Neurosurgical Review

, Volume 37, Issue 1, pp 63–71 | Cite as

Endovascular treatment of 170 consecutive cranial dural arteriovenous fistulae: results and complications

  • Gerasimos BaltsaviasEmail author
  • Anton Valavanis
Original Article


This study aims to evaluate a single-center experience with endovascular treatment of cranial dural arterievenous fistulae (CDAVF). The clinical and radiological records of 170 consecutive patients harboring a CDAVF and treated endovascularly in a 16-year period were reviewed. A variety of data related to demographics, features of the lesion, treatment, outcome, and follow-up were analyzed with emphasis to the results and complications. Half of the lesions had cortical venous drainage (CVD) in the initial angiographic investigation, whereas 26 % had exclusively CVD. Sixty-seven percent of our patients presented with benign symptoms and 33 % with aggressive symptoms. In 60.5 % of the patients with benign lesion (without CVD), an anatomic cure in the immediate postinterventional angiogram without complication or permanent morbidity was achieved, whereas 69 % of the patients with aggressive lesions (with CVD) had an anatomic cure in the postinterventional final angiogram with all permanent-morbidity cases belonging to this group. The average of endovascular operation sessions per patient was 1.2. In a mean follow-up period of 2.8 years, the overall complete occlusion rate was 85.5 % (78 % for the benign group and 89.5 % for the aggressive group) and clinical cure and/or improvement rate of 93 %. The operative mortality was zero, and permanent neurologic morbidity was 2.3 %. In 73 % of our cases, N-butyl cyanoacrylate (NBCA) was used as the only or main embolic material. Endovascular embolization is the treatment of choice for CDAVF. High rates of good anatomical and clinical results, associated with very low operative complication rate can be achieved with few embolization sessions. Although mastering of a permanent embolic material is important, the therapeutic strategy should be individulized and not material based.


Dural Arteriovenous Cranial Intracranial Fistula Shunt Malformation Endovascular treatment Embolization 


Financial support



  1. 1.
    Awad IA, Little JR, Akarawi WP, Ahl J (1990) Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:839–850PubMedCrossRefGoogle Scholar
  2. 2.
    Bink A, Berkefeld J, Wagner M, You SJ, Ackermann H, Lorenz MW et al (2011) Detection and grading of dAVF: prospects and limitations of 3T MRI. Eur Radiol 22:429–438Google Scholar
  3. 3.
    Borden JA, Wu JK, Shucart WA (1995) A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82:166–179PubMedCrossRefGoogle Scholar
  4. 4.
    Castaigne P, Bories J, Brunet P, Merland JJ, Meininger V (1976) Les fistules arterioveineuses meningres pures drainage veineux cortical. Rev Neurol 132:169–181PubMedGoogle Scholar
  5. 5.
    Chen JC, Tsuruda JS, Halbach VV (1992) Suspected dural arteriovenous fistula: results with screening MR angiography in seven patients. Radiology 183:265–271PubMedGoogle Scholar
  6. 6.
    Chung SJ, Kim JS, Kim JC, Lee SK, Kwon SU, Lee MC et al (2002) Intracranial dural arteriovenous fistulas: analysis of 60 patients. Cerebrovasc Dis 13:79–88PubMedCrossRefGoogle Scholar
  7. 7.
    Cognard C, Gobin YP, Pierot L, Bailly AL, Houdart E, Casasco A et al (1995) Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194:671–680PubMedGoogle Scholar
  8. 8.
    Cognard C, Januel AC, Silva NA Jr, Tall P (2008) Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx. AJNR Am J Neuroradiol 29:235–241PubMedCrossRefGoogle Scholar
  9. 9.
    Collice M, D’Alberti G, Talamonti G, Branca V, Boccardi E, Scialfa G, Versari P (1996) Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage. J Neurosurg 84:810–817PubMedCrossRefGoogle Scholar
  10. 10.
    DaCosta LB, Terbrugge K, Farb R, Wallace MC (2007) Surgical disconnection of cortical venous reflux as a treatment for Borden type II dural arteriovenous fistulae. Acta Neurochir (Wien) 149:1103–1110CrossRefGoogle Scholar
  11. 11.
    Davies MA, Saleh J, Ter Brugge K, Willinsky R, Wallace MC (1997) The natural history and management of intracranial dural arteriovenous fistulae. Part 1: benign lesions. Interv Neuroradiol 3:295–302PubMedGoogle Scholar
  12. 12.
    Fermand M, Reizine D, Melki JP, Riche MC, Merland JJ (1987) Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus. Neuroradiology 29:348–353PubMedCrossRefGoogle Scholar
  13. 13.
    Geibprasert S, Pereira V, Krings T, Jiarakongmun P, Toulgoat F, Pongpech S et al (2008) Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations. Stroke 39:2783–2794PubMedCrossRefGoogle Scholar
  14. 14.
    Geibprasert S, Pongpech S, Armstrong D, Krings T (2009) Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol 30:1459–1468PubMedCrossRefGoogle Scholar
  15. 15.
    Guedin P, Gaillard S, Boulin A, Condette-Auliac S, Bourdain F, Guieu S et al (2010) 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 112:603–610PubMedCrossRefGoogle Scholar
  16. 16.
    Halbach VV, Higashida RT, Hieshima GB, Goto K, Norman D, Newton TH (1987) Dural fistulas involving the transverse and sigmoid sinuses: results of treatment in 28 patients. Radiology 163:443–447PubMedGoogle Scholar
  17. 17.
    Houser OW, Baker HL Jr, Rhoton AL Jr, Okazaki H (1972) Intracranial dural arteriovenous malformations. Radiology 105:55–64PubMedGoogle Scholar
  18. 18.
    Jankowitz BT, Vora N, Jovin T, Horowitz M (2009) Ear necrosis resulting from the endovascular onyx-18 embolization of a dural arteriovenous fistula fed by the posterior auricular artery. J Neuroimaging 19:259–262PubMedCrossRefGoogle Scholar
  19. 19.
    Kakarla UK, Deshmukh VR, Zabramski JM, Albuquerque FC, McDougall CG, Spetzler RF (2007) Surgical treatment of high-risk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications. Neurosurgery 61:447–457, discussion 457-449PubMedCrossRefGoogle Scholar
  20. 20.
    Kim DJ, Kim DI, Suh SH, Kim J, Lee SK, Kim EY et al (2006) Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management. AJNR Am J Neuroradiol 27:2078–2082PubMedGoogle Scholar
  21. 21.
    Kim DJ, Willinsky RA, Krings T, Agid R, Terbrugge K (2011) Intracranial dural arteriovenous shunts: transarterial glue embolization–experience in 115 consecutive patients. Radiology 258:554–561PubMedCrossRefGoogle Scholar
  22. 22.
    Kirsch M, Henkes H, Liebig T, Weber W, Esser J, Golik S et al (2006) Endovascular management of dural carotid-cavernous sinus fistulas in 141 patients. Neuroradiology 48:486–490PubMedCrossRefGoogle Scholar
  23. 23.
    Kirsch M, Liebig T, Kuhne D, Henkes H (2009) Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients. Neuroradiology 51:477–483PubMedCrossRefGoogle Scholar
  24. 24.
    Lasjaunias P, Chiu M, ter Brugge K, Tolia A, Hurth M, Bernstein M (1986) Neurological manifestations of intracranial dural arteriovenous malformations. J Neurosurg 64:724–730PubMedCrossRefGoogle Scholar
  25. 25.
    Lv X, Jiang C, Li Y, Wu Z (2008) Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18. J Neurosurg 109:1083–1090PubMedCrossRefGoogle Scholar
  26. 26.
    Malik GM, Pearce JE, Ausman JI, Mehta B (1984) Dural arteriovenous malformations and intracranial hemorrhage. Neurosurgery 15:332–339PubMedCrossRefGoogle Scholar
  27. 27.
    Meyers PMHV, Dowd CF, Lempert TE, Malek AM, Phatouros CC, Lefler JE, Higashida RT (2002) Dural carotid cavernous fistula: definitive endovascular management and long-term follow-up. Am J Ophthalmol 134:85–92PubMedCrossRefGoogle Scholar
  28. 28.
    Nishimura S, Hirai T, Sasao A, Kitajima M, Morioka M, Kai Y et al (2010) Evaluation of dural arteriovenous fistulas with 4D contrast-enhanced MR angiography at 3T. AJNR Am J Neuroradiol 31:80–85PubMedCrossRefGoogle Scholar
  29. 29.
    Noguchi K, Kuwayama N, Kubo M, Kamisaki Y, Kameda K, Tomizawa G et al (2011) Flow-sensitive alternating inversion recovery (fair) imaging for retrograde cortical venous drainage related to intracranial dural arteriovenous fistula. Neuroradiology 53:153–158PubMedCrossRefGoogle Scholar
  30. 30.
    Panagiotopoulos V, Moller-Hartmann W, Asgari S, Sandalcioglu IE, Forsting M, Wanke I (2009) Onyx embolization as a first line treatment for intracranial dural arteriovenous fistulas with cortical venous reflux. Rofo 181:129–138PubMedCrossRefGoogle Scholar
  31. 31.
    Pekkola J, Kangasniemi M (2011) Posterior fossa dural arteriovenous fistulas: diagnosis and follow-up with time-resolved imaging of contrast kinetics (TRICKS) at 1.5T. Acta Radiol 52:442–447PubMedCrossRefGoogle Scholar
  32. 32.
    Saini J, Thomas B, Bodhey NK, Periakaruppan A, Babulal JM (2009) Susceptibility-weighted imaging in cranial dural arteriovenous fistulas. AJNR Am J Neuroradiol 30:E6PubMedCrossRefGoogle Scholar
  33. 33.
    Sakamoto S, Shibukawa M, Kiura Y, Matsushige T, Abe N, Kurisu K (2010) Evaluation of dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment using time-resolved MR angiography. Neurosurg Rev 33:217–222, discussion 222-213PubMedCrossRefGoogle Scholar
  34. 34.
    Saraf R, Shrivastava M, Kumar N, Limaye U (2010) Embolization of cranial dural arteriovenous fistulae with ONYX: indications, techniques, and outcomes. Indian J Radiol Imaging 20:26–33PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Saraf R, Shrivastava M, Siddhartha W, Limaye U (2010) Evolution of endovascular management of intracranial dural arteriovenous fistulas: single center experience. Neurol India 58:62–68PubMedCrossRefGoogle Scholar
  36. 36.
    Satomi J, van Dijk JM, Terbrugge KG, Willinsky RA, Wallace MC (2002) Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion. J Neurosurg 97:767–770PubMedCrossRefGoogle Scholar
  37. 37.
    Schanker BD, Walcott BP, Nahed BV, Ogilvy CS, Kiruluta AJ, Rabinov JD et al (2011) Time-resolved contrast-enhanced magnetic resonance angiography in the investigation of suspected intracranial dural arteriovenous fistula. J Clin Neurosci 18:837–839PubMedCrossRefGoogle Scholar
  38. 38.
    Shah SB, Lalwani AK, Dowd CF (1999) Transverse/sigmoid sinus dural arteriovenous fistulas presenting as pulsatile tinnitus. Laryngoscope 109:54–58PubMedCrossRefGoogle Scholar
  39. 39.
    Stiefel MF, Albuquerque FC, Park MS, Dashti SR, McDougall CG (2009) Endovascular treatment of intracranial dural arteriovenous fistulae using Onyx: a case series. Neurosurgery 65:132–139, discussion 139-140PubMedCrossRefGoogle Scholar
  40. 40.
    Sundt TM Jr, Piepgras DG (1983) The surgical approach to arteriovenous malformations of the lateral and sigmoid dural sinuses. J Neurosurg 59:32–39PubMedCrossRefGoogle Scholar
  41. 41.
    Willems PW, Brouwer PA, Barfett JJ, terBrugge KG, Krings T (2011) Detection and classification of cranial dural arteriovenous fistulas using 4D-CT angiography: initial experience. AJNR Am J Neuroradiol 32:49–53PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Department of NeuroradiologyUniversity Hospital ZurichZurichSwitzerland

Personalised recommendations