To delineate the current standard of endovascular treatment for intracranial dural arteriovenous (AV) fistulas, we retrospectively evaluated the results of endovascular procedures in the last 10 years.
We experienced 98 lesions of intracranial dural AV fistulas in 93 patients from 1991 to 2001. Location of the lesion was the cavernous sinus (CS) in 37 patients, transverse-sigmoid sinus (TSS) in 37, superior sagittal sinus (SSS) in 4, marginal sinus (MS) in 1, tentorium in 3, anterior cranial base (ACB) in 6, craniocervical junction (CCJ) in 7, and other cortical veins in 3. Of these 93 patients, 9 (6 with CS, 2 with TSS, and 1 with CCJ lesions) were treated conservatively, and 10 (6 with ACB, 2 with CCJ, and 2 with tentorial lesions) were treated with surgical intervention. Seventy-five patients (32 males and 43 females with 79 lesions, mean age of 62.6 years) underwent 155 sessions of endovascular treatment. Thirty-one CS lesions were treated with 52 endovascular procedures (13 transarterial embolization (TAE), 37 transvenous embolization (TVE), and 2 surgical transvenous embolization (surgical TVE)). Thirty-five TSS lesions were treated with 82 procedures (45 TAE, 26 TVE, and 11 surgical TVE). The other 13 lesions (4 SSS, 1 MS, 1 tentorium, 4 CCJ, and 3 cortical lesions) were treated with 21 procedures (19 TAE, 1 TVE, 1 surgical TVE).
The outcome and complications of these treatments were retrospectively analyzed and the current standard of endovascular treatment was delineated.
[CS] Angiographic results were complete or subtotal obliteration of the fistula in 30 of 31 patients. Transient minor complications occurred in 3 procedures. Eye symptoms were relieved in all patients but one who experienced the so-called paradoxical worsening after treatment (TAE). Hemiparesis remained in 1 patient, who had presented with an intracerebral hematoma. [TSS] Angiographic results were complete obliteration in 21, subtotal in 8 of 35 patients. Transient and permanent complications occurred in 2 and 1 patients, respectively. Clinical outcome was GR in 28, MD in 3, SD in 1, VS in 1, and D in 2 (acute myocardial infarction and pulmonary embolism after treatment). [other lesions] Angiographic results were complete obliteration in 5, subtotal in 4, and partial in 4 patients. Two permanent complications occurred in TAE of CCJ lesion. Clinical results were GR in 9 patients, MD in 1, SD in 1, and VS in 1. One patient died from hemorrhagic shock caused by retroperitoneal bleeding.
Endovascular procedures were a very efficacious method to treat dural AV fistulas involving the cavernous and transverse-sigmoid sinuses. Transarterial embolization effectively played a supplementary role of reducing the arterial inflow. Transvenous embolization, if available, was a radical treatment for these lesions. Surgical transvenous embolization was an alternative treatment for lesions with no venous access routes. Surgical intervention played a leading part for lesions involving the tentorium and cortical veins at the anterior cranial base and craniocervical junction.
