Chapter 11 - Endovascular management of intracranial dural arteriovenous fistulas
Introduction
Intracranial dural arteriovenous fistulas (DAVFs) account for 10–15% of all intracranial vascular malformations and about 6% of supratentorial arteriovenous malformations (AVMs) (Santillan et al., 2013). The arterial supply is generally attributed to the meningeal arteries. The hemorrhage risk for DAVFs is approximately 1.5% per year but varies by location and type of DAVF (Santillan et al., 2013).
Although there are different classification systems for intracranial DAVFs, the most commonly used are the Cognard and Borden classification systems. The Cognard classification system of four types of DAVFs is based on the venous drainage pattern: (1) patients who have type I DAVFs present with immediate drainage into a dural sinus or meningeal vein; (2) patients who have type II DAVFs present with initial drainage into the sinus and retrograde flow into other sinuses or cortical veins; (3) patients with type III DAVFs present with initial drainage into a cortical vein; and (4) patients with type IV DAVFs present with initial drainage into a cortical vein with venous ectasia (Table 11.1 and Fig. 11.1, Fig. 11.2, Fig. 11.3) (Borden et al., 1995, Cognard et al., 1995, Santillan et al., 2013). In contrast, the Borden classification system simply stratifies DAVFs into type I, type II, and type III. In this classification system, type I lesions drain into dural venous sinuses or meningeal veins, and type II lesions have retrograde drainage into subarachnoid veins. The third type of DAVFs, type III lesions, drain into subarachnoid veins and do not have dural sinus or meningeal venous drainage.
Section snippets
Aggressive DAVFs
Some DAVFs can be quite aggressive, in particular those with cortical or leptomeningeal venous drainage and/or an associated varix. In these cases, the source of hemorrhage is not the arterial component but instead is the distended leptomeningeal venous varices (Liu et al., 2009). In a meta-analysis by Awad et al. (1990), leptomeningeal venous drainage, variceal or aneurysmal (venous) dilations, and galenic drainage were found to be significantly associated with an aggressive presentation (
Patient evaluation
The decision to proceed with endovascular treatment should be based on the presentation of the patient, the patient's history of any previous hemorrhage, and the patient's age and medical comorbidities. Other key considerations that influence the decision include the venous drainage pattern, angiographic features, and the location of the DAVF. A history of a previous hemorrhage and low operative risk push the provider toward intervention. Low-risk features, such as a lack of cortical venous
Summary
Endovascular management of intracranial DAVFs has made tremendous advancements in recent years. Of paramount importance is the assessment of the risk of hemorrhage or neurologic decline based on the clinical presentation of the patient and the type and location of the DAVF. Occlusion rates for the most common DAVFs are promising and, with continued technologic advancement, we may begin to see higher cure rates for DAVFs that are more technically difficult.
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