Surgical Treatment of Carotid-Cavernous Fistula and Intracranial Dural Arteriovenous Malformations

Kim, Gook Ki

Abstract

Dural arteriovenous malformations(DAVM) or Dural Arteriovenous fistulas(DAVF) consists of multiple arteriovenous shunt between arteries and a dural venous sinuses or a meningeal vein, constitute 10% to 15% of all intracranial arteriovenous malformations Most commonly they involve the transverse, the sigmoid and the cavernous sinuses. Other locations include the tentorial incisure, the superior sagittal sinus, the torcular Herophili, anterior cranial fossa, the convexity dura mater, and the foramen magnum. In angiographic features, leptomeningeal retrograde venous drainage, variceal or aneurysmal venous structure, and galenic venous drainage are significantly associated with aggressive neurological course caused by intracranial hemorrhage(ICH or SAH). Lesion at tentorial incisura and anterior cranial fossa has a tendency to have aggressive neurological course. Dural AVM located at cavernous sinus are classified as 4 types according to arterial distribution. Treatment of Dural AVF or CCF includes conservative monitoring, manual compression, arterial embolization, transvenous occlusion, surgical excision and radiation therapy. Surgical therapy with or without preparatory embolization remains the most versatile and effective therapeutic option. It is usually aimed at resecting the dural leaflets harboring the AVM(and adjacent sinus) and at disconnecting leptmeningeal draining pathways which are typically the source of serious neurological sequelae. In Tentorial AVF or anterior cranial fossa AVF the first choice of treatment is surgery because of difficulty in accessibility through transarterial or transvenous embolization.