Dural Arteriovenous Fistulae: Imaging and Management

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Key points

  • Intracranial dural arteriovenous fistulae (DAVF) are pathologic shunts between dural arteries to dural veins or a venous sinus and are an important cause of pulsatile tinnitus.

  • Digital subtraction angiography allows the accurate characterization and classification of DAVF and remains the gold standard modality for their diagnosis.

  • The pattern of venous drainage determines the type and risk of intracranial bleeding of DAVF.

  • The goal of treatment is to obliterate the site of the shunt with

Classification

Several classification schemes have been proposed from different aspects of DAVF to grade their risk and natural course. The classifications put forward by Cognard and colleagues18 and Borden and colleagues19 are currently the most widely used (Box 1). Both are used in everyday clinical practice and emphasize the venous drainage patterns associated with the fistula.20 The 3-step Borden classification is simple to apply and categorizes DAVF based on the site of venous drainage (dural sinus vs

Imaging findings

Given their wide range of clinical presentations and the lack of specificity of symptoms, the diagnosis of DAVF can be challenging. Nonenhanced computed tomography (CT) and conventional magnetic resonance (MR) imaging can often appear unremarkable with benign DAVF.25 When symptomatic, the 2 most common presentations of DAVF are intracranial hemorrhage and nonhemorrhagic neurologic manifestations.11, 26 In either case, diagnostic evaluation usually starts with noncontrast head CT and MR imaging.

General management

Conservative treatment is often a consideration for patients with low-grade, benign fistulas (Borden I; Cognard I, IIa).16, 17 Spontaneous thrombosis of DAVF may occasionally occur, more commonly in slow-flow cavernous sinus lesions. Carotid self-compression may help promote resolution of the fistula in a minority of these cases.38, 39 However, patients with benign, low-grade lesions electing conservative management should undergo clinical and imaging follow-up because of the risk of conversion

Endovascular treatment

The goal of endovascular therapy is the elimination of the arteriovenous shunt.16, 17, 38, 44 Note that the pathologic entity of DAVF seems to be located within the wall of dural sinuses, veins, or leptomeningeal veins. The pathophysiologic effect of the shunt is exercised on the venous system. Complete and permanent cure can be achieved only by obliterating all pathologic connections between the arterial and venous side of the lesion. This outcome can be obtained by approaching the site of the

Embolization access routes

The optimal endovascular approach for treatment of DAVF remains a highly debated and controversial topic. Transarterial, transvenous, and sometimes combined approaches have been used to successfully treat DAVF. A consideration of the advantages and disadvantages of each approach should be given in each case before proceeding with embolization.

Embolic agents

Endovascular obliteration of DAVF can be accomplished using a variety of embolic agents, including particles, coils, ethanol, nBCA, and Onyx.41, 54, 65, 66 Coils have been used successfully in transvenous embolization.62 When used in a transarterial approach, they are for the most part used as an adjunct to liquid embolic agents to reduce the rate of shunt in high-flow lesions but are rarely curative when used alone.16 For example, coils can be placed in the venous pouch located close to the

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      The Borden classification system categorizes DAVFs based on their venous drainage (dural sinus or cortical vein). A more detailed classification system was proposed by Cognard; in addition to the venous drainage pattern, this system includes the direction of flow into the affected dural sinus (antegrade or retrograde), as well as the occurrence of venous ectasia(s) in recruited cortical veins [2–4]. The rate of bleeding is estimated at approximately 1.8-6.9% per year.

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      Cavernous sinus (CS) dural arteriovenous fistula (dAVF) is a main subtype of intracranial dAVF, which is defined as an abnormal arteriovenous connection involving the dura mater.1

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    Disclosure: The authors have nothing to disclose.

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