Resection of the transverse sinuses and confluence of sinuses for treatment of multiple dural arteriovenous fistulas

Abstract

Dural arteriovenous fistulas (DAVFs) occurring simultaneously at two or more separate locations are not frequent. In fact, the incidence of multiple DAVFs is 7 to 8% of all DAVFs. Patients harboring multiple DAVFs have a higher incidence of hemorrhage, venous infarction, and neurological deficits due to a greater frequency of leptomeningeal venous drainage. To the authors' knowledge only a few cases of DAVFs involving both transverse sinuses (TSs) have been reported. These patients underwent various combined treatments (transarterial embolization, transvenous obliteration, surgical isolation, resection, and radiosurgery). Treatments performed that do not include resection of the involved sinuses do not always guarantee a cure. The authors present a patient who harbored multiple DAVFs of the TSs, both distally occluded with secondary reflux into the superior sagittal sinus (SSS), the straight sinus, the deep venous system, and the leptomeningeal veins of both hemispheres. An en bloc removal of the portions including the fistulas of the TSs, the confluence of sinuses, and the distal parts of the SSS, and straight sinus allowed for the patient to be cured. The fact is emphasized that despite the progress of endovascular treatment and radiosurgery this kind of DAVF must be surgically treated. The operation may be complex and dangerous.

Intraoperative Angiography for Cranial Dural Arteriovenous Fistula

“…26,27,34,35 Various surgical techniques, including packing of the sinus, skeletonization of the sinus, disconnection of the feeders, as well as disconnection of the leptomeningeal venous drainage, have been described. [9][10][11]13,[36][37][38][39][40] Although it has been mentioned in many surgical series that routine IA for DAVF is recommended and is useful, there is no report specifically analyzing the role of IA in surgery for DAVF, to our knowledge.…”

Evolutionary History of Multiple Dural Fistula

“… 22 - 24 Söderman et al showed that the annual risk of bleeding was 7.4% in patients presenting with intracranial bleeding when compared with those who had no bleeding (1.5%). 25 , 36 Cognard et al reported a dramatic increase in the incidence of aggressive clinical presentation in those with high-grade DAVF, when compared to those who had low-grade DAVF (89% vs 10%, respectively). 12 This would explain why, in our case, the patient initially had few symptoms.…”

“… 1 , 11 However, there are multiple dural arteriovenous fistulas, which represent 2% to 7% of all DAVFs. 6 , 25 …”

Progress in research on intracranial multiple�dural�arteriovenous fistulas (Review)

“…In the treatment of MDAVFs, a number of principles are generally followed: One priority of treatment is to target fistulas with cortical venous reflux with a higher Borden/Cognard classification; additionally, treatment for a DAVF is performed in multiple stages, and focuses on decreasing venous hypertension and improving cerebral hemodynamics rather than completely obliterating all fistulas ( 9 , 11 ). It is important to obtain a precise understanding of each DAVF's vascular anatomy, as not all fistulas contribute to venous hypertension ( 24 , 30 , 55 ). At present, treatment for intracranial MDAVFs may include endovascular treatment, microsurgery, stereotactic radiosurgery or a combination of several methods( 3 ).…”