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Standard and Guidelines: Intracranial Dural Arteriovenous Shunts
  1. Seon-Kyu Lee1,
  2. Steven W Hetts2,
  3. Van Halbach2,
  4. Karel terBrugge3,
  5. Sameer A Ansari4,
  6. Barb Albani5,
  7. Todd Abruzzo6,
  8. Adam Arthur7,
  9. Michael J Alexander7,
  10. Felipe C Albuquerque8,
  11. Blaise Baxter9,
  12. Ketan R Bulsara10,
  13. Michael Chen11,
  14. Josser E Delgado Almandoz12,
  15. Justin F Fraser13,
  16. Don Frei14,
  17. Chirag D Gandhi15,
  18. Don Heck16,
  19. Muhammad Shazam Hussain17,
  20. Michael Kelly18,
  21. Richard Klucznik19,
  22. Thabele Leslie-Mazwi20,
  23. Ryan A McTaggart21,
  24. Philip M Meyers22,
  25. Athos Patsalides23,
  26. Charles Prestigiacomo24,
  27. G Lee Pride25,
  28. Robert Starke26,
  29. Peter Sunenshine27,
  30. Peter Rasmussen28,
  31. Mahesh V Jayaraman29,
  32. on behalf of the Standard and Guidelines Committee for the Society of Neurointerventional Surgery
  1. 1Department of Radiology, the University of Chicago, USA
  2. 2Department of Radiology, University of California at San Francisco, USA
  3. 3Department of Medical Imaging, University of Toronto, Canada
  4. 4Department of Radiology, Northwestern University, USA
  5. 5Department of Radiology, Christiana Healthcare System, USA
  6. 6Department of Neurosurgery, University of Cincinnati, USA
  7. 7Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  8. 8Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  9. 9Radiology, Erlanger Medical Center, Chattanooga, Tennessee, USA
  10. 10Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
  11. 11Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
  12. 12Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
  13. 13Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
  14. 14Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
  15. 15Neurological Institute of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
  16. 16Radiology, Forsyth Medical Center, Forsyth Radiological Associates, Winston Salem, North Carolina, USA
  17. 17Cleveland Clinic Stroke Program, Cleveland Clinic, Cleveland Heights, Ohio, USA
  18. 18Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
  19. 19Neuroradiology, Methodist Hospital, Houston, Texas, USA
  20. 20Neurointerventional Service, Massachusetts General Hospital, Boston, Massachusetts, USA
  21. 21Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
  22. 22Radiology and Neurological Surgery, Columbia University, New York, New York, USA
  23. 23Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
  24. 24Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  25. 25Neuroradiology, UT Southwestern, Dallas, Texas, USA
  26. 26Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
  27. 27Department of Radiology, Banner Univeristy Medical Center, Phoenix, Arizona, USA
  28. 28Neurosurgery Department, Cleveland Clinic, Cleveland, Ohio, USA
  29. 29Warren Alpert School of Medical at Brown University, Providence, Rhode Island, USA
  1. Correspondence to Dr Seon-Kyu Lee, Department of Radiology, Univeristy of Chicago, 5801 S Ellis Ave, Chicago, IL 60637, USA; slee{at}radiology.bsd.uchicago.edu

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Introduction

Intracranial dural arteriovenous shunts (DAVS), also known as dural arteriovenous fistulas or dural arteriovenous malformations, are abnormal connections between dural (and occasionally pial) arteries and the veno vasora within the dura mater, comprising the walls of the dural sinuses, the leptomeningeal (bridging) veins, or the transosseous emissary veins within or adjacent to the dura mater. DAVS are rare, accounting for about 5–15% of intracranial vascular malformations.1 ,2 Although incompletely understood, DAVS are thought to be acquired lesions3 resulting from dural sinus or cortical venous thrombosis, possibly precipitated by hormonal changes, hypercoagulability states, trauma, or a combination of these factors.4–6 The clinical implications of intracranial DAVS are directly associated with its venous drainage pattern. For example, intracranial DAVS can cause either intracranial hemorrhages or non-hemorrhagic neurologic events such as regional or global venous congestive encephalopathy.

The aims of this document are (1) to review existing knowledge about the natural history, diagnostic methodology, and treatment modalities/techniques for DAVS; and (2) to provide recommendations on management strategies for intracranial DAVS using evidence-based medicine approaches when possible but, of necessity, relying frequently on expert opinion concerning this rare disease. Recommendations follow the American College of Cardiology/American Heart Association (ACC/AHA) Classification of Recommendation/Level of Evidence (COR/LOE) and the definition of classes and levels of evidence used in the AHA/American Stroke Association (AHA/ASA) recommendations (tables 1 and 2).

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Table 1

ACC/AHA Classification of Recommendations and Level of Evidence (COR/LOE)

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Table 2

Definition of classes and levels of evidence used in AHA/ASA recommendations

Natural history

Given the rarity of DAVS and the challenge of diagnosing them with non-invasive tools, the natural history of intracranial DAVS is not completely understood. There are few data on the progressive enlarge of DAVS over time with respect to recruitment or enlargement of arterial feeders or appearance of de novo fistulas over time. …

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