Intracranial dural arteriovenous fistulas: a review of their current management based on emerging knowledge

Intracranial dural arteriovenous fistulas are a rarely diagnosed type of vascular malformations, yet they are clinically relevant in a subspecialized neurovascular setting because a misdiagnosis may lead to permanent morbidity and mortality. Modern brain imaging techniques such as flat panel detector computed tomographic angiography and magnetic resonance imaging angiography have a significant role in the preoperative work-up, still digital subtraction angiography remains the neuroimaging mainstay. The most important factor guiding their management is the presence of cortical venous reflux, significantly associated with aggressive symptoms due to cerebral or spinal cord venous congestion and hemorrhage. Cutting-edge developments in endovascular and neurosurgical treatment of these vascular malformations, which should be undertaken in specialized referral centers, have substantially improved their prognosis. While transarterial or transvenous endovascular techniques represent frequently the therapy of choice, surgery remains a very valuable option both as a first line treatment and after partial embolization has been carried out. A significant neurosurgical advance is the introduction of indocyanine green video angiography, which allows precise identification of the arterialized draining vein of the dural fistula to be disconnected and confirms interruption of the arteriovenous shunt. Stereotactic radiosurgery may be considered in case of intracranial dural arteriovenous fistulas without cortical venous drainage for which surgical and endovascular options have been consumed or for palliation.