Dural Arteriovenous Fistulae Static or Dynamic?

• Cognard et al– seven patients with documented worsening of

venous drainage– aggressive natural history

Neuroradiology 39:59, 1997

Dural AVFsExperimental Investigation

Common carotid/external jugular anstamosis

Dural AVFs only with sinus thrombosis

J Neurosurg 80:884, 1994

J Neurosurg 83:539, 1995

Dural AVFsExperimental Investigation

Dural AVFs with sinus thrombosis and venous hypertension

Correlation with angiogenesis index

Implied role in pathogenesis of vascular growth factors (VEGF)

J Neurosurg 87:267, 1997

Dural Arteriovenous Fistulae Etiology

Arteriovenous malformation affecting the transverse dural venous sinus - an aquired lesion

Houser et al. Mayo Clin Proc 54:651, 1979

Dural Arteriovenous Fistulae Embolization

Transarterial and/or Transvenous

Symptom palliation

Angiographic cure

Transvenous Embolization

Venous access

Indication for therapy

24 patients

4% perm morbidity

96% clinical cureRoy & Raymond Neurosurgery 40:1133, 1997

Dural Arteriovenous Fistulae Surgical Options

• resection

• packing• Endo et al J Neurosurg 88:449, 1998

• disconnection• Collice et al J Neurosurg 84:810, 1996

Surgical Disconnection:Work in Progress

• Norris J et al• 1988- present, 141 patients with dural AVFs• Surgical disconnection

– 35 Borden Grade III, 12 Borden Grade II

• All grade III patients disconnected had angiographic cure

• All Grade II lesions converted to Grade I with stable clinical follow-up

Dural Arteriovenous Fistulae:Radiation?

• case reports

• biological target

• target size eg thickness

• indication for therapy– time to cure vs natural history

Cavernous Malformations