Diagnosis and management of intracranial dural arteriovenous fistulas

ABSTRACT

Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.

KEYWORDS:

• cerebral veno-sinus thrombosis
• dural arteriovenous fistula
• embolization
• intracranial hemorrhage
• stroke
• venous infarct

Financial and competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Key issues

• The clinical manifestations of dural arteriovenous fistula (DAVF) range from benign symptoms to intracranial hemorrhage and nonhemorrhagic neurological deficits associated with venous hypertension.

• The aggressiveness of DAVF depends primarily upon the pattern of venous drainage from the fistulas.

• The Borden classification and Cognard classification are the two most commonly used systems that classify DAVF with cortical venous reflux or fistulas draining directly into cortical veins as ‘high grade’ DAVF.

• Catheterization with cerebral angiography remains the gold standard in the diagnosis and characterization of DAVFs. However, recent advances in magnetic resonance imaging and computed tomography imaging have markedly improved diagnosis by permitting the visualization of affected surrounding brain structures and the evaluation of hemodynamics of draining veins in patients with suspected DAVF.

• Patients with low-grade DAVF may be treated conservatively.

• Intra-arterial or intravenous endovascular embolization remains the primary therapy for high-grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options.