Intracranial Dural Arteriovenous Fistulae with Pial Venous Drainage: Combined Endovascular - Neurosurgical Therapy

Intracranial dural arteriovenous fistula with pial venous drainage may present with hemorrhage or focal neurologic deficit and may be difficult to treat. We wish to summarize the therapeutic approaches to these potentially dangerous lesions and to demonstrate how endovascular and neurosurgical therapies may have complimentary roles in their management.

The clinical and radiological records of all patients who presented to our institution with intracranial dural arteriovenous fistula over the last 5 years were reviewed. In those cases demonstrating pial venous drainage, details of presentation, imaging features, endovascular and surgical therapy and outcome were analyzed.

We identified 13 patients with these lesions, 7 of whom presented with intracranial hemorrhage. Six patients were treated with embolization alone. Angiographic cure was achieved in 4. There was one complication in this group, a subarachnoid hemorrhage following glue injection. Four patients were treated with embolization followed by surgical occlusion of the pial venous drainage. Angiographic cure was achieved in all 4. There was one complication in this group, a facial nerve palsy following glue injection. Three patients were treated by surgery alone, with no complications and complete cure in all.

Endovascular therapy of intracranial dural arteriovenous fistula may be curative but is often complex and carries definite risks. Neurosurgical ligation of pial draining veins, with pre-operative embolization when safe, may be a relatively more controlled method to achieve complete cure.