Surgical treatment of intrarcranial dural arteriovenous fistulas

: Surgical treatment is indicated in patients who present clinical symptoms for intracranial dural arteriovenous fistula and retrograde cortical venous filling on cerebral angiography. Further, surgery is indicated in those patients that cannot be cured by endovascular procedures. For dural arteriovenous fistulas in the anterior fossa, tentorium, craniovertebral junction or convex, surgery was considered as the first option. Morphologically, non-sinus dural arteriovenous fistulas and dural arteriovenous fistulas with isolated sinus should be treated with surgery. The surgical procedure for intracranial dural arteriovenous fistulas basically consisted of the coagulation and disconnection of the retrograde-flow cortical veins at the point of entry into the dural sinus, and the coagulation of the affected dura and dural sinus. The remaining affected dural sinus could be removed if the patient could tolerate the surgery. Preoperative transarterial embolization of the feeding artery is effective in reducing the amount of blood loss intraoperatively. During surgery, microvascular Doppler sonography is useful for confirming the retrograde-flow cortical veins, and stereotactic localization system and duplicated ultrasound sonography are also useful in detecting the shunting point of the dural arteriovenous fistula and the range of the affected dura and dural sinus. The surgical procedure for intracranial dural arteriovenous fistulas is a radical and invasive treatment. However, surgery is a reliable treatment because it can cure the intracranial dural arteriovenous fistula and correct the intracranial hemodynamics immediately after surgery due to the extirpation of the dural arteriovenous shunt and retrograde-flow cortical veins.