J Cerebrovasc Endovasc Neurosurg.  2012 Sep;14(3):192-202. 10.7461/jcen.2012.14.3.192.

Intracranial Dural Arteriovenous Fistulas: Clinical Characteristics and Management Based on Location and Hemodynamics

• Oh JT
• Chung SY
• Lanzino G
• Park KS
• Kim SM
• Park MS
• Kim HK

• KMID: 1808455
• DOI: http://doi.org/10.7461/jcen.2012.14.3.192

Abstract

OBJECTIVE
A dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period.
METHODS
Between January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern.
RESULTS
Borden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS).
CONCLUSION
The hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

Keyword

Dural arteriovenous fistula; Signs and symptoms; Therapeutics

MeSH Terms

Central Nervous System Vascular Malformations
Colon, Sigmoid
Drainage
Facial Paralysis
Hemodynamics
Humans
Intracranial Hemorrhages
Paresis
Radiosurgery
Retrospective Studies
Superior Sagittal Sinus
Treatment Outcome
Vascular Malformations

Figure

• 

  Fig. 1 42-year-old female patient with altered mentality and vomiting visited the emergency unit. Computed tomographic angiography (CTA) on initial assessment shows an acute intracerebral hemorrhage at the right temporo-parietal lobe and a mass effect. She underwent stereotactic hematoma evacuation and had no fixed neurological deficit (A). After six months, she revisited the emergency unit due to recurrent hemorrhage in the right temporo-parietal lobe. CT shows an intracerebral hematoma at the right temporo-parietal lobe and an intraventricular hemorrhage (B). Lateral view of an external carotid angiogram shows a transverse-sigmoid sinus dural arteriovenous fistula (DAVF) supplied by the middle meningeal artery and occipital artery (C). Lateral view of a common carotid angiogram obtained after glue embolization shows the remaining minimal DAVF. Glue embolization was followed by gamma knife stereotactic radiosurgery (GKS) because she had a DAVF with cortical venous reflux (CVR) only (D).

• 

  Fig. 2 A 64-year-old male patient presented with a chronic headache and pulsatile tinnitus. Magnetic resonance imaging (MRI) on initial assessment shows chronic cortical laminar necrosis and petechial hemorrhage, resulting from a previous venous infarction at the right temporo-occipital area (A, B). Lateral view of an external carotid angiogram shows a Borden type II, transverse-sigmoid sinus DAVF with occlusion of the sigmoid sinus and disturbed flow in the right transverse sinuses. Prominent cortical reflux is evident (C). Immediate postoperative assessment shows a complete fistula obliteration after transarterial embolization (D). The mean transit time (MTT) map on MRI shows a perfusion deficit in the right temporo-occipital lobe due to venous hypertension on preoperative assessment (E). At three months after embolization, the MTT map shows improved perfusion at the right temporo-occipital lobe. However, a regional prolonged MTT area remains at the right temporo-occipital lobe because of irreversible changes due to the venous infarction (F).

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