Demonstration of Microsurgical Technique and Nuances for the Obliteration of Complex Intracranial Dural Arteriovenous Fistulas in Three Consecutive Cases: Operative Video.

An intracranial dural arteriovenous fistula (DAVF) is an uncommon acquired dural shunt between an artery and a vein without a parenchymal nidus. DAVF occlusion may be achieved using either endovascular or open surgical means. Combining both techniques is also frequently used in clinical practice. In this video, we present three patients with Borden type III, complex intracranial DAVFs. The first patient presented with intracranial hemorrhage and underwent a successful microsurgical obliteration of the fistula in the tentorium. Two other patients had DAVFs that were incidentally found. Both underwent embolization procedures which did not result in complete DAVF obliteration. Both patients then subsequently underwent microsurgical obliteration of these DAVFs. All three patients had very good outcomes. In two of these cases, we performed indocyanine green video angiography to identify fistulous connections. As demonstrated in this video, microsurgical obliteration of DAVFs is relatively straightforward. This provides a valuable treatment option of some selected DAVFs and should be considered as a primary initial treatment option of complex DAVFs in certain locations. Open surgical obliteration is the best possible, most durable, and most effective therapeutic option when there are failures or shortcomings with endovascular management.