Microsurgical Treatment of Intracranial Dural Arteriovenous Fistulas: A Collaborative Investigation From the Multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research
Authors: Raygor Kunal P. , Abdelsalam Ahmed , Tonetti Daniel A. , Raper Daniel M. S. , Guniganti Ridhima , Durnford Andrew J. , Giordan Enrico , Brinjikji Waleed , Chen Ching-Jen , Abecassis Isaac Josh , Levitt Michael R. , Polifka Adam J. , Derdeyn Colin P. , Samaniego Edgar A. , Kwasnicki Amanda , Alaraj Ali , Potgieser Adriaan R. E. , Chen Stephanie , Tada Yoshiteru , Kansagra Akash P. , Satomi Junichiro , Eatz Tiffany , Peterson Eric C. , Starke Robert M. , van Dijk J. Marc C. , Amin-Hanjani Sepideh , Hayakawa Minako , Gross Bradley A. , Fox W. Christopher , Kim Louis , Sheehan Jason , Lanzino Giuseppe , Du Rose , Lai Pui Man Rosalind , Bulters Diederik O. , Zipfel Gregory J. , Abla Adib A. ,   on behalf of the Consortium for Dural Arteriovenous Fistula Outcomes Research
Published: October 2024

BACKGROUND AND OBJECTIVES:
First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each.

METHODS:
The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05.

RESULTS:
In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location.

CONCLUSION:
Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.