40 Endovascular Approaches to Intracranial Dural Arteriovenous Fistulas

Karl Abi-Aad, Rudy J. Rahme, Devi P. Patra, Evelyn L. Turcotte, Mathew E. Welz, Arjun Syal, Ryan Hess, Brian Kalen, and Bernard R. Bendok

Abstract

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal connections between arteries and veins involving the dura and often the venous sinuses. The pathogenesis of DAVFs remains unclear. Trauma and sinus thrombosis have been postulated as potential etiologies. Arterial supply of DAVFs typically arises from any of the dural branches of the internal and external carotid arteries as well as the vertebral arteries. Venous drainage of DAVFs relates to normal venous drainage of the dura and is often linked to the venous sinuses. Drainage can also be into other head and neck veins and/or cortical veins. The single most important anatomic feature of DAVFs is cortical venous drainage as it has been linked to a worse natural history. In fact, both the Cognard and Borden classifications are based on the drainage characteristics of DAVFs. Management options include observation, endovascular embolization, microsurgical disconnection, and radiosurgery. Treatment success requires a thorough understanding of a comprehensive head and neck angiogram and a thoughtful strategy that optimizes chances for cure while minimizing risk. While both transarterial and transvenous approaches can be considered, transarterial options have become more prevalent in recent years due to the high cure rates achieved with Onyx embolization (Medtronic, Minneapolis, Minnesota, United States) in carefully selected fistulas. Certain cases are more readily and easily treated via microsurgical approaches and some require multimodal approaches including radiosurgery, microsurgery, and endovascular therapies. In this chapter, we present an overview of the DAVF anatomy and pathophysiology and discuss diagnostic and endovascular treatment strategies.

Schlüsselwörter

dural arteriovenous fistula - Borden classification - Cognard classification - endovascular embolization - transarterial embolization - transvenous embolization

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