Zerebrale durale arteriovenöse Fisteln

Zusammenfassung

Die durale arteriovenöse Fistel (dAVF), auch als durale arteriovenöse Malformation bezeichnet, macht ca. 10–15% aller intrakraniellen vaskulären Malformationen mit AV-Shunt aus. Es handelt es sich um einen Kurzschluss zwischen Arterien und Venen unter Umgehung des regulären Kapillarbetts, wobei der sogenannte Fistelpunkt in der Dura mater liegt. Am häufigsten betroffen sind der Sinus transversus, sigmoideus, cavernosus, sagittalis superior sowie das Tentorium. Als Pathomechanismen werden vor allem Thrombosen venöser Blutleiter, entzündliche Prozesse und Traumata aufgeführt, wobei häufig auch keine der vorgenannten zugrunde liegenden Erkrankungen nachweisbar ist. In Abhängigkeit von Fistellokalisation, Shuntvolumen und Drainagemuster reicht das klinische Spektrum von asymptomatisch bis hin zu schwersten neurologischen Defiziten. Durale AVF werden meist nach Cognard oder Borden klassifiziert, wobei beide Klassifikationen vor allem die venöse Drainage berücksichtigen, welche das Blutungsrisiko bestimmt. So haben direkt in einen antegrad fliessenden Sinus drainierende Fisteln meist ein zu vernachlässigendes Blutungsrisiko, während Fisteln mit primär kortikaler Drainage ein hohes Blutungsrisiko aufweisen. Die Behandlungsindikation leitet sich demnach aus Klinik und venösem Drainagemuster ab. Als Sonderfall ist die Carotis-Cavernosus-Fistel zu betrachten, welche nach Barrow klassifiziert wird. Bei gegebener Indikation kann die Behandlung in Abhängigkeit von der Anatomie der Fistel neuroradiologisch endovaskulär (transarteriell oder transvenös), neurochirurgisch, oder radiochirurgisch erfolgen. Auch Kombinationen der unterschiedlichen Verfahren sind möglich. Daher sollte die Indikationsstellung und Behandlung duraler AVF interdisziplinär von Neurologen, Neuroradiologen, Neurochirurgen, und Strahlentherapeuten in neurovaskulären Zentren durchgeführt werden.

Abstract

Dural arteriovenous fistulas (DAVF), also called dural arteriovenous malformations, account for 10–15% of all intracranial vascular malformations with AV-shunt. DAVF are pathologic shunts between dural arteries and dural venous sinuses, meningeal or cortical veins. Most frequently, DAVF are located within the wall of the transverse, sigmoid, cavernous, sagittal superior sinus or within the cerebellar tentorium. Whereas in many cases no underlying pathomechanism is found, thrombosis of venous vessels, inflammatory processes and trauma have been listed as underlying causes. Depending on localization of the fistula, shunt volume, and venous drainage pattern, the clinical presentation of patients ranges from asymptomatic to severe neurological deficits. Dural AVF can be graded using the classifications of Cognard et al. or Borden et al., both of which stratify the lesions with special emphasis on venous drainage patterns, as cortical venous drainage has been found to be associated with an increased risk for intracranial haemorrhage. The indication to treat a DAVF thus mainly depends on the patients’ clinical presentation as well as the venous drainage pattern. Carotid cavernous fistulas likewise are DAVF, but since more frequently they are traumatic, they are categorized according to Barrow et al. Treatment options include (transvenous and/or transarterial) endovascular approaches, neurosurgery, and radiosurgery. A combination of the afore- mentioned treatment modalities is feasible. Thus, treatment of DAVF should be performed in a neurovascular center with close interdisciplinary cooperation of a team of neurologists, neuroradiologists, neurosurgeons, and radiotherapists.

Schlüsselwörter

Cerebrale durale arteriovenöse Fistel - durale AV-Fistel - dAVF

Keywords

cerebral dural arteriovenous fistula - dural AV-fistula - DAVF

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