Surgical treatment of high-risk intracranial dural arteriovenous fistulae: Clinical outcomes and avoidance of complications

Udaya K. Kakarla, Vivek R. Deshmukh, Joseph M. Zabramski, Felipe C. Albuquerque, Cameron G. McDougall, Robert F. Spetzler

Research output: Contribution to journalArticlepeer-review

Abstract

OBJECTIVE: An increasing number of intracranial dural arteriovenous fistulae (DAVFs) are amenable to endovascular treatment. However, a subset of patients with high-risk lesions requires surgical intervention for complete obliteration. We reviewed our experience with the surgical management of high-risk intracranial DAVFs and offer recommendations to minimize complications based on fistula location and type. METHODS: Hospital records for 53 patients (16 women, 37 men) with high-risk intracranial DAVFs treated surgically between 1995 and 2004 were reviewed to determine their presenting symptoms, location, endovascular and surgical interventions, angiographic outcome, and treatment complications. Most patients (76%) presented with intracranial hemorrhage, progressive neurological deficits, or seizures. All patients had high-risk angiographic features such as cortical venous drainage or venous varix. Preoperative embolization was performed in 27 patients. Surgical approaches were tailored to the lesion location. Fistulae were located in the transverse-sigmoid junction (n = 18), tentorium (n = 17), ethmoid (n = 7), superior sagittal sinus (n = 6), torcula (n = 4), and sphenoparietal sinus (n = 3). RESULTS: At the time of the last follow-up evaluation, 49 patients (92%) had good or excellent outcomes (Glasgow Outcome Scale score, 4 or 5) and three (6%) were deceased. Five patients had a residual fistula. One residual spontaneously thrombosed, one was treated with gamma knife radiosurgery, and two were successfully embolized. The overall morbidity and mortality rate was 13%. CONCLUSION: Despite fulminant presenting symptoms, high-risk intracranial DAVFs can be successfully managed with good outcomes. When anatomic features prevent endovascular access, or embolization fails to obliterate the lesion, urgent surgical treatment is indicated. Patients with residual filling of the DAVF should be considered for adjuvant therapy, including further embolization or radiosurgery.

Original languageEnglish (US)
Pages (from-to)447-457
Number of pages11
JournalNeurosurgery
Volume61
Issue number3
DOIs
StatePublished - Sep 1 2007
Externally publishedYes

Keywords

  • Dural arteriovenous fistula
  • Endovascular treatment
  • Surgical results

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

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