Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery...

Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery

David Barnett, MDChief of NeurosurgeryBaylor University Medical Center

August 13, 2013 7am

August 13, 2013Multispecialty Treatment of Dural Arteriovenous Fistulas

• What is a Dural Arteriovenous Fistula (DAVF)?

• How do they present?

• What constitutes a potentially dangerous DAVF?

• The roles of the different treatment options.

Definition of DAVF

• An arteriovenous shunt in which the nidus is solely contained within the leaflets of the dura mater.

• Also referred to as Dural Arteriovenous Malformation (DAVM).

Background

• 10-15% of all intercranial AVM

• More common in women

• Mean age at presentation is fifties

• Rare in children

Pathogensis

• Not completely understood

• Most popular theory is collateral revascularication (i.e. sinus thrombosis followed by recanalization of the dura)

• Precipitating factors include…trauma, hypercoagulable states, and infection

Presentation

• Highly variable• Location, location, location• Pulsatile tinnitus, Bruit, Headache• Opthalmoplegia, Chemosis, Proptosis• Papilledema• Focal or Global Neurologic Deficit• Intracranial hemorrhage

Radiographic Evaluation

• CT/CT Angiogram, MR/MR Angiogram• Initial investigation• Abnormal blood vessels, white matter edema, hemorrhage• Cannot exclude DAVF

• Intracranial Angiography• The Gold Standard• Accurate classification

Hallmark Angiographic Feature

• Premature appearance of venous structures• Within or next to the dura during the arterial phase

Arterial Supply

• Arterial branches that supply the dura• Middle menigeal artery• Anterior Fossa: Ethmodial branches of the opthalmic

artery• Cavernous Sinus: Dural branches from ICA and

accessory menigeal branch of the maxillary artery• Posterior Fossa: Dural branches of vertebral, occipital,

and ascending Pharyngeal Arteries

Location of DAVFAWAD and Little: J Neurosurgery 1990; 72: 839-850

Review of Literature with 377 DAVF cases

Aggressive / Benign

Transverse/ Sigmoid Sinus 62.6% 1:8.8

Cavernous Sinus 11.9% 1:6.5

Tentorial Incisura 8.4% 31:1

Convexity Sagittal Sinus 7.4% 1:1

Anterior Cranial Fossa 3.7% 2.1:1

Sylvian – Middle Fossa 3.7% 2.5:1

Classification

• Anatomic Location

• Associated Dural Sinus

• Hemodynamics

• Venous Drainage Pattern• Aggressive / Benign

Angiographic Classifaction

• Borden• 3 types based on cortical venous reflux and sinus drainage

• Cognard• 5 types based on cortical venous reflux, sinus drainage and

direction of flow with involved sinus

• Barrow• Used for Cavernous sinus fistulas

Borden Classification(Journal of Neurosurgery 1995; 82:166-179)

Type 1: Anterograde sinus flow and no cortical venous reflux

Type 2: Retrograde sinus flow and cortical venous reflux

Type 3: No flow inside the sinus and exclusive cortical venous reflux

Cognard Classification(Radiology 194(3): 671-680, 1995

Type 1: Drainage into venous sinus only; anterograde flow

Type 2A: Draining into dural sinus with retrograde flow

Type 2B: Anterograde drainage into sural sinus and CVR

Type 2A & B: Retrograde drainage into dural sinus and CVR

Type 3: CVR only without venous ectasia

Type 4: CVR only with venous ectasia

Type 5: Drainage into spinal perimedullary veins

Natural History(Interventional Neuroradiology 1997; 3:295-302)

• Aggressive presentation• Intracranial Hemorrhage, Focal Neurologic Deficit or Death

Borden Type 1 2%

Borden Type 2 39%

Borden Type 3 79%

Borden Type 2 & 3 19.2% / patient-year ICH

Bottom Line

• Presence of retrograde cortical venous drainage is significant prognostic factor for aggressive or unfavorable natural history

Treatment Options

• Observation• Medical Management• Endovascular

• Transarterial• Transvenous• Liquid Embolic, Coils, Stents

Treatment Options Continued

• Surgery• Exposure• Ligation, Resection or Disconnection of DAVF

• Stereotactic Radiosurgery• Gamma Knife• Cyber Knife• Novalis

• Combination• Endovascular, Surgery, Radiosurgery

Management Goals

• Identify which DAVFs are potentially aggressive

• Determine when to treat and which treatment method to use

• Partial vs. Complete obliteration

Case 1Type 1 DAVF

Sigmoid Sinus DAVF

• 52 year old male presents with pulsatile tinnitus and occipital bruit

• Past medical history significant for Nephrotic Syndrome, Antithrombin III deficiency and dural sinus thrombosis

Case 2High Flow Indirect Carotid Cavernous

Fistula with Exclusive Cortical Venous Drainage

• 71 year old presents with progressively worsening diplopia, left eye chemosis and blurred vision

• Had seen several ophthalmologists

• Increased intraocular pressure

Case 2 - OutcomeHigh Flow Indirect Carotid Cavernous

Fistula with Exclusive Cortical Venous Drainage

• Full Recovery

Case 3High Flow DAVF at the Sinus Torcula

• 21 year old female presents with severe medically recalcitrant headaches and progressive blindness

• Previously diagnosed and treated for pseudotumor cerebri

• Bilateral optic nerve fenestrations

Case 3 - TreatmentHigh Flow DAVF at the Sinus Torcula

• Staged 3 preop embolizations

• Bilateral Occipital and Suboccipital Craniotomies and intraoperative angiograms

• Gamma Knife Radiosurgery

Case 3 - OutcomeHigh Flow DAVF at the Sinus Torcula

• Overall excellent

• Developed radiation necrosis 3 years later and lost some vision

• Completed college and now 5 years later, is engaged and in the working world

Case 4Left Transverse Sinus DAVF with CVR

• 60 year old male presenting to outside hospital with severe headache and visual loss

• MRI: Left Occipital hemorrhage and abnormal flow voids

Case 4 – Treatment & OutcomeLeft Transverse Sinus DAVF with CVR

• Transvenous embolization

• Full Recovery

Case 5High Flow Direct CCF

• 27 year old female presents with headache, right eye proptosis and ecchymosis and right temporal bruit

• Patients medical history significant for motor vehicle collision and craniotomy at outside hospital one month before

Case 6High Flow DAVF with CVR

• 37 year old female presents with right sided weakness and expressive aphasia for one day duration

• Patient’s medical history: Diabetes

Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery...

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