Long-term Outcomes after Staged and Multimodal Treatment for Diffuse Intracranial Dural Arteriovenous Fistulas...

Diffuse intracranial dural arteriovenous fistulas involving interconnected dural sinuses are uncommon lesions with complex angioarchitecture and an evolving clinical course. However, long-term treatment outcomes and surveillance strategies remain poorly characterized. We retrospectively reviewed 49 consecutive patients with intracranial dural arteriovenous fistulas treated at our institution for 10 years. The study included 9 patients with diffuse intracranial dural arteriovenous fistulas involving 2 or more interconnected dural sinus compartments. Endovascular treatment was used as the first-line therapy for symptomatic or hemodynamically significant lesions, and stereotactic radiosurgery was incorporated for residual low-flow shunts or selected lesions that were not amenable to safe or complete endovascular treatment. Follow-up magnetic resonance imaging and digital subtraction angiography were used to assess shunt occlusion, recurrence, and newly detected shunt lesion in other dural sinus compartments. Nine patients were male. On a sinus-compartment basis, 30 shunt-related sinuses were identified. Shunting most commonly involved the transverse-sigmoid sinus, followed by the torcular confluence and the superior sagittal sinus. Cortical venous reflux was observed in 6 patients. Five patients showed multi-compartment shunt involvement at diagnosis, whereas 4 indicated newly detected shunt involvement during follow-up. Staged multimodal treatment achieved complete occlusion in 18 shunting compartments and partial occlusion in 8 with improved venous drainage; the remaining 4 were managed conservatively. The mean follow-up was 49 months (range, 20-70 months), and patients had favorable outcomes with a modified Rankin Scale score of 0-2. Diffuse intracranial dural arteriovenous fistulas may follow an evolving angiographic course even after treatment, underscoring the importance of long-term follow-up and individualized staged management.