Concepts of combined endovascular and surgical treatment for dural arteriovenous fistulae: concepts derived from experience in treating three unusual lesions.

Abstract

We describe a treatment protocol for patients who have a dural arteriovenous fistulae (dAVF) not curable solely by an endovascular approach. Three patients suffering from neurological impairment due to a complex dAVM (intracranial haemorrhage 2, intracranial hypertension 1) were treated by a combination of arterial embolization treatment and subsequent surgery. Marked reduction of flow was achieved by embolization of the main arterial feeders of the fistulae. Surgery eliminated the residual dAVFs completely and without permanent morbidity. It is necessary to eliminate a dural fistula completely, especially in a patient whose fistula had drainage or reflux into cortical veins, which have a high risk of intracranial haemorrhage and venous hypertension. We present an approach to treatment using transarterial embolization and early surgery which may offer a safe and effective way to achieve complete elimination of the lesion, avoiding increased risk to important venous drainage.