How to treat dural arteriovenous malformations or fistulas

The clinical symptoms of intracranial dural arteriovenous fistulas (AVFs) depend mainly on the site and venous drainage pattern of the lesion. The goal of treatment of the lesion is the permanent and complete elimination of the arteriovenous shunt. Transarterial embolization or stereotactic radiation may affect feeding arteries or nidus. The involved sinus can be obliterated by percutaneous or surgical transvenous embolization, or resected by surgery. In cases of patients with pure leptomeningeal drainage, surgical interruption of leptomeningeal drainage may be effective. Based on the experiences reported in the literature, transarterial embolization of accessible feeding arteries is the initial treatment to decrease arterial blood flow. Transvenous embolization may be effective depending on the venous drainage pattern. For the AVFs remaining after transarterial embolization, stereotactic radiosurgery is recommended if feasible. Transvenous embolization may be applied cautiously considering the risk of venous hypertension and intracranial hemorrhage. Direct microsurgery is indicated if stereotactic radiosurgery is not performed safely. For cases without dural sinus drainage, surgical interruption of leptomeningeal drainage may be applied safely. The decision to intervene in dural AVFs is based on the following factors: age and general condition of the patient, severity of the presenting symptoms, natural history of the lesion if left untreated, angiographic features on the location of dural AVFs and the venous drainage pattern, and morbidity and mortality of the procedure being considered.