Intracranial dural arteriovenous fistulas: A Review

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Abstract

Dural arteriovenous fistulas are fistulas connecting the branches of dural arteries to dural veins or a venous sinus. Digital subtraction angiography remains the gold standard for diagnosing these fistulas. Endovascular treatment is one of the first line options available for their management. This review article reviews the etiopathogenesis, natural history, common classification systems and various available treatment options.

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Most cited references 27

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Classification and treatment of spontaneous carotid-cavernous sinus fistulas.

G T Tindall, Saori I. Braun, S C Tindall … (1985)

An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.

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Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course.

W P Akarawi, J Ahl, Susan Little … (1990)

The natural history of cranial dural arteriovenous malformations (AVM's) is highly variable. The authors present their clinical experience with 17 dural AVM's in adults, including 10 cases with an aggressive neurological course (strictly defined as hemorrhage or progressive focal neurological deficit other than ophthalmoplegia). Two of these 10 patients died prior to surgical intervention and a third was severely disabled by intracerebral hemorrhage. Six patients underwent surgical resection of their dural AVM, with preparatory embolization in two cases. One patient received embolization and radiation therapy without surgery. Six of the seven cases without an aggressive neurological course were treated conservatively, and the seventh patient underwent embolization of a cavernous sinus dural AVM because of worsening ophthalmoplegia. In order to clarify features associated with aggressive behavior, a comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information. The location and angiographic features of 100 aggressive cases were compared to those of 277 benign cases. No location of dural AVM's was immune from aggressive neurological behavior; however, an aggressive neurological course was least often associated with cases involving the transverse-sigmoid sinuses and cavernous sinus and most often associated with cases at the tentorial incisura. Contralateral contribution to arterial supply and rate of shunting (high vs. low flow) did not correlate with aggressive neurological behavior as defined. Leptomeningeal venous drainage, variceal or aneurysmal venous dilations, and galenic drainage correlated significantly (p less than 0.05) with aggressive neurological presentation. The latter three angiographic features often coexisted in the same dural AVM. It is concluded that these features significantly increase the natural risk of dural AVM's, and warrant a more vigilant therapeutic strategy.

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Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion.

R Willinsky, Junichiro Satomi, K G TerBrugge … (2002)

Cranial dural arteriovenous fistulas (DAVFs) can be classified into benign or aggressive, based on their patterns of venous drainage. A benign condition requires the absence of cortical venous drainage (CVD). The clinical and angiographic features of a consecutive single-center group of 117 patients harboring benign cranial DAVFs were evaluated over time to validate the behavior and appropriate management of these lesions. At the initial assessment four patients were asymptomatic. Two infants presented with congestive heart failure. All other patients presented with other benign symptoms: chronic headache, bruit, or orbital phenomena. Observational management was instituted in 73 patients (62%). Intolerable bruit or ophthalmological sequelae were deemed indications for palliative embolization in 43 patients and surgical treatment in one patient. A median follow-up period of 27.9 months (range 1 month-17.5 years) was available in 112 patients (95.7%), among whom repeated angiography was performed in 50. Overall, observational and palliative management resulted in a benign and tolerable level of disease in 110 (98.2%) of 112 cases. In two cases managed conservatively CVD developed. In both of these cases the conversion from benign to aggressive DAVF was associated with spontaneous progressive thrombosis of venous outlets. The disease course of a cranial DAVF without CVD is indeed benign, obviating the need for a cure of these lesions. Symptoms are well tolerated with either observation or palliative treatment. After a long-term follow-up review of 68 patients, this conservative management resulted in a benign and tolerable level of disease in 98.5% of cases. It is noteworthy, however, that a benign DAVF carries a 2% risk of developing CVD, mandating close clinical follow-up review in such cases and renewed radiological evaluation in response to any deterioration in the patient's condition.

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Author and article information

Journal

Journal ID (nlm-ta): Indian J Radiol Imaging

Journal ID (publisher-id): IJRI

Title: The Indian Journal of Radiology & Imaging

Publisher: Medknow (India )

ISSN (Print): 0971-3026

ISSN (Electronic): 1998-3808

Publication date (Print): February 2009

Volume: 19

Issue: 1

Pages: 43-48

Affiliations

Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 695 011, India

Author notes

Correspondence: Dr. Arun Gupta, A-4, New Faculty Hostel, Sree Chitra Residential Complex, Poonthi Road, Kumarpuram, Trivandrum, India. E-mail: gupta209@ 123456gmail.com

Article

Publisher ID: IJRI-19-43

DOI: 10.4103/0971-3026.45344

PMC ID: 2747405

PubMed ID: 19774139

SO-VID: 46755208-7420-4022-8c2c-9dbf1246073b

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Intracranial dural arteriovenous fistulas: A Review

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Most cited references 27

Classification and treatment of spontaneous carotid-cavernous sinus fistulas.

Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course.

Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion.

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