J Cerebrovasc Endovasc Neurosurg.  2023 Jun;25(2):117-131. 10.7461/jcen.2023.E2022.10.006.

Role of surgery in management of intracranial dural arteriovenous fistulas

• Kang YS
• Cho WS
• Lee SH
• Kim K
• Kang HS
• Kim JE

• KMID: 2543508
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.006

Abstract

Intracranial dural arteriovenous fistulas (DAVF) are abnormal connections between intracranial arterial and venous systems within the dural layers. Intracranial DAVFs are rare but can occur wherever dural components exist. The pathogenesis of DAVFs is controversial. Venous hypertension is considered as a main cause of clinical symptoms which are subclassified into asymptomatic, benign and aggressive manifestations. To date, several classification schemes have been proposed to stratify the natural course and risks of DAVFs. Currently, endovascular therapy is the main treatment modality. Moreover, the use of radiosurgery and radiotherapy has been limited. Open surgery is also selectively performed as a main treatment modality for specific types of DAVFs and an adjunctive modality for the endovascular approach. Herein, we present a review of the general perspectives of intracranial DAVFs with an emphasis on the role of surgery.

Keyword

Intracranial; Dural; Arteriovenous fistula; Surgery; DAVF

Figure

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  Fig. 1. Axial CT images after TVE for the intracranial DAVF. Two hours after TVE, the patient complained of severe headache (A). After three hours, the patient lost consciousness due to ICH, intraventricular hemorrhage, and hydrocephalus (B). Twelve hours later, brain swelling and hemorrhage in the deep venous system were observed on brain CT, implying a compromise of the deep venous system after TVE (C). CT, computed tomography; TVE, transvenous embolization; DAVF, dural arteriovenous fistulas; ICH, intracerebral hemorrhage

• 

  Fig. 2. An ECA angiogram showing a Cognard type IIa+b CS DAVF. TVE through the inferior petrosal sinus was infeasible (A). Microcatheter navigation through the ophthalmic vein and TVE were successful via a surgical direct puncture (B and C). A postprocedural angiogram showed a complete occlusion (D). ECA, external carotid arteries; CS, cavernous sinus; DAVF, dural arteriovenous fistulas; TVE, transvenous embolization

• 

  Fig. 3. An ECA angiogram showed an isolated Cognard type III SSS DAVF (A). Exposing the SSS via a craniotomy, a direct puncture and following TVE were successfully performed (B and C). A postinterventional angiogram showed no remaining shunt (D). ECA, external carotid arteries; SSS, superior sagittal sinus; DAVF, dural arteriovenous fistulas; TVE, transvenous embolization

• 

  Fig. 4. Preoperative ICA angiography showing a right ethmoidal DAVF (A). Opening the dura at the right high frontal lobe, the target fistula was identified after cerebrospinal fluid drainage and frontal retraction (B and C). The fistulas were easily coagulated and cut (D). Postoperative ICA angiography showed complete obliteration of the fistulas (E). Reprinted from Jang et al.(2019), with permission from Elsevier[33]. ICH, intracerebral hemorrhage; DAVF, dural arteriovenous fistulas; ICA, internal carotid arteries

• 

  Fig. 5. An occluded transverse sinus (TS) DAVF fed by left ECA arteries was identified on left anteroposterior ICA angiogram (A) and ECA angiogram (B). Small feeders were coagulated and cut (C), and occluded left TS was resected (D). DAVF, dural arteriovenous fistulas; ECA, external carotid arteries; ICA, internal carotid arteries

• 

  Fig. 6. A Cognard type IIa+b SSS DVAF fed by branches of superficial temporal, occipital and middle meningeal arteries was identified on an ECA angiogram (A). TAE with Onyx® via the middle meningeal artery was partially performed (B and C). Surgical obliteration was planned for remnant lesion. Small transosseous feeders from superficial temporal artery (arrow) were coagulated and cut during scalp reflection (D). After craniotomy, remnant feeders from middle meningeal arteries (dotted arrows) were coagulated and cut (E). A fistulous segment of a draining vein beside the SSS was coagulated and cut (F). A postoperative ECA angiogram showed no remaining fistulas (G). SSS, superior sagittal sinus; DAVF, dural arteriovenous fistulas; ECA, external carotid arteries; TAE, transarterial embolization

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