Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage

Abstract

Intracranial dural arteriovenous fistulas (AVFs) have been recognized as acquired lesions that can behave aggressively depending on the pattern of venous drainage. Based on the type of venous drainage, they can be classified as fistulas drained only by venous sinuses, those drained by venous sinuses with retrograde flow in arterialized leptomeningeal veins, and fistulas drained solely by arterialized leptomeningeal veins. Serious symptoms, including hemorrhage and focal deficit, are related to the presence of arterialized leptomeningeal veins. In this paper, the authors report a consecutive series treated between 1988 and 1993 of 20 cases of intracranial dural AVFs with "pure leptomeningeal drainage." All patients underwent surgical interruption of the leptomeningeal draining veins. Based on the arterial supply, nine patients were managed by direct surgery, whereas 11 patients were prepared for surgery by means of preoperative arterial embolization. Radioanatomical cure of the fistula and good neurological recovery were achieved in 18 cases. Complete obliteration of the fistula was documented angiographically in two cases, but fatal hemorrhage occurred, probably due to partial thrombosis of the venous drainage. Based on this experience, the authors believe that surgical interruption of the draining veins is the best treatment option for intracranial dural AVFs. However, surgical results may be affected by the extension of postoperative thrombosis, which in turn may be related to the degree of preoperative venous engorgement.

Clinical Course of Cranial Dural Arteriovenous Fistulas With Long-Term Persistent Cortical Venous Reflux

“…This can be achieved by either surgical or endovascular procedures. [13][14][15][16][17][18] Total resection of the DAVF itself with or without sacrifice of the dural sinus may not be necessary. Disconnection of the CVR alone may suffice because lesions without CVR have been shown to follow a benign course.…”

Dural Arteriovenous Fistula at the Anterior Clinoid Process Draining Directly Into the Superficial Middle Cerebral Vein

“…6,15) In this patient, two saccular aneurysms were present, and the lesion responsible for the subarachnoid hemorrhage could not be determined preoperatively. Therefore, we decided to perform surgical treatment of all lesions simultaneously, and complete obliteration of all these lesions was achieved without difficulty or neurological deterioration.…”

“…2,3,6,15) The most common locations of the non-sinus type DAVF are tentorial, ethmoidal, and spinal. We report a rare case of non-sinus type DAVF at the anterior clinoid process with retrograde venous drainage into the superficial middle cerebral vein (SMCV).…”

Intraoperative Angiography for Cranial Dural Arteriovenous Fistula

“…[3][4][5][6][7][8] However, there is a small subset of patients who have DAVFs with anatomic features requiring surgical treatment. [9][10][11] Because DAVFs do not have a compact nidus and are surgically treated by various means, including packing of the sinus, disconnection of the leptomeningeal veins, and disconnection of the dural feeders from the sinus, [12][13][14] it is important to document complete resection of the DAVF and absence of any early draining veins intraoperatively to avoid the risk of hemorrhage postoperatively and to avoid a second surgery for the patient.…”