The treatment of complex dural arteriovenous fistulae through cranial base techniques.

INTRODUCTION: The endovascular modality of treatment is the preferred treatment modality for DAVF. In some circumstances, successful obliteration may not be possible by endovascular means, and such cases may require a direct surgical treatment. The authors report on their experience with the use of cranial base approaches in the treatment of deep and complex DAVF. MATERIALS AND METHODS: Nine patients were treated between 1992 and 2003. There were six females and three males. Four patients presented with intracerebral hemorrhage, two with progressive myelopathy, two with tinnitus, and one with incapacitating chronic seizures. Four DAVF were tentorial, two transverse sigmoid, one craniocervical, one straight sinus, and one sphenoparietal. Endovascular embolization was attempted and unsuccessful in four cases, and was successful only as an adjunct to surgery in four others. All patients required the use of cranial base approaches to disconnect the fistula or resect the nidus. RESULTS: Complete obliteration of the fistula was possible in all cases. Six-month follow-up results were obtained on seven patients where there was no evidence of recurrence. One postoperative temporal-lobe hematoma required surgical evacuation. One patient died two years postoperatively from an unrelated cause. CONCLUSION: This retrospective study demonstrates that complex DAVF can be successfully treated with the assistance of cranial base techniques.

Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases.

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulae (DAVFs) with leptomeningeal drainage have an aggressive natural history. Urgent treatment is necessary to arrest neurological deterioration and to prevent the risk of intracranial hemorrhage. In many patients, a primary endovascular approach is the most appropriate and most successful treatment available. In some circumstances, however, surgical intervention is required for complete obliteration. Posterior fossa DAVFs are generally deep-seated and difficult to gain access to with standard surgical approaches. The advent of cranial base surgery allows 360-degree access to the draining venous complex or sinus via extradural bone removal. CLINICAL PRESENTATION: Four patients with posterior fossa DAVFs presented to the neurosurgical service at our institutions. One DAVF was located at the craniocervical junction, and three were tentorial DAVFs of the superior petrosal sinus. All four patients were treated surgically with extradural bone removal. INTERVENTION: Postoperative angiography documented complete obliteration of all four DAVFs. All patients had normal recoveries, with the exception of one patient who experienced persistent temporal lobe seizure activity as a result of the presenting hematoma. One patient died of unrelated causes 2 years after surgery. One postoperative temporal lobe hematoma required evacuation. CONCLUSION: Recent advances in cranial base techniques have allowed the successful obliteration of aggressive posterior fossa DAVFs with acceptable morbidity. The use of these techniques should be considered in selected patients who cannot be treated with endovascular approaches.