Evolution of the management of tentorial dural arteriovenous malformations.
OBJECTIVE
Tentorial dural arteriovenous malformations (DAVMs) are uncommon lesions associated with an aggressive natural history. Controversy exists regarding their optimal treatment. We present a single-institution series of tentorial DAVMs treated during a 12-year period, address the current controversies, and present the rationale for our current therapeutic strategy.


METHODS
Twenty-two patients with tentorial DAVMs were treated between 1988 and 2000. Treatment consisted of transarterial or transvenous embolization, surgical resection, disconnection of venous drainage, or a combination of these therapies. The clinical presentations, radiological features, treatment strategies, and results were studied.


RESULTS
Eighteen patients (82%) presented with intracranial hemorrhage or progressive neurological deficits. Retrograde leptomeningeal venous drainage was documented in 22 cases (100%), classifying the lesions as Borden Type III. Angiographic follow-up monitoring was performed for 0 to 120 months and clinical follow-up monitoring for 1 to 120 months. Posttreatment angiography demonstrated obliteration in 22 cases (100%). Two patients experienced neurological decline after endovascular treatment and died. All of the 20 surviving patients exhibited clinical improvement; there were no episodes of rehemorrhage or new neurological deficits. Outcomes were excellent in 17 cases (77%), good in 2 cases (9%), and fair in 1 case (5%), and there were 2 deaths (9%).


CONCLUSIONS
Tentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.
Tomak
Patrick R
PR
Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA. prtomak@netscape.net
Cloft
Harry J
HJ
Kaga
Akihiko
A
Cawley
C Michael
CM
Dion
Jacques
J
Barrow
Daniel L
DL
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001158:Arteries / Q000601:surgery; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000601:surgery*; D002533:Cerebral Angiography; D004388:Dura Mater / Q000098:blood supply; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014680:Veins