gms | German Medical Science

Objective: There is consensus that intracranial dural arteriovenous fistulas (dAVF) with direct (non-sinus-type) or indirect (sinus-type) retrograde filling of a leptomeningeal vein should be treated due to the high risk of neurological deficits and hemorrhage. No consensus exists on treatment modality (surgery and/or embolisation) and, if surgery is performed, on the best surgical strategy. This series aims to evaluate the role of surgery in the management of aggressive dAVFs.

Methods: Forty-one patients underwent surgery. Opening and packing the sinus with thrombogenic material was performed in 10 of the 12 sinus-type dAVFs. In 2 sinus-type fistulas of the cavernous sinus, microsurgery was used as prerequisite for subsequent embolisation by providing access to the sinus. In the 29 non-sinus-type dAVFs, surgery consisted of interruption of the draining vein at the intradural entry point.

Results: In all but one case, total elimination of the arterio-venous shunting could be achieved (97.6%); in 2 patients 2 operations had been necessary for complete occlusion. In one case, a minimal persistent venous drainage of a dilated vein had been detected angiographically. Transient, surgery-associated, neurological deficits were found in 5 (12.2%) and permanent neurological deficits in 3 out of 41 patients (7.3%).

Conclusions: Our surgical strategy was to focus on the arterialized leptomeningeal vein in the non-sinus-type fistulae and on the arterialized sinus segment in the sinus-type fistulae. With this surgical strategy, the operative morbidity was low, but the dAVF occlusion rate high. In the light of these favourable surgical results, we propose, that microsurgery should be considered early in the treatment of both types of aggressive cranial dAVFs. In selected cases of cavernous sinus dAVFs, the role of microsurgery is reduced to that of an adjunct to endovascular therapy.