gms | German Medical Science

Objective: Treatment of dural arteriovenous fistulas (dAVF) requires careful choice of microsurgical, endovascular and radiosurgical treatment options. Deep-seated dAVF of the posterior fossa tend to present with aggressive symptoms like hemorrhage or progressive neurological deficit.

Methods: We present five patients with dAVF of the petrous apex and medial portion of the petrous margin. Two patients presented with cerebral hemorrhage and three patients with cranial nerve palsies. Cerebral angiography revealed arterial supply from meningeal branches of the ECA, ICA or VA. All fistulas were Type 3 or 4 according to Cognard’s classification with cortical venous drainage.

Results: Three patients received endovascular treatment prior to surgery. Arterial supply could largely be reduced. Steady occlusion of the fistula, however, could not be achieved. Thus, all 5 patients received surgical interruption of the leptomeningeal drainage via a standard suboccipital retrosigmoid approach. One patient suffered transient worsening of a facial nerve palsy after embolization. No complications occurred after surgery.

Conclusions: The presented fistulas receive multiple feeders from meningeal branches of the ECA and ICA/VA and drain into a single leptomeningeal vein. Due to the distal localization of the draining vein complete neuroradiological occlusion from the venous side is difficult but significant reduction of flow by occlusion of large parts of the arterial supply can be achieved. Complete cure at a low risk can be achieved by interruption of the leptomeningeal drainage via a suboccipital approach to the cerebellopontine angle.