolution rates. RESULTS Across a cohort of 251 patients with 260 distinct dAVFs, the overall initial angiographic occlusion rate was 70%; recurrence or occult residual lesions were seen on subsequent angiography in 3% of cases. The overall complication rate was 8%, with permanent neurological complications occurring in 3% of cases. Among 102 patients with dAVFs without cortical venous reflux, rates of resolution/improvement of pulsatile tinnitus and ocular symptoms were 79% and 78%, respectively. Following the introduction of Onyx during the latter half of the study period, the number of treated dAVFs doubled; the initial angiographic occlusion rate increased significantly from 60% before the use of Onyx to 76% after (p = 0.01). In addition, during the latter period compared with the pre-Onyx period, the rate of dAVFs obliterated via a transarterial-only approach was significantly greater (43% vs 23%, p = 0.002), as was the number of dAVFs obliterated via a single arterial pedicle (29% vs 11%, p = 0.002). CONCLUSIONS Overall, in the Onyx era, the rate of initial angiographic occlusion was approximately 80%, as was the rate of meaningful clinical improvement in tinnitus and/or ocular symptoms after initial endovascular treatment of cranial dAVFs.

OBJECT Intracranial dural arteriovenous fistulas (DAVFs) are complex intracranial vascular malformations that can lead to hemorrhage. The authors recently found that chronic local hypoperfusion seems to be the main cause of angiogenesis in the dura mater, which leads to the formation of DAVFs. As a natural derivative of estradiol, 2-methoxyestradiol (2-ME) has an antiangiogenic effect and can be used safely in patients with advanced carcinoid tumors. This study was conducted to examine the antiangiogenic effects of 2-ME on a rat DAVF model. METHODS Male Sprague-Dawley rats (n = 72) were used in the experiments. Intracranial venous hypertension was induced for modeling, and 2-ME was used in the early or late stage for treatment. The effects were examined by immunohistochemistry, Western blot analysis, and quantitative real-time polymerase chain reaction assays. RESULTS 2-Methoxyestradiol significantly reduced angiogenesis in the dura in early- and late-intervention treatment groups, as proven by the results of immunohistochemical staining, Western blotting, real-time polymerase chain reaction assays, and microvessel density counts. The antiangiogenic effect even lasted for up to 2 weeks after 2-ME cessation. CONCLUSIONS These data collectively suggest that 2-ME can reduce the angiogenic effect caused by venous hypertension in a rat DAVF model, mainly by suppressing the inhibitor of differentiation 1 (ID-1) and hypoxia-inducible factor 1α (HIF-1α) pathways.

The occurrence of multiple spinal dural arteriovenous fistulas (AVFs) is rare. The majority of cases reported are synchronous and the lesions are mainly found at different spinal levels. Metachronous AVFs have been defined as lesions that manifest in a temporal sequence after treatment of a first AVF. In this report, we present two distinct cases of multiple spinal AVFs. Also, we review the main features of the cases previously reported, with emphasis on the proposed theories for the origin of multiple AVFs. In patients with failure to improve after treatment of a spinal DAVF, a whole-spine angiographic examination is mandatory, not only to ascertain the complete closure of the treated fistula, but also to look for a possible second lesion at a different spinal level., (Copyright © 2015 Elsevier B.V. All rights reserved.)

The rupture of dural arteriovenous fistula (DAVF) is a serious complication endangering the lives of patients. It is difficult to treat such ruptured DAVF with large intracranial hematoma since lacking of early diagnostic methods. Meanwhile, there was no consensus of how to surgically treat these patients in early stage. In this study, we tried to use 4D-CTA to diagnose DAVF and guide surgical treatment. Based on the result of 4D-CTA, we attempted to eliminate DAVF at the same time we removed hematoma. The result was encouraging. 7 patients with ruptured DAVF presented as large spontaneous intracranial hemorrhage were included in this research between May, 2010 and August, 2012 in our hospital. 4D-CTA was performed in all cases. All results of 4D-CTA inspections were studied by both neurosurgeon and neuroradiologist. The therapeutic options were evaluated based on the clinical and angiographic results. All fistulas of seven patients were eliminated at the same time the hematoma being evacuated. 4D-CTA was sufficient for detecting and recognizing basic vessel angioarchitecture of DAVF to guide surgical treatment. Main arterial supplies, fistula location and CVDs found during surgery are consistent with the results 4D-CTA. All seven cases achieved completely fistula occlusion in operation without new neurological complication. We favor one stage surgical treatment for ruptured DAVF with large intracranial hemorrhage. 4D-CTA plays an important role in preoperative emergent inspection for its safety, rapidity and accuracy. However, it still needs further and larger investigations to optimize such treatment methods and to find out other potential risks.

Open surgical disconnection has long been the treatment of choice for dural arteriovenous fistulas (dAVFs) of the anterior cranial fossa. However, advanced patient age and the presence of medical comorbidities can substantially increase the risk of craniotomy and favor a less invasive endovascular approach. Optimal positioning within the distal ophthalmic artery, beyond the origin of the central retinal branch, is achievable using current microcatheter technology and embolic materials. Here we present the case of an 88-year-old female with an incidentally discovered dAVF of the anterior cranial fossa. Angiographic cure was achieved with one-stage Onyx embolization. The video can be found here: http://youtu.be/KVE0fUIECQM .

Type 1 spinal dural arteriovenous fistula (dAVF) constitute the vast majority of all spinal vascular malformations. Here we present the case of a 71-year-old male with progressive myelopathy, lower-extremity weakness and numbness, and urinary incontinence. MRI imaging of the thoracic spine demonstrated cord edema, and catheter spinal angiography confirmed a type 1 spinal dAVF. The fistula was supplied by small dural branches of the left L-2 segmental artery. Angiographic cure was achieved with a one-stage procedure in which coils were used to occlude the distal segmental vessels, followed by balloon-assisted embolization with Onyx. The video can be found here: http://youtu.be/8aehJbueH0U .

Background: Dural arteriovenous fistulas (DAVFs) have traditionally been approached through a bilateral laminectomy procedure with intradural exploration and ligation of the fistulae. A minimally invasive approach for DAVF ligation may be associated with fewer complications and a shorter recovery than the traditional laminectomy procedure. Our objective was to determine the feasibility, safety, and efficacy of intradural DAVF ligation via the use of a minimally invasive microsurgical technique., Methods: Seven patients with thoracolumbar DAVFs were microsurgically treated with a minimally invasive technique. The procedure entailed localization with the use of fluoroscopy followed by a midline 2.2-cm skin opening. Exposure was facilitated by the use of a tubular retractor. Intradural access was obtained after hemilaminectomy, and the fistula was identified and ligated. Dural closure was facilitated by the use of self-closing nitinol clips. The incidence of postoperative complications, blood loss, and length of hospital stay were reviewed., Results: Each patient tolerated the procedure well. There were no intraoperative or postoperative complications. Specifically, there were no new neurological deficits and no cerebrospinal fluid leaks. Each patient was ambulatory within 18 hours with only mild incisional back pain. Mean length of stay was 1.6 days. One-year follow-up demonstrated obliteration of the fistula with improvement or stabilization of neurological deficits in all cases., Conclusions: The minimally invasive approach for intradural ligation of DAVFs appears to be a reasonable alternative to bilateral full laminectomies. Although no direct comparison with the more extensive bilateral laminectomy approach has been performed, our initial experience suggests that this novel approach may reduce blood loss and length of hospital stay., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Sphenoid wing region dural arteriovenous fistulas (DAVFs) are rare lesions that are typically fed by middle meningeal artery feeders and that drain via the sphenoparietal sinus or middle cerebral vein. We describe a unique case of a medial sphenoid wing fistula draining exclusively via the basal vein of Rosenthal., Methods: A 55-year-old man presented with progressive right temporal homonymous hemianopsia. Cerebral angiography revealed a DAVF that rapidly filled into the deep venous system via the basal vein of Rosenthal with a large venous varix compressing the optic nerve. The sphenoid wing DAVF was not amenable to endovascular embolization due to direct ophthalmic artery feeders and was therefore treated with surgical obliteration. A right pterional craniotomy with orbitozygomatic osteotomy was performed., Results: The fistula was clip ligated, and the venous varix was incised and drained. Intraoperative angiography demonstrated complete obliteration of the fistula., Conclusions: Sphenoid wing DAVFs may drain via the deep venous system and have a complex arterial feeding network. Key features of the fistula, including deep venous drainage, presence of venous varices, and retrograde leptomeningeal venous drainage, make this an aggressive lesion with a high risk of rupture based on the available natural history data., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Dural arteriovenous fistulas (DAVFs) are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus. A retrospective review was conducted to present the results of endovascular obliteration of DAVFs, with particular emphasis of newer liquid embolic agents, including Onyx-18 (MV3, Irvine, California, USA)., Methods: A review of the literature was performed, and a presentation of the number of treatments, complications, and outcomes is included here. The number of arterial embolizations and need for transvenous embolization, open surgery, and radiosurgery was assessed as well as normalization of retrograde cortical venous drainage., Results: Thirty-nine patients (22 men and 17 women) underwent endovascular treatment of DAVFs at our institution from 2001 to 2009. Ages ranged from 39 to 71 years (mean, 48 years). Seventy-nine percent of patients had retrograde cortical venous drainage. The average number of embolizations in all patients was 2.1. Twelve patients underwent 40 embolization treatments with Onyx, with an obliteration rate of 75% and cortical venous drainage obliteration rate of 85%. Seventy-one percent (28/39) of patients had complete treatment of the fistula: 21 by purely endovascular treatment and 7 with endovascular therapy followed by craniotomy, as well as seven patients who underwent stereotactic radiosurgery after embolization., Conclusions: Endovascular management of DAVFs is a safe and effective method of treating these complex lesions., (Copyright © 2013 Elsevier Inc. All rights reserved.)