Peer-Review Short ReportSurgical Treatment of Dural Arteriovenous Fistulas of the Petrous Apex
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)
- et al.
Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course
J Neurosurg
(1990) - et al.
Intracranial dural arteriovenous fistula with perimedullary venous drainage
J Neuroradiol
(1998) - et al.
Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage
Radiology
(1995) - et al.
Surgical treatment of intracranial dural arteriovenous fistulae: role of venous drainage
Neurosurgery
(2000) - 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) - et al.
Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space: report of four cases
J Neurosurg
(1984) - et al.
Peripheral facial palsy after embolization of a dural arteriovenous fistula with Onyx(R)
Head Neck Otolaryngol
(2011) - et al.
Endovascular treatment of cerebral arteriovenous malformations
Neurosurg Rev
(1986) - et al.
Surgical management of deep-seated dural arteriovenous malformations
J Neurosurg
(1997) - et al.
Treatment for intracranial dural arteriovenous malformations: a meta-analysis from the English language literature
Neurosurgery
(1997)
Cited by (8)
Cerebral dural arteriovenous fistulae presenting with acute hemorrhage: A systematic review
2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementDural Arteriovenous Fistulas at the Petrous Apex with Pial Arterial Supplies
2018, World NeurosurgeryCitation 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 NeurosurgeryCitation 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].
Facial nerve arterial arcade supply in dural arteriovenous fistulas: Anatomy and treatment strategies
2020, American Journal of NeuroradiologyEndovascular treatment for dural arteriovenous fistulas in the petroclival region
2020, International Journal of Medical Sciences
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.