Surgical treatment of high-risk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications.
OBJECTIVE
An increasing number of intracranial dural arteriovenous fistulae (DAVFs) are amenable to endovascular treatment. However, a subset of patients with high-risk lesions requires surgical intervention for complete obliteration. We reviewed our experience with the surgical management of high-risk intracranial DAVFs and offer recommendations to minimize complications based on fistula location and type.


METHODS
Hospital records for 53 patients (16 women, 37 men) with high-risk intracranial DAVFs treated surgically between 1995 and 2004 were reviewed to determine their presenting symptoms, location, endovascular and surgical interventions, angiographic outcome, and treatment complications. Most patients (76%) presented with intracranial hemorrhage, progressive neurological deficits, or seizures. All patients had high-risk angiographic features such as cortical venous drainage or venous varix. Preoperative embolization was performed in 27 patients. Surgical approaches were tailored to the lesion location. Fistulae were located in the transverse-sigmoid junction (n = 18), tentorium (n = 17), ethmoid (n = 7), superior sagittal sinus (n = 6), torcula (n = 4), and sphenoparietal sinus (n = 3).


RESULTS
At the time of the last follow-up evaluation, 49 patients (92%) had good or excellent outcomes (Glasgow Outcome Scale score, 4 or 5) and three (6%) were deceased. Five patients had a residual fistula. One residual spontaneously thrombosed, one was treated with gamma knife radiosurgery, and two were successfully embolized. The overall morbidity and mortality rate was 13%.


CONCLUSIONS
Despite fulminant presenting symptoms, high-risk intracranial DAVFs can be successfully managed with good outcomes. When anatomic features prevent endovascular access, or embolization fails to obliterate the lesion, urgent surgical treatment is indicated. Patients with residual filling of the DAVF should be considered for adjuvant therapy, including further embolization or radiosurgery.
Kakarla
Udaya K
UK
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
Deshmukh
Vivek R
VR
Zabramski
Joseph M
JM
Albuquerque
Felipe C
FC
McDougall
Cameron G
CG
Spetzler
Robert F
RF
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control*; D012307:Risk Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*