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Dural Arteriovenous Fistula Treatment
Carlos E. Baccin, MD; James D. Rabinov, MD
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KEY FACTS

  • Terminology

    • Pre-Procedure

      • Procedure

        TERMINOLOGY

        • Definitions

          • Dural arteriovenous fistula (dAVF): Arteriovenous shunts associated with dural venous sinus wall; can involve any dural venous sinus
            • Although often called dural arteriovenous malformation as synonym, no nidus (unlike AVM)
            • Infant dAVFs are congenital
              • Association with dural venous sinus enlargement
            • Adult dAVFs usually acquired, not congenital
              • Often idiopathic
              • Can result from trauma, venous sinus thrombosis
            • Pathological activation of neoangiogenesis
              • Proliferating capillaries within granulation tissue in dural sinus obliterated by organized thrombi
              • Microvascular network develops in inner dura
                • Connects to plexus of thin-walled venous channels; creates microfistulae
            • Associated abnormalities/symptoms
              • Cerebral edema, encephalopathy
              • May cause developmental delay in children
              • Increased risk of intracranial hemorrhage or stroke
                • Arterialized flow in cortical veins
                • High-flow venopathy causes venous stenosis, tortuosity, aneurysm, thrombosis
            • Common locations and incidence
              • Transverse-sigmoid sinus (35-40%)
              • Cavernous sinus (35%)
              • Tentorium/superior petrosal sinus (5%)
              • Superior sagittal sinus (5%)
              • Anterior fossa (5%)
              • Multiple (6.7%)
          • Carotid artery to cavernous sinus fistula (CCF): 2nd most common dAVF site
            • Barrow classification based on arterial supply
              • Type A: Direct internal carotid artery (ICA) to cavernous sinus high-flow shunt (not dAVF)
              • Type B: Dural ICA branches to cavernous shunt
              • Type C: Dural external carotid artery (ECA) to cavernous shunt
              • Type D: ECA/ICA dural branches shunt to cavernous sinus
            • CCF signs/symptoms
              • Orbital pain/congestion, proptosis, diplopia
              • Decreased visual acuity, elevated ocular pressure
          • Borden classification for dAVF
            • Type I: Venous drainage directly into dural venous sinus or meningeal vein
            • Type II: Venous drainage into dural venous sinus with cortical venous reflux (CVR)
            • Type III: Venous drainage directly into subarachnoid veins (CVR only)
          • Overall annual risk of hemorrhage (1.8%); mortality from hemorrhage (20%)
            • Risk factors for hemorrhage
              • Leptomeningeal/galenic venous drainage
              • Stenosis/occlusion of associated venous sinuses
              • Variceal/aneurysmal venous dilatation
              • Tentorial incisura/anterior or middle cranial fossa location
            • Cognard classification of intracranial dAVF correlates venous drainage pattern with intracranial hemorrhage (ICH) risk
              • Grade I: Located in sinus wall, normal antegrade venous drainage; clinically benign
              • Grade IIA: Located in main sinus, reflux into sinus but not cortical veins; clinically benign
              • Grade IIB: Reflux (retrograde drainage) into cortical veins; 10-20% hemorrhage rate
              • Grade III: Direct cortical venous drainage, no venous ectasia; 40% hemorrhage rate
              • Grade IV: Direct cortical venous drainage, venous ectasia; 65% hemorrhage rate
              • Grade V: Spinal perimedullary venous drainage; associated with progressive myelopathy
          • Venous sinus thrombosis association in some cases
          • Clinical features of dAVFs
            • May be asymptomatic, incidentally found
            • Benign features: Pulsatile bruit, tinnitus, orbital congestion, cranial nerve palsy, chronic headache
            • Aggressive features: ICH, focal neurological deficit, dementia, papilledema, stroke, death
            • Borden type I lesions (Cognard grade I/IIA) considered "benign"; higher grades "aggressive"

        PRE-PROCEDURE

        • Indications

          • Contraindications

            • Pre-Procedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST-PROCEDURE

                          • Expected Outcome

                            • Things to Do

                              • Things to Avoid

                                OUTCOMES

                                • Complications

                                  Selected References

                                  1. Guedin P et al: Therapeutic management of intracranial dural arteriovenous shunts with leptomeningeal venous drainage: report of 53 consecutive patients with emphasis on transarterial embolization with acrylic glue. J Neurosurg. 112(3):603-10, 2010
                                  2. Jung KH et al: Clinical and angiographic factors related to the prognosis of cavernous sinus dural arteriovenous fistula. Neuroradiology. Epub ahead of print, 2010
                                  3. Natarajan SK et al: Multimodality treatment of intracranial dural arteriovenous fistulas in the Onyx era: a single center experience. World Neurosurg. 73(4):365-79, 2010
                                  4. van Rooij WJ et al: Curative embolization with Onyx of dural arteriovenous fistulas with cortical venous drainage. AJNR Am J Neuroradiol. 31(8):1516-20, 2010
                                  5. Chew J et al: Arterial Onyx embolisation of intracranial DAVFs with cortical venous drainage. Can J Neurol Sci. 36(2):168-75, 2009
                                  6. Cognard C et al: Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx. AJNR Am J Neuroradiol. 29(2):235-41, 2008
                                  7. Piske RL et al: Dural sinus compartment in dural arteriovenous shunts: a new angioarchitectural feature allowing superselective transvenous dural sinus occlusion treatment. AJNR Am J Neuroradiol. 26(7):1715-22, 2005
                                  8. Cognard C et al: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 194(3):671-80, 1995
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Pre-Procedure

                                      • Procedure

                                        TERMINOLOGY

                                        • Definitions

                                          • Dural arteriovenous fistula (dAVF): Arteriovenous shunts associated with dural venous sinus wall; can involve any dural venous sinus
                                            • Although often called dural arteriovenous malformation as synonym, no nidus (unlike AVM)
                                            • Infant dAVFs are congenital
                                              • Association with dural venous sinus enlargement
                                            • Adult dAVFs usually acquired, not congenital
                                              • Often idiopathic
                                              • Can result from trauma, venous sinus thrombosis
                                            • Pathological activation of neoangiogenesis
                                              • Proliferating capillaries within granulation tissue in dural sinus obliterated by organized thrombi
                                              • Microvascular network develops in inner dura
                                                • Connects to plexus of thin-walled venous channels; creates microfistulae
                                            • Associated abnormalities/symptoms
                                              • Cerebral edema, encephalopathy
                                              • May cause developmental delay in children
                                              • Increased risk of intracranial hemorrhage or stroke
                                                • Arterialized flow in cortical veins
                                                • High-flow venopathy causes venous stenosis, tortuosity, aneurysm, thrombosis
                                            • Common locations and incidence
                                              • Transverse-sigmoid sinus (35-40%)
                                              • Cavernous sinus (35%)
                                              • Tentorium/superior petrosal sinus (5%)
                                              • Superior sagittal sinus (5%)
                                              • Anterior fossa (5%)
                                              • Multiple (6.7%)
                                          • Carotid artery to cavernous sinus fistula (CCF): 2nd most common dAVF site
                                            • Barrow classification based on arterial supply
                                              • Type A: Direct internal carotid artery (ICA) to cavernous sinus high-flow shunt (not dAVF)
                                              • Type B: Dural ICA branches to cavernous shunt
                                              • Type C: Dural external carotid artery (ECA) to cavernous shunt
                                              • Type D: ECA/ICA dural branches shunt to cavernous sinus
                                            • CCF signs/symptoms
                                              • Orbital pain/congestion, proptosis, diplopia
                                              • Decreased visual acuity, elevated ocular pressure
                                          • Borden classification for dAVF
                                            • Type I: Venous drainage directly into dural venous sinus or meningeal vein
                                            • Type II: Venous drainage into dural venous sinus with cortical venous reflux (CVR)
                                            • Type III: Venous drainage directly into subarachnoid veins (CVR only)
                                          • Overall annual risk of hemorrhage (1.8%); mortality from hemorrhage (20%)
                                            • Risk factors for hemorrhage
                                              • Leptomeningeal/galenic venous drainage
                                              • Stenosis/occlusion of associated venous sinuses
                                              • Variceal/aneurysmal venous dilatation
                                              • Tentorial incisura/anterior or middle cranial fossa location
                                            • Cognard classification of intracranial dAVF correlates venous drainage pattern with intracranial hemorrhage (ICH) risk
                                              • Grade I: Located in sinus wall, normal antegrade venous drainage; clinically benign
                                              • Grade IIA: Located in main sinus, reflux into sinus but not cortical veins; clinically benign
                                              • Grade IIB: Reflux (retrograde drainage) into cortical veins; 10-20% hemorrhage rate
                                              • Grade III: Direct cortical venous drainage, no venous ectasia; 40% hemorrhage rate
                                              • Grade IV: Direct cortical venous drainage, venous ectasia; 65% hemorrhage rate
                                              • Grade V: Spinal perimedullary venous drainage; associated with progressive myelopathy
                                          • Venous sinus thrombosis association in some cases
                                          • Clinical features of dAVFs
                                            • May be asymptomatic, incidentally found
                                            • Benign features: Pulsatile bruit, tinnitus, orbital congestion, cranial nerve palsy, chronic headache
                                            • Aggressive features: ICH, focal neurological deficit, dementia, papilledema, stroke, death
                                            • Borden type I lesions (Cognard grade I/IIA) considered "benign"; higher grades "aggressive"

                                        PRE-PROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Pre-Procedure Imaging

                                              • Getting Started

                                                PROCEDURE

                                                • Patient Position/Location

                                                  • Equipment Preparation

                                                    • Procedure Steps

                                                      • Findings and Reporting

                                                        • Alternative Procedures/Therapies

                                                          POST-PROCEDURE

                                                          • Expected Outcome

                                                            • Things to Do

                                                              • Things to Avoid

                                                                OUTCOMES

                                                                • Complications

                                                                  Selected References

                                                                  1. Guedin P et al: Therapeutic management of intracranial dural arteriovenous shunts with leptomeningeal venous drainage: report of 53 consecutive patients with emphasis on transarterial embolization with acrylic glue. J Neurosurg. 112(3):603-10, 2010
                                                                  2. Jung KH et al: Clinical and angiographic factors related to the prognosis of cavernous sinus dural arteriovenous fistula. Neuroradiology. Epub ahead of print, 2010
                                                                  3. Natarajan SK et al: Multimodality treatment of intracranial dural arteriovenous fistulas in the Onyx era: a single center experience. World Neurosurg. 73(4):365-79, 2010
                                                                  4. van Rooij WJ et al: Curative embolization with Onyx of dural arteriovenous fistulas with cortical venous drainage. AJNR Am J Neuroradiol. 31(8):1516-20, 2010
                                                                  5. Chew J et al: Arterial Onyx embolisation of intracranial DAVFs with cortical venous drainage. Can J Neurol Sci. 36(2):168-75, 2009
                                                                  6. Cognard C et al: Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx. AJNR Am J Neuroradiol. 29(2):235-41, 2008
                                                                  7. Piske RL et al: Dural sinus compartment in dural arteriovenous shunts: a new angioarchitectural feature allowing superselective transvenous dural sinus occlusion treatment. AJNR Am J Neuroradiol. 26(7):1715-22, 2005
                                                                  8. Cognard C et al: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 194(3):671-80, 1995