Elsevier

World Neurosurgery

Volume 77, Issues 3–4, March–April 2012, Pages 591.e7-591.e13
World Neurosurgery

Peer-Review Short Report
Surgical Treatment of Dural Arteriovenous Fistulas of the Petrous Apex

https://doi.org/10.1016/j.wneu.2011.07.009Get rights and content

Objective

To report a series of four patients with dural arteriovenous fistulas (DAVF) at the petrous apex with drainage into the deep cerebral venous system and the surgical treatment employed.

Methods

Four patients with DAVFs at the petrous apex are presented. One patient was admitted with cerebral hemorrhage from a second occipital DAVF, and three patients had cranial nerve palsies. All fistulas were type III or IV according to Cognard's classification with venous drainage into the deep cerebral veins.

Results

Transarterial embolization was performed in two patients. Partial transarterial embolization was possible resulting in a marked flow reduction. In one further patient, surgical treatment via a subtemporal approach was attempted, but complete obliteration of the fistula was impossible. In all patients, complete occlusion of the DAVF was achieved by surgical interruption via a standard retrosigmoid approach to the cerebellopontine angle.

Conclusions

Treatment of these type III or IV DAVFs was indicated. The fistulas were supplied by multiple meningeal feeders originating from the external and internal carotid and vertebral arteries. Preoperative transarterial embolization resulted in significant flow reduction. Complete cure at low risk was achieved by interruption of the venous drainage via a retrosigmoid approach.

Introduction

Dural arteriovenous fistulas (DAVFs) account for 15% of all intracranial vascular malformations (12). The necessity of treatment and the choice of various treatment options depend on the type and location of the fistula. The behavior of the fistula is primarily determined by the venous drainage. The common classifications that attempt to determine the risk of an aggressive clinical course and the indication for treatment are based on the venous drainage pattern (3). Deep-seated DAVFs involve the skull base dura, the tentorium, and the dural sinuses. They frequently have an aggressive nature because the fistula tends to drain into leptomeningeal veins (6, 9, 19), and treatment is indicated. The optimal treatment for this kind of lesion is the complete interruption of the arteriovenous shunt. Various treatment options have been proposed and attempted alone or in combination. Endovascular occlusion of the fistula, if possible, has become the first-choice treatment. Surgical occlusion of feeding arteries or draining veins with or without complete excision of the fistula is the other main choice of treatment of DAVF. In some cases, stereotactic radiosurgery may be indicated (17).

DAVFs at the petrous apex—the part of the petrous bone anterior to the internal auditory canal—are rare. There is no specific report in the literature on this pathologic subentity. Single cases can be extracted from larger series of deep-seated DAVFs (9, 19) or fistulas with perimedullary drainage (2). In this article, we report a series of four patients with DAVFs at the petrous apex with drainage into the deep cerebral venous system.

Section snippets

Illustrative Cases

All four patients were admitted within a 4-year period. One patient presented with cerebral hemorrhage, one patient presented with progressive tinnitus, and two patients presented with cranial nerve palsies. In two patients, partial transarterial embolization was performed before surgical occlusion. In one patient, surgery via a subtemporal approach was attempted, but the origin of the draining vein could not be sufficiently visualized. In all patients, surgical occlusion of the fistula was

Discussion

In this article, we present a series of four patients with DAVF in the region of the petrous apex. All fistulas showed a complex pattern of arterial supply via meningeal branches of the external and internal carotid arteries and of the vertebral artery and drainage into the vein of Galen via an arterialized cerebral vein (Figure 7). All fistulas corresponded to type III or IV according to Cognard's classification. Transarterial embolization was performed in two cases. Clinical cure and

Conclusions

We showed in our four patients that the standard retrosigmoid approach is sufficient to occlude the draining vein originating from the medial part of the petrous apex to achieve complete clinical and radiologic long-term cure of DAVF at low risk.

References (20)

  • I.A. Awad et al.

    Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course

    J Neurosurg

    (1990)
  • E. Brunet et al.

    Intracranial dural arteriovenous fistula with perimedullary venous drainage

    J Neuroradiol

    (1998)
  • C. Cognard et al.

    Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage

    Radiology

    (1995)
  • M. Collice et al.

    Surgical treatment of intracranial dural arteriovenous fistulae: role of venous drainage

    Neurosurgery

    (2000)
  • G.P. Greenough et al.

    Venous hypertension associated with a posterior fossa dural arteriovenous fistula: another cause of bithalamic lesions on MR images

    AJNR Am J Neuroradiol

    (1999)
  • F. Grisoli et al.

    Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space: report of four cases

    J Neurosurg

    (1984)
  • T.J. Kupfer et al.

    Peripheral facial palsy after embolization of a dural arteriovenous fistula with Onyx(R)

    Head Neck Otolaryngol

    (2011)
  • P. Lasjaunias et al.

    Endovascular treatment of cerebral arteriovenous malformations

    Neurosurg Rev

    (1986)
  • A.I. Lewis et al.

    Surgical management of deep-seated dural arteriovenous malformations

    J Neurosurg

    (1997)
  • C.P. Lucas et al.

    Treatment for intracranial dural arteriovenous malformations: a meta-analysis from the English language literature

    Neurosurgery

    (1997)
There are more references available in the full text version of this article.

Cited by (8)

  • Cerebral dural arteriovenous fistulae presenting with acute hemorrhage: A systematic review

    2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
  • Dural Arteriovenous Fistulas at the Petrous Apex with Pial Arterial Supplies

    2018, World Neurosurgery
    Citation Excerpt :

    Complete obliteration of the lesion is of paramount importance because residual DAVFs have a strong tendency to recruit more feeding arteries and exacerbate the hypertension of the draining vein, increasing the chances of recurrence and complications significantly (up to 43% and 55%, respectively).9-11 Pial arterial supplies are observed more often in patients with high-flow DAVFs, making treatment more complex and dangerous.10-14 There have been only a few case reports concerning the treatment strategy for DAVFs with pial arterial supply.15,16

  • Treatment of dural arteriovenous fistula by balloon-assisted transarterial embolization with Onyx

    2013, Clinical Neurology and Neurosurgery
    Citation Excerpt :

    Intracranial DAVF with retrograde flow or direct drainage into a cortical vein carries a high risk of hemorrhage and requires active treatment to disconnect the cortical vein, with or without obliteration of the fistula [3,6,17–21]. This can be achieved by surgery or by embolization with n-butyl cyanoacrylate or coils, but these procedures may be difficult or dangerous [22–25]. Embolization with Onyx is easier because of its non-adherence to the microcatheter tip, appropriate viscosity, and superior permeability, allowing slow and intermittent injection to achieve occlusion of the whole vascular network including all feeding arteries, the fistula, and the drainage veins [1–16].

View all citing articles on Scopus

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text