Acta Neurologica Belgica

, Volume 119, Issue 1, pp 5–14 | Cite as

Current status of endovascular treatment for dural arteriovenous fistulae in the tentorial middle region: a literature review

  • Dan Tong
  • Xuan Chen
  • Xianli Lv
  • Kailing Li
  • Kan Xu
  • Jinlu YuEmail author
Review Article


The tentorial middle region (TMR) includes the midline and paramedian tentorium. TMR dural arteriovenous fistulae (DAVFs) are complex. We performed a review of the literature on TMR DAVFs. TMR DAVFs are divided into the following four types: incisural DAVF, Galenic DAVF, straight sinus DAVF and torcular DAVF. TMR DAVFs often drain into pial veins; therefore, most TMR DAVFs are classified as Borden II–III and Cognard types IIb–IV, whose characteristics cause TMR DAVFs to be prone to hemorrhage. TMR DAVFs have a very disappointing natural progression, and treatment is necessary. TMR DAVFs have extensive arterial supply and complex venous drainages, making them difficult to treat. Currently, for TMR DAVF, endovascular treatment (EVT) has become a better option. In EVT, transarterial embolization is the first-line treatment. Many complications can occur when treating TMR DAVFs, but complete EVT can generally achieve good clinical outcomes. In this review, three educational cases with demonstrating figures are provided to elaborate TMR DAVFs.


Tentorial middle region Dural arteriovenous fistula Endovascular treatment Review 



We would like to acknowledge the reviewers for their helpful comments on this paper.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest.

Ethical approval

This work is a review of the literature and did not require ethical approval to be carried out.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Jiang C, Lv X, Li Y, Zhang J, Wu Z (2009) Endovascular treatment of high-risk tentorial dural arteriovenous fistulas: clinical outcomes. Neuroradiology 51(2):103–111. Google Scholar
  2. 2.
    Zhou LF, Chen L, Song DL, Gu YX, Leng B (2007) Tentorial dural arteriovenous fistulas. Surg Neurol 67(5):472–481. discussion 481 – 472.Google Scholar
  3. 3.
    Lawton MT, Sanchez-Mejia RO, Pham D, Tan J, Halbach VV (2008) Tentorial dural arteriovenous fistulae: operative strategies and microsurgical results for six types. Neurosurgery 62(3 Suppl 1):110–124. discussion 124 – 115.Google Scholar
  4. 4.
    Martins C, Yasuda A, Campero A, Ulm AJ, Tanriover N, Rhoton A (2005) Microsurgical anatomy of the dural arteries. Neurosurgery 56(2 Suppl):211–251; (discussion 211–251) Google Scholar
  5. 5.
    Kim HJ, Yang JH, Lee HJ, Lee HJ (2015) Tentorial Dural Arteriovenous Fistula Treated Using Transarterial Onyx Embolization. J Korean Neurosurg Soc 58(3):276–280. Google Scholar
  6. 6.
    Choudhri O, Marks MP (2014) Endovascular treatment of a tentorial dural arteriovenous fistula. Neurosurg Focus 37(1 Suppl):1. Google Scholar
  7. 7.
    Puffer RC, Daniels DJ, Kallmes DF, Cloft HJ, Lanzino G (2012) Curative Onyx embolization of tentorial dural arteriovenous fistulas. Neurosurg Focus 32(5):E4. Google Scholar
  8. 8.
    van Rooij WJ, Sluzewski M, Beute GN (2006) Tentorial artery embolization in tentorial dural arteriovenous fistulas. Neuroradiology 48(10):737–743. Google Scholar
  9. 9.
    Pichierri A, Delfini R (2012) Incisural and superior petrous dural arteriovenous fistulas: a contemporary perspective. World Neurosurg 77(3–4):472–474. Google Scholar
  10. 10.
    Matsushige T, Nakaoka M, Ohta K, Yahara K, Okamoto H, Kurisu K (2006) Tentorial dural arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: A case report. Surg Neurol 66(5):519–523. (discussion 523).Google Scholar
  11. 11.
    Yu J, Guo Y, Xu B, Xu K (2016) Clinical importance of the middle meningeal artery: A review of the literature. Int J Med Sci 13(10):790–799. Google Scholar
  12. 12.
    Yu J, Guo Y, Wu Z, Xu K (2017) Traumatic arteriovenous fistula between the extracranial middle meningeal artery and the pterygoid plexus: A case report and literature review. Interv Neuroradiol 23(1):90–96. Google Scholar
  13. 13.
    Reisch R, Vutskits L, Patonay L, Fries G (1996) The meningohypophyseal trunk and its blood supply to different intracranial structures. An anatomical study. Minim Invasive Neurosurg 39(3):78–81. Google Scholar
  14. 14.
    Inoue T, Rhoton AL, Theele D, Barry ME (1990) Surgical approaches to the cavernous sinus: a microsurgical study. Neurosurgery 26(6):903–932Google Scholar
  15. 15.
    Lasjaunias PL (1984) Anatomy of the tentorial arteries. J Neurosurg 61(6):1159–1160Google Scholar
  16. 16.
    Hatano T, Bozinov O, Burkhardt JK, Bertalanffy H (2013) Surgical treatment of tentorial dural arteriovenous fistulae located around the tentorial incisura. Neurosurg Rev 36(3):429–435. Google Scholar
  17. 17.
    Tubbs RS, Nguyen HS, Shoja MM, Benninger B, Loukas M, Cohen-Gadol AA (2011) The medial tentorial artery of Bernasconi-Cassinari: a comprehensive review of its anatomy and neurosurgical importance. Acta Neurochir (Wien) 153(12):2485–2490. Google Scholar
  18. 18.
    Peltier J, Fichten A, Havet E, Foulon P, Page C, Le Gars D (2010) Microsurgical anatomy of the medial tentorial artery of Bernasconi-Cassinari. Surg Radiol Anat 32(10):919–925. Google Scholar
  19. 19.
    Liu S, Lee DC, Tanoura T (2016) Tentorial dural arteriovenous fistula of the medial tentorial artery. Radiol Case Rep 11(3):242–244. Google Scholar
  20. 20.
    Shukla V, Hayman LA, Ly C, Fuller G, Taber KH (2002) Adult cranial dura I: intrinsic vessels. J Comput Assist Tomogr 26(6):1069–1074Google Scholar
  21. 21.
    Tayebi Meybodi A, Vigo V, Lawton MT, Benet A (2017) The artery of Wollschlaeger and Wollschlaeger: an anatomical-clinical illustration. Br J Neurosurg 31(5):593–595. Google Scholar
  22. 22.
    Griessenauer CJ, Loukas M, Scott JA, Tubbs RS, Cohen-Gadol AA (2013) The artery of Davidoff and Schechter: an anatomical study with neurosurgical case correlates. Br J Neurosurg 27(6):815–818. Google Scholar
  23. 23.
    Byrne JV, Garcia M (2013) Tentorial dural fistulas: endovascular management and description of the medial dural-tentorial branch of the superior cerebellar artery. Am J Neuroradiol 34(9):1798–1804. Google Scholar
  24. 24.
    Singh D, Garg A, Gupta A, Goel G, Gupta R, Bansal A (2013) Tentorial dural arteriovenous fistula presenting as episodic weakness mimicking periodic paralysis. J Neurointerv Surg 5(5):e32. Google Scholar
  25. 25.
    Panagiotopoulos V, Kastrup O, Wanke I (2009) Endovascular treatment resolves non-hemorrhagic brainstem dysfunction due to tentorial dural AV fistula. J Clin Neurosci 16(2):317–320. Google Scholar
  26. 26.
    Khan S, Polston DW, Shields RW, Rasmussen P, Gupta R (2009) Tentorial dural arteriovenous fistula presenting with quadriparesis: case report and review of the literature. J Stroke Cerebrovasc Dis 18(6):428–434. Google Scholar
  27. 27.
    Pannu Y, Shownkeen H, Nockels RP, Origitano TC (2004) Obliteration of a tentorial dural arteriovenous fistula causing spinal cord myelopathy using the cranio-orbito zygomatic approach. Surg Neurol 62(5):463–467. (discussion 467).Google Scholar
  28. 28.
    Benndorf G, Schmidt S, Sollmann WP, Kroppenstedt SN (2003) Tentorial dural arteriovenous fistula presenting with various visual symptoms related to anterior and posterior visual pathway dysfunction: case report. Neurosurgery 53(1):222–226; (discussion 226–227)Google Scholar
  29. 29.
    Ardeshiri A, Ardeshiri A, Tonn JC, Winkler PA (2006) Microsurgical anatomy of the lateral mesencephalic vein and its meaning for the deep venous outflow of the brain. Neurosurg Rev 29(2):154–158. (discussion 158).Google Scholar
  30. 30.
    Cannizzaro D, Rammos SK, Peschillo S, El-Nashar AM, Grande AW, Lanzino G (2016) The lateral mesencephalic vein: surgical anatomy and its role in the drainage of tentorial dural arteriovenous fistulae. World Neurosurg 85:163–168. Google Scholar
  31. 31.
    Lasjaunias P, Chiu M, ter Brugge K, Tolia A, Hurth M, Bernstein M (1986) Neurological manifestations of intracranial dural arteriovenous malformations. J Neurosurg 64(5):724–730. Google Scholar
  32. 32.
    Picard L, Bracard S, Islak C, Roy D, Moreno A, Marchal JC, Roland J (1990) Dural fistulae of the tentorium cerebelli. Radioanatomical, clinical and therapeutic considerations. J Neuroradiol 17(3):161–181Google Scholar
  33. 33.
    Mariniello G, Briganti F, Vergara P, Maiuri F (2012) Dural tentorial arteriovenous fistula causing isolated trochlear nerve palsy: remission after endovascular embolization. J Neurointerv Surg 4(3):e5. Google Scholar
  34. 34.
    van Lindert E, Hassler W, Kuhne D, Henkes H (2000) Combined endovascular-microsurgical treatment of tentorial-incisural dural arteriovenous malformations. Report of five cases. Minim Invasive Neurosurg 43(3):138–143. Google Scholar
  35. 35.
    Tomak PR, Cloft HJ, Kaga A, Cawley CM, Dion J, Barrow DL (2003) Evolution of the management of tentorial dural arteriovenous malformations. Neurosurgery 52(4):750–760; (discussion 760–752)Google Scholar
  36. 36.
    Weil AG, McLaughlin N, Denis D, Bojanowski MW (2011) Tentorial branch of the superior cerebellar artery. Surg Neurol Int 2:71. Google Scholar
  37. 37.
    Zink WE, Meyers PM, Connolly ES, Lavine SD (2004) Combined surgical and endovascular management of a complex posttraumatic dural arteriovenous fistula of the tentorium and straight sinus. J Neuroimaging 14(3):273–276. Google Scholar
  38. 38.
    Gioppo A, Farago G, Caldiera V, Caputi L, Cusin A, Ciceri E (2017) Medial Tentorial Dural Arteriovenous Fistula Embolization: Single Experience with Embolic Liquid Polymer SQUID and Review of the Literature. World Neurosurg 107:1050. Google Scholar
  39. 39.
    Huang Q, Xu Y, Hong B, Li Q, Zhao W, Liu J (2009) Use of onyx in the management of tentorial dural arteriovenous fistulae. Neurosurgery 65(2):287–292. (discussion 292–283).Google Scholar
  40. 40.
    Minamide H, Hayashi Y, Uchiyama N (2017) Multiple tentorial dural arteriovenous fistulas with acquired pial arteriovenous fistula presented with unilateral eye symptoms successfully treated by transarterial embolization and direct surgery: a case report. No Shinkei Geka 45(3):239–245. Google Scholar
  41. 41.
    Umeoka K, Takusakawa Y, Kominami S, Kobayashi S, Morita A (2016) The meningeal branches of the superior cerebellar artery: a surgical observation study. J Neurosurg 124(1):244–247. Google Scholar
  42. 42.
    Deshmukh VR, Maughan PH, Spetzler RF (2006) Resolution of hemifacial spasm after surgical obliteration of a tentorial arteriovenous fistula: case report. Neurosurgery 58(1):E202; (discussion E202)Google Scholar
  43. 43.
    Alvarez H, Sasaki-Adams D, Castillo M (2015) Resolution of brainstem edema after treatment of a dural tentorial arteriovenous fistula. Interv Neuroradiol 21(5):603–608. Google Scholar
  44. 44.
    Gross R, Ali R, Kole M, Dorbeistein C, Jayaraman MV, Khan M (2014) Tentorial dural arteriovenous fistula presenting as myelopathy: Case series and review of literature. World J Clin Cases 2(12):907–911. Google Scholar
  45. 45.
    Santillan A, Safdieh JE, Gobin YP, Patsalides A (2011) Neurological picture. Bilateral thalamic venous hypertension caused by a tentorial dural arteriovenous fistula: endovascular treatment. J Neurol Neurosurg Psychiatry 82(7):749–750. Google Scholar
  46. 46.
    Iwamuro Y, Nakahara I, Higashi T, Iwaasa M, Watanabe Y, Hirata E, Tsunetoshi K, Taha M (2006) Tentorial dural arteriovenous fistula presenting symptoms due to mass effect on the dilated draining vein: case report. Surg Neurol 65(5):511–515. Google Scholar
  47. 47.
    Borha A, Emery E, Courtheoux P, Lefevre P, Derlon JM (2010) Tentorial dural fistula with giant venous ampulae treated with embolisation and surgery. A case report. Acta Neurochir (Wien) 152(10):1745–1753. Google Scholar
  48. 48.
    Wajnberg E, Spilberg G, Rezende MT, Abud DG, Kessler I, Mounayer C, Association of Rothschild Foundation A (2012) Endovascular treatment of tentorial dural arteriovenous fistulae. Interv Neuroradiol 18(1):60–68. Google Scholar
  49. 49.
    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(2):166–179. Google Scholar
  50. 50.
    Cognard C, Gobin YP, Pierot L, Bailly AL, Houdart E, Casasco A, Chiras J, Merland JJ (1995) Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194(3):671–680. Google Scholar
  51. 51.
    Gomez J, Amin AG, Gregg L, Gailloud P (2012) Classification schemes of cranial dural arteriovenous fistulas. Neurosurg Clin N Am 23(1):55–62. Google Scholar
  52. 52.
    Awad IA, Little JR, Akarawi WP, Ahl J (1990) Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72(6):839–850. Google Scholar
  53. 53.
    Gross BA, Ducruet AF, Jankowitz BT, Gardner PA (2017) An Intraoperative Look at a Residual/Recurrent Tentorial Dural Arteriovenous Fistula. World Neurosurg. Google Scholar
  54. 54.
    Deasy NP, Gholkar AR, Cox TC, Jeffree MA (1999) Tentorial dural arteriovenous fistulae: endovascular treatment with transvenous coil embolisation. Neuroradiology 41(4):308–312Google Scholar
  55. 55.
    Troffkin NA, Graham CB, Berkmen T, Wakhloo AK (2003) Combined transvenous and transarterial embolization of a tentorial-incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus. Case report. J Neurosurg 99(3):579–583. Google Scholar
  56. 56.
    Zhang J, Lv X, Jiang C, Li Y, Wu Z (2010) Superior cerebellar artery infarction in endovascular treatment for tentorial dural arteriovenous fistulas. Eur J Radiol 74(3):e33–e37. Google Scholar
  57. 57.
    Wu Q, Zhang XS, Wang HD, Zhang QR, Wen LL, Hang CH, Zhang X (2016) Onyx Embolization for Tentorial Dural Arteriovenous Fistula with Pial Arterial Supply: Case Series and Analysis of Complications. World Neurosurg 92:58–64. Google Scholar
  58. 58.
    Kim ST, Jeong HW, Seo J (2013) Onyx Embolization of Dural Arteriovenous Fistula, using Scepter C Balloon Catheter: a Case Report. Neurointervention 8(2):110–114. Google Scholar
  59. 59.
    Sato K, Matsumoto Y, Endo H, Tominaga T (2017) A hemorrhagic complication after Onyx embolization of a tentorial dural arteriovenous fistula: a caution about subdural extension with pial arterial supply. Interv Neuroradiol 23(3):307–312. Google Scholar
  60. 60.
    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. Am J Neuroradiol 30(8):1459–1468. Google Scholar
  61. 61.
    van Rooij WJ, Sluzewski M, Slob MJ, Rinkel GJ (2005) Predictive value of angiographic testing for tolerance to therapeutic occlusion of the carotid artery. Am J Neuroradiol 26(1):175–178Google Scholar
  62. 62.
    Liu C, Xu B, Song D, Leng B, Mao Y, Gu Y, Liao Y (2014) Clinical approach of using Onyx via transarterial access in treating tentorial dural arteriovenous fistula. Neurol Res 36(11):983–991. Google Scholar
  63. 63.
    Dozic A, Cetkovic M, Marinkovic S, Mitrovic D, Grujicic M, Micovic M, Milisavljevic M (2014) Vascularisation of the geniculate ganglion. Folia Morphol (Warsz) 73(4):414–421. Google Scholar
  64. 64.
    Flores BC, See AP, Weiner GM, Jankowitz BT, Ducruet AF, Albuquerque FC (2018) Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas. J Neurosurg. Google Scholar
  65. 65.
    Gross BA, Ropper AE, Popp AJ, Du R (2012) Stereotactic radiosurgery for cerebral dural arteriovenous fistulas. Neurosurg Focus 32(5):E18. Google Scholar
  66. 66.
    Lewis AI, Tomsick TA, Tew JM (1994) Management of tentorial dural arteriovenous malformations: transarterial embolization combined with stereotactic radiation or surgery. J Neurosurg 81(6):851–859. Google Scholar
  67. 67.
    Morparia N, Miller G, Rabinstein A, Lanzino G, Kumar N (2012) Cognitive decline and hypersomnolence: thalamic manifestations of a tentorial dural arteriovenous fistula (dAVF). Neurocrit Care 17(3):429–433. Google Scholar
  68. 68.
    Shin M, Kurita H, Tago M, Kirino T (2000) Stereotactic radiosurgery for tentorial dural arteriovenous fistulae draining into the vein of Galen: report of two cases. Neurosurgery 46(3):730–733; (discussion 733–734)Google Scholar
  69. 69.
    Azuma M, Hirai T, Shigematsu Y, Kitajima M, Kai Y, Yano S, Nakamura H, Makino K, Iryo Y, Yamashita Y (2015) Evaluation of intracranial dural arteriovenous fistulas: comparison of unenhanced 3T 3D time-of-flight MR angiography with digital subtraction angiography. Magn Reson Med Sci 14(4):285–293. Google Scholar
  70. 70.
    Meckel S, Maier M, Ruiz DS, Yilmaz H, Scheffler K, Radue EW, Wetzel SG (2007) MR angiography of dural arteriovenous fistulas: diagnosis and follow-up after treatment using a time-resolved 3D contrast-enhanced technique. Am J Neuroradiol 28(5):877–884Google Scholar
  71. 71.
    Nishimura S, Hirai T, Sasao A, Kitajima M, Morioka M, Kai Y, Omori Y, Okuda T, Murakami R, Fukuoka H, Awai K, Kuratsu JI, Yamashita Y (2010) Evaluation of dural arteriovenous fistulas with 4D contrast-enhanced MR angiography at 3T. Am J Neuroradiol 31(1):80–85. Google Scholar

Copyright information

© Belgian Neurological Society 2018

Authors and Affiliations

  1. 1.Department of RadiologyThe First Hospital of Jilin UniversityChangchunChina
  2. 2.Department of NeurosurgeryThe First Hospital of Jilin UniversityChangchunChina
  3. 3.Department of Neurosurgery, Beijing Tsinghua Changgung HospitalTsinghua UniversityBeijingChina

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