Dural Arteriovenous Fistula Diagnosis and Treatment Strategies

Dural arteriovenous fistulas (dAVFs) are pathological shunts between dural arteries and venous sinuses or cortical veins that account for around 10–15% of intracranial vascular malformations. Their clinical significance ranges from benign tinnitus or headache to aggressive presentations with intracranial haemorrhage and neurological deficits when cortical venous reflux is present. Diagnosis relies on high clinical suspicion and multimodal imaging: contrast‐enhanced CT and MRI may suggest venous arterialisation or venous pouching, but digital subtraction angiography remains the gold standard, enabling precise angioarchitecture mapping and risk stratification. Classification schemes based on venous drainage patterns guide management decisions. First‐line therapy is endovascular embolisation, typically via transarterial or transvenous routes, employing liquid embolic agents such as non-adhesive copolymers to occlude the fistulous connections. Transarterial delivery allows targeted penetration into arterial feeders, whereas transvenous approaches secure occlusion of the venous side in lesions with inaccessible arterial anatomy. Stereotactic radiosurgery and microsurgical disconnection serve as adjuncts or alternatives when endovascular access is limited or incomplete. Recent advances include refined liquid embolic formulations, balloon‐assisted techniques to protect normal sinuses, and image-guided radiosurgical planning. A tailored approach based on fistula location, venous drainage, patient comorbidities and risk of haemorrhage underpins modern management, yielding high cure rates and low complication profiles when performed in specialised centres.

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Dural Arteriovenous Fistula Diagnosis and Treatment Strategies publication trend

The graph below shows the total number of articles in dural arteriovenous fistula diagnosis and treatment strategies across all publications each year (not limited to Nature Index journals).

Technical terms

Dural arteriovenous fistula (dAVF): An abnormal connection between dural arteries and dural venous sinuses or cortical veins resulting in arteriovenous shunting.

Cortical venous reflux: Retrograde flow of arterialised blood into cortical veins, associated with increased risk of haemorrhage and neurological injury.

Embolization: Endovascular technique in which embolic materials are delivered to occlude abnormal vessels or shunts.

Transarterial approach: Delivery of embolic agent via arterial feeders to penetrate and occlude the fistula from the arterial side.

Transvenous approach: Delivery of embolic materials via the venous drainage pathway to seal the fistulous site or venous pouch.

Liquid embolic agent (e.g., Onyx, PHIL): Non-adhesive polymer solutions that solidify on contact with blood, used to occlude vascular malformations.

References

1. Updates in the management of cranial dural arteriovenous fistula. Stroke and Vascular Neurology (2019).
2. Intracranial Dural Arteriovenous Fistulas: Classification, Imaging Findings, and Treatment. American Journal of Neuroradiology (2012).
3. Cranial Dural Arteriovenous Fistula: Diagnosis and Classification with Time-Resolved MR Angiography at 3T. American Journal of Neuroradiology (2009).
4. Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus. American Journal of Neuroradiology (2017).
5. Transarterial Onyx Embolization of Cranial Dural Arteriovenous Fistulas: Long-Term Follow-Up. American Journal of Neuroradiology (2014).
6. Embolization of Intracranial Dural Arteriovenous Fistulas Using PHIL Liquid Embolic Agent in 26 Patients: A Multicenter Study. American Journal of Neuroradiology (2016).