Microsurgical treatment of intracranial dural arteriovenous fistulas. Case series and review of the literature
Objective ‒ to evaluate peculiarities and results of microsurgical treatment of intracranial dural arteriovenous fistulas (DAVF).
Materials and methods. A retrospective analysis of microsurgical treatment of 7 patients with DAVF (4 (57. 1%) women and 3 (42.9 %) men, average age ‒ 43.4 years), who were hospitalized and surgically treated at the SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» from 2016 to 2020, was made. DAVF was drained into the superior sugittal sinus in 4 (57.1 %) patients, transverse and sigmoid sinuses in 2 (28.6 %) cases, in the middle cranial fossa in 1 (14.3 %). According to the Cognard classification there were 3 (42.9 %) DAVFs belong to type IIb, 2 (28.6 %) ‒ to type IIa + b, 1 (14.3 %) DAVF ‒ to type II, 1 (14.3 %) DAVF ‒ to type IV.
Results. In 3 (42.9 %) patients were primarily treated with endovascular method. Follow up studies revealed a recurrence of the disease, and microsurgical disconnection was performed. In 4 (57.1 %) cases, endovascular access to superficial DAVF was risky due to anatomical features, and microsurgery was preferred. In all patients, surgical treatment aimed the disconnecting of the shunt. In 1 (14.3 %) case of DAVF the transverse sinus was ligated. In all cases angiographic confirmation of the DAVFs exclusion was performed. In the postoperative period, there was no evidence of an increasing of clinical symptoms. All patients with pulsatile tinnitus and headache noted their regression after surgery.
Conclusions. Considering the efficacy of modern endovascular techniques, microsurgery of DAVF has been indicated in cases where endovascular embolization has proven to be no-n-efficient or technically impossible. Among surgical methods of DAVF treatment, there are disconnection of the meningeal arteries directly at the site of the fistula, resection of the abnormal dura mater with feeding vessels, ligation and intersections of the injured venous sinus, skeletonization of the sinus with the feeding dural vessels. Treatment should be performed in all cases of DAVF with cortical venous drainage and progressive symptoms of the disease. The choice of optimal treatment should be made in a multidisciplinary manner, and all possible methods should be taken into consideration.
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