Surgical treatment of intracranial dural arteriovenous fistulas

BACKGROUND When considering the treatment strategies for dural arteriovenous fistulas (DAVFs), it is important to clarify the exact location of the fistula and venous drainage route from both DAVFs and normal brain tissue. DAVFs with leptomeningeal retrograde venous drainage carry a high risk of neurological deficits and require aggressive treatment. When AVFs involve the dural sinus, transvenous embolization via the transfemoral approach is usually the first choice of treatment. For DAVFs draining directly into the cortical veins without dural sinus involvement, transarterial embolization may be a curative treatment. However, when embolization is technically difficult or results in incomplete occlusion, surgical treatment is required. The purpose of the present study was to review our experience with surgical treatment of DAVFs. METHODS The present series included 17 patients; 9 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage and 8 had DAVFs draining directly into the cortical veins. For DAVFs involving the sinus, embolization of the diseased sinus by direct surgical exposure was performed in 8 patients, and surgical excision in one. For DAVFs draining directly into the cortical veins, interruption of the draining veins close to DAVFs was undertaken in 7 and surgical excision in 1. RESULTS Complete obliteration of DAVFs was demonstrated in 16 patients. At final follow-up, 15 patients were asymptomatic and the other 2 showed clinical improvement. CONCLUSIONS For DAVFs involving the dural sinus, direct operative sinus packing is indicated. For DAVFs directly draining into the cortical veins, surgical interruption of the draining veins is indicated.