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Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series

BACKGROUND: Intracranial dural arteriovenous fistulae (dAVFs) with cortical venousdrainage (CVD) require treatment because of their aggressive clinical presentation andnatural history. Although endovascular treatment is effective for the majority of theselesions in the current endovascular era, surgical management has been required if thelesions are not amenable to or fail endovascular treatments.OBJECTIVE: To demonstrate the angioarchitecture that may necessitate surgical intervention.

METHODS: A retrospective review of the patients with intracranial dAVFs with CVD treatedat 2 academic institutions between January 1, 2009, and July 31, 2019 was performed.Patients who required surgical intervention were selected in this study, and angiographicfindings were analyzed.

RESULTS: A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in completeobliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolizationwas deterred by the angioarchitecture, which included dominant feeding vessels fromthe ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery,or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venoussystem, or isolated sinus made transvenous approach challenging.

CONCLUSION: Despite continued improvement in endovascular technology, surgicalapproaches to dAVFs are still of great value as initial and salvage treatment of dAVFs withangioarchitecture hampering endovascular treatment.

KEY WORDS: Surgery, Intracranial dural arteriovenous fistula, Cortical venous drainage

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