August 13, 2013 7am
Multispecialty Treatment of Dural
Arteriovenous Fistulas:
Embolization, Craniotomy and
Radiosurgery
David Barnett, MD
Chief of Neurosurgery
Baylor University Medical Center
2
Goals
• What is a Dural Arteriovenous Fistula
(DAVF)?
• How do they present?
• What constitutes a potentially dangerous
DAVF?
• The roles of the different treatment options.
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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).
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Background
• 10-15% of all intercranial AVM
• More common in women
• Mean age at presentation is fifties
• Rare in children
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Presentation
• Highly variable
• Location, location, location
• Pulsatile tinnitus, Bruit, Headache
• Opthalmoplegia, Chemosis, Proptosis
• Papilledema
• Focal or Global Neurologic Deficit
• Intracranial hemorrhage
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Hallmark Angiographic Feature
• Premature appearance of venous structures
• Within or next to the dura during the arterial phase
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Location of DAVF
AWAD 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Classification
• Anatomic Location
• Associated Dural Sinus
• Hemodynamics
• Venous Drainage Pattern
• Aggressive / Benign
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Bottom Line
• Presence of retrograde cortical venous
drainage is significant prognostic factor for
aggressive or unfavorable natural history
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Treatment Options
• Observation
• Medical Management
• Endovascular
• Transarterial
• Transvenous
• Liquid Embolic, Coils, Stents
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Treatment Options Continued
• Surgery
• Exposure
• Ligation, Resection or Disconnection of DAVF
• Stereotactic Radiosurgery
• Gamma Knife
• Cyber Knife
• Novalis
• Combination
• Endovascular, Surgery, Radiosurgery
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Management Goals
• Identify which DAVFs are potentially
aggressive
• Determine when to treat and which treatment
method to use
• Partial vs. Complete obliteration
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Cases
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 1
Type 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 2
High 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 2 - Outcome
High Flow Indirect Carotid Cavernous
Fistula with Exclusive Cortical Venous
Drainage
• Full Recovery
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 3
High 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 3 - Treatment
High Flow DAVF at the Sinus Torcula
• Staged 3 preop embolizations
• Bilateral Occipital and Suboccipital
Craniotomies and intraoperative angiograms
• Gamma Knife Radiosurgery
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 3 - Outcome
High 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 4
Left 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 4 – Treatment & Outcome
Left Transverse Sinus DAVF with CVR
• Transvenous embolization
• Full Recovery
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 5
High 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
Case 6
High 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
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System
August 13, 2013
Multispecialty Treatment of Dural
Arteriovenous Fistulas
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© 2005 Baylor Health Care System