Endovascular management of dural arteriovenous fistulas

Mark Dannenbaum MD (Dr. Dannenbaum of Emory University School of Medicine has no relevant financial relationships to disclose. Alireza Noorian MD (Dr. Noorian of Emory University School of Medicine has no relevant financial relationships to disclose.)
Albert J Schuette Jr MD (Dr. Schuette of Emory University School of Medicine has no relevant financial relationships to disclose.)
Daniel B Case MD (Dr. Case of Emory University School of Medicine has no relevant financial relationships to disclose.)
Rishi Gupta MD (Dr. Gupta of Emory University School of Medicine and Marcus Stroke and Neuroscience Center received consulting fees from Coviden, Concentric, and Rapid Medical.)
Raul G Nogueira MD (Dr. Nogueria of Emory University School of Medicine and Marcus Stroke and Neuroscience Center received consulting fees from Concentric, Coviden, Coaxia, and Reverse Medical.)
Originally released July 29, 2013; expires July 29, 2016
Notice: This article has expired and is therefore not available for CME credit.

Overview

In this article, the authors review dural arteriovenous fistulas in the brain and spinal cord. Dural arteriovenous fistula (DAVF) results from shunting of arterial blood into the wall of a dural venous sinus potentially resulting in venous hypertension and retrograde venous reflux into the dural sinuses or cortical veins. Presenting symptoms are heterogeneous, ranging from tinnitus caused by turbulent flow to focal neurologic deficits due to cerebral edema, venous congestion, or intraparenchymal, subdural, or subarachnoid hemorrhages. In spinal DAVFs patients present with a range of symptoms, including gradually progressive back pain, radiculopathy, and myelopathy typically manifested as paraparesis and bowel or bladder dysfunction. Different anatomic variations, subtypes, pathophysiology, natural history, and best treatment approach and endovascular techniques are addressed.

Key points

 

• Dural arteriovenous fistula (DAVF) is a pathological entity that results from shunting of arterial blood into the wall of a dural venous sinus or into cortical, osteodural, cerebellar, or perimedullary veins.

 

• The pathophysiology of DAVFs is quite complex. DAVFs have been associated with many different conditions, including previous venous sinuses thrombosis, surgery, trauma, and post-partum.

 

• Based on pathophysiology, several classification schemes have been developed to predict the potential natural history of these lesions.

 

• The symptoms attributable to a DAVF are variable and are a reflection of the anatomical location of the fistula as well as the underlying pathophysiology created by the shunt.

 

• Conventional catheter-based cerebral angiography is the gold standard to diagnose this condition.

 

• Urgent treatment should be instituted in the presence of hemorrhage given the relatively high chances of rebleeding.

Historical note and terminology

Endovascular surgical neuroradiology or interventional neuroradiology uses cerebral angiography to diagnose and treat disorders of the head, neck, and central nervous system. It was first described by Moniz in 1927 (Moniz 1927). With development of the Seldinger technique for percutaneous vascular access in 1953, angiography became widely utilized for the diagnosis of vascular disease throughout the body (Seldinger 1953).

Because of advances in the development of microcatheters and other devices combined with an increased understanding of CNS vascular pathophysiology and improved angiographic technique, interventional neuroradiology has developed a major and increasing role in the safe and effective management of a host of vascular and neoplastic disorders.

Currently, interventional neuroradiology techniques should be routinely considered in the management of most vascular disorders of the CNS, including aneurysms, stroke, and arteriovenous malformations like dural fistulas.

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