gms | German Medical Science

Objective: Endovascular embolisation is assumed to be the first line therapy option in patients with dural arteriovenous fistulas (DAVFs). Nevertheless in particular cases like posterior fossa DAVFs endovascular cure is not possible. In these lesions surgery still is a valuable alternative treatment. We report on our experience with eight surgically treated patients suffering from rare DAVFs in the posterior fossa.

Method: We reviewed the medical records and imaging studies of 8 patients (6 women and 2 men) with DAVFs in the posterior fossa, who underwent surgery between July 2008 and December 2012 at our department. The angiographic classification of the DAVFs was based on the Cognard grading system. The fistulas were located at: tentorium (n=5), sinus sigmoideus (n= 2) and sinus petrosus superior (n=1). Before the operation all patients were evaluated by a neurovascular team of interventional neuroradiologists and neurosurgeons. The decision for a surgical intervention was based on clinical presentation, location of the lesion and venous drainage. Postoperative digital subtraction angiography (DSA) was performed in all patients.

Results: Complete angiographic occlusion of the DAVF was achieved in all patients. In six patients a complete occlusion was achieved by surgery alone. Spontaneous occlusion was seen in one instance. There were no intraoperative complications. One patient developed transient aphasia and visual field loss postoperatively. Three recurrences were successfully treated either by surgery (n=2) or by endovascular embolization (n=1). Cerebrospinal fluid (CSF) leakage occurred in two patients and required a second operative intervention. All five patients with a tentorial DAVF (Cognard type III and IV) presented with an intracerebral hemorrhage but recovered gradually and were seen at the last follow-up with a Glasgow Outcome Scale score (GOS) of 4 or 5. After a mean follow-up of 20 months six patients had a GOS score of 5, one patient a GOS score of 4 and one patient a GOS score of 3.

Conclusions: In our experience most patients with DAVFs in the posterior fossa can be successfully treated by advanced surgical and endovascular techniques. According to the results of our series and in line with recent reports we recommend an early operative treatment of high-risk DAVFs in posterior fossa.