Cranial Dural Arteriovenous Fistula Disconnection

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Indications

The indication for treatment of cranial dural arteriovenous fistulas (DAVFs) is dictated by their natural history. Because the risk of hemorrhage and neurologic deficit is directly correlated to the presence of cortical venous reflux (CVR), a general principle is that only these lesions should be treated.
Two accepted classifications, the Borden and the Cognard classification, relate the different hemodynamic patterns of DAVFs and stratify their risk of aggressive progression by considering CVR and the involvement of major venous sinus drainage. These classification systems are important to determine the indication for treatment and to direct the treatment strategy. For simplicity, only the Borden classification is used in this chapter.

Because the risk of hemorrhage is very low in these lesions, they should be treated only in patients with intolerable symptoms, such as tinnitus, ophthalmologic symptoms, or pain. These benign lesions should be observed clinically and radiologically, however, because a small percentage (2% to 3%) eventually develop CVR.

Patients with Borden II lesions should be treated because they have CVR. In patients with neurologic deficits, most often secondary to venous congestion, the sinus cannot be sacrificed, generally precluding a total obliteration of the fistula by surgery or endovascular therapy. The treatment is limited to disconnecting the arterial feeders and skeletonization of the involved sinus. In patients without neurologic deficits, CVR can be disconnected; the fistula can be totally excised with sacrifice of the sinus only if the brain does not use the draining sinus.

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