Role and Efficacy of Direct Surgery in the Management of Intracranial Dural Arteriovenous Fistulas.

Purpose: Although endovascular treatment (EVT) is often the treatment of choice for intracranial dural arteriovenous fistula (dAVF), direct surgery is an efficient option for many types of dAVFs. Herein, we present a relatively large case series of direct surgical patients to discuss the role and efficacy of direct surgery in managing intracranial dAVFs.

Methods: 43 consecutive patients with dAVFs (ethmoid, n = 11; middle fossa, n = 1; convexity, n = 2; tentorium, n = 11; superior sagittal sinus, n = 2; transverse-sigmoid sinus, n = 11; and cranio-vertebral junction [CVJ], n = 5) treated with direct surgery were retrospectively assessed. Here, 21 (48.8%) and six (14.0%) patients presented with intracranial hemorrhage (ICH) and nonhemorrhagic neurological deficits, respectively. Factors for the selection of direct surgery, prior EVT, surgical procedure, and surgical outcomes were investigated.

Results: The ethmoidal location and massive ICH presentation were associated with the predominant selection of direct surgery. Incomplete obliteration via prior EVT was frequently observed in CVJ dAVF, as well as in tentorial dAVFs with pial arterial supply. Permanent surgery-related complications and incomplete obliteration were observed in 7.0% and 2.4% of the patients, respectively. Regarding long-term outcomes, recurrence was not observed postoperatively during the 1336 patient-month follow-up period, and favorable outcomes (modified Rankin scale of 0-2) at the last evaluation were achieved in 82.5% of patients.

Conclusion: Direct surgery is an effective therapeutic option for dAVFs located in the ethmoid, CVJ, or tentorium; those presenting with massive ICH; and those with pial arterial supply.