Surgical management of cerebral dural arteriovenous fistulae

A cerebral dural arteriovenous fistula (DAVF) is an abnormal arteriovenous shunt, supplied primarily by dural feeding arteries, in which the fistulous connection occurs within the dural leaflets that surround the brain. Venous drainage then occurs via an adjacent dural venous sinus, cortical vein, or both. Pathologically increased blood flow through these venous pathways may remain clinically silent or may manifest in a variety of ways, including pulsatile tinnitus, bruit, headache, cranial nerve palsy, orbital venous congestion, seizures, cognitive decline, focal neurological deficit, cerebral venous hypertension, or intracranial hemorrhage. Importantly, DAVFs with retrograde cortical venous drainage often behave in a “malignant” fashion, with high associated rates of intracranial hemorrhage, neurological deficits, and death. While endovascular approaches have emerged as the primary treatment for most DAVFs, certain fistula types are still best dealt with via open surgery as the first-line strategy. Furthermore, surgery has been used to successfully treat DAVFs after previous partial, incomplete, or failed endovascular treatment. Finally, surgery can be used adjunctively in a combined approach to provide direct access for embolization of DAVFs that are inaccessible by a purely endovascular route. This chapter will briefly review historical and clinical features of cerebral DAVFs and then describe the principles of their treatment through open surgical techniques.