Management of Aggressive Cerebral Dural Arteriovenous Fistulae: Experience Using Endovascular Embolization

Abstract

The true incidence of cerebral dural arteriovenous fistulae (DAVF) is largely unknown [1]. It is estimated that
these malformations account for less than 10% of all
intracranial vascular malformations [2]. It is hypothesized that these fistulae develop following venous or
cortical sinus thrombosis following which multiple fistulous communications develop, typically between numerous branches of the ECA, ICA, and/or vertebral artery
and a venous sinus and/or intracranial veins [3]. Any
intracranial venous sinus may be involved. Clinical
manifestations depend upon the location and anatomy of
the lesion. Various classification systems have been used
to address the nature of these fistulae; however, the commonly used ones include the Borden classification [4] or
the one proposed by Cognard [5]. The aggressive subtypes of DAVFs are associated with retrograde venous
sinus, cortical venous, or spinal venous reflux, which
lead to intracranial haemorrhage or neurological deficit
[6]. Other features suggestive of the aggressiveness of
DAVFs are stenosis of the draining sinus, deep venous
drainage, certain locations like the anterior cranial fossa
and tentorium, venous congestion and venous aneurysm,
or varix, mainly in those DAVFs with direct leptomeningeal venous drainage [7]. Endovascular management is
now the primary modality of treatment for all DAVFs.
We wish to present our experience in treating 22 patients
with 25 aggressive intracranial DAVFs using transarterial embolization with ethylene vinyl alcohol (EVOH)
co-polymer or transvenous coiling aimed at occlusion of
the venous drainage along with all its arterial supply.