gms | German Medical Science

Objective: Cranial dural arteriovenous fistulas (cDAVFs) are rare vascular malformations associated with relevant neurological morbidity and mortality. cDAVFs with cortical venous drainage hold a considerable risk of intracranial hemorrhage. This single-center study presents results of a multidisciplinary approach in an unselected group of patients with symptomatic cDAVFs.

Methods: Twenty-six patients with cranial DAVFs Borden class II/III treated and observed between 1998 and 2018 were included. Patient demographics, clinical characteristics, cDAVF morphology, treatment characteristics, risk factors, radiologic and neurological outcomes were reviewed. Treatment modality, perioperative and mid-/long-term complications, target fistula rupture, retreatment/recurrence rates, and long-term neurologic outcome using the mRS were analyzed.

Results: Borden Type II fistulas were diagnosed in 38.5% of patients and Type III fistulas in 61.5% of patients. Aggressive symptoms occurred in 57.7% of patients. Venous ectasia was present in 30.8% of cases. Fistulas were most commonly located at the transverse or sigmoid sinus (65.4%). A single treatment modality was applied in 65.4% of patients (surgery in 6 patients, endovascular treatment in 9, radiotherapy in 1 patient) while combined treatment was performed in 34.6% of patients (endovascular/surgery in 8 patients, surgery/radiosurgery in 1). Periprocedural endovascular complications occurred in 7 out of 17 patients (41,2%), leading to permanent neurological deficits in 3 patients (17,6%). Surgery-related complications appeared in one patient (wound healing disturbance, 6,7%). Complete occlusion was achieved in 77% of patients. Worsening of the mRS due to the target fistula was noted in 11.5% of patients, whereas 88.5% of patients showed stable/improved neurological outcome. One patient died due to traumatic acute subdural hematoma, possibly caused by fistula rerupture. Seventy-seven percent of patients achieved a favorable long-term neurological outcome (mRS<2) with no need of assistance in a daily life.

Conclusion: Patients with symptomatic cranial DAVFs should be considered for management with either single or combined treatment approaches. The optimal cDAVF-management is defined on a case-by-case basis carefully comparing the risk of invasive treatment with the natural history of the disease. The multidisciplinary treatment of aggressive cDAVFs can be performed with acceptable rates of neurological complications and adequate occlusion rates.