title: Angio-Architectural Features of High-Grade Intracranial Dural Arteriovenous Fistulas: Correlation With Aggressive Clinical Presentation and Hemorrhagic Risk.
abstract: BACKGROUND
  High-grade dural arteriovenous fistulas (dAVFs) can present shunts with very different angio-architectural characteristics. Specific hemodynamic factors may affect clinical history and determine very different clinical courses.
  
  
  OBJECTIVE
  To evaluate the relationship between some venous angio-architectural features in high-grade dAVFs and clinical presentation. Specific indicators of moderate or severe venous hypertension were analyzed, such as altered configurations of the dural sinuses (by a single or a dual thrombosis), or overload of cortical vessels (restrictions of outflow, pseudophlebitic cortical vessels, and venous aneurysms).
  
  
  METHODS
  The institutional series was retrospectively reviewed (49 cases), and the pattern of venous drainage was analyzed in relationship with clinical presentation (benign/aggressive/hemorrhage).
  
  
  RESULTS
  Thirty-five of 49 cases displayed cortical reflux (high-grade dAVFs). This subgroup displayed a benign presentation in 31.42% of cases, an aggressive in 31.42%, and hemorrhage in 37.14%.
  
  
  CONCLUSIONS
  Our data confirm that within high-grade dAVFs, 2 distinct subpopulations exist according to severity of clinical presentation. Some indicators we examined showed correlation with aggressive nonhemorrhagic manifestations (outflow restriction and pseudophlebitic cortical vessels), while other showed a correlation with hemorrhage (dual thrombosis and venous aneurysms). Current classifications appear insufficient to identify a wide range of conditions that ultimately determine the organization of the cortical venous drainage. Intermediate degrees of venous congestion correlate better with the clinical risk than the simple definition of cortical reflux. The angiographic aspects of venous drainage presented in this study may prove useful to assess dAVF hemodynamic characteristics and identify conditions at higher clinical risk.
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Giuseppe Maria
authors.initials: GM
authors.lastname: Della Pepa
authors.affiliation: Institute of Hygiene and Population Medicine, Catholic University of Rome, Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Parente
authors.affiliation: Institute of Neuroradiology, Catholic University of Rome, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: D'Argento
authors.affiliation: Institute of Neuroradiology, Catholic University of Rome, Rome, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Pedicelli
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Carmelo Lucio
authors.initials: CL
authors.lastname: Sturiale
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Sabatino
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Alessio
authors.initials: A
authors.lastname: Albanese
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Puca
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Fernandez
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Alessando
authors.initials: A
authors.lastname: Olivi
authors.affiliation: Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Marchese
mesh_terms: D000792:Angiography; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000473:pathology / Q000503:physiopathology; D006470:Hemorrhage; D006801:Humans; D012189:Retrospective Studies; D012306:Risk
keywords: Aggressive symptoms; Cerebral hemorrhage; Dural arteriovenous fistulas; dAVF; dAVF angio-architecture; dAVF classification; dAVF venous anatomy