title: Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas.
abstract: OBJECTIVE
  A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated.
  
  
  METHODS
  Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated. Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4-138.3 months). Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower.
  
  
  CONCLUSIONS
  Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.
authors.affiliation: University of Toronto Brain Vascular Malformation Study Group, Division of Neurosurgery, Toronto, Ontario, Canada. vandijk.md@planet.nl
authors.forename: J Marc C
authors.initials: JM
authors.lastname: van Dijk
authors.forename: Karel G
authors.initials: KG
authors.lastname: TerBrugge
authors.forename: Robert A
authors.initials: RA
authors.lastname: Willinsky
authors.forename: M Christopher
authors.initials: MC
authors.lastname: Wallace
mesh_terms: D000328:Adult; D000368:Aged; D020785:Central Nervous System Vascular Malformations / Q000628:therapy*; D002550:Cerebral Veins / Q000601:surgery*; D002560:Cerebrovascular Circulation; D003392:Cranial Sinuses; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D011183:Postoperative Complications; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome