Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series

UMMS Affiliation

Division of Interventional Neuroradiology, Department of Radiology

Publication Date


Document Type



Nervous System Diseases | Neurology | Neurosurgery | Surgery


BACKGROUND: Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments.

OBJECTIVE: To demonstrate the angioarchitecture that may necessitate surgical intervention.

METHODS: A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed.

RESULTS: A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging.

CONCLUSION: Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.


Cortical venous drainage, Intracranial dural arteriovenous fistula, Surgery

DOI of Published Version



Akamatsu Y, Gomez-Paz S, Vergara-Garcia D, Moholkar VM, Kuhn AL, Chida K, Singh J, Rodrigues KM, Massari F, Moore JM, Puri AS, Ogilvy CS, Thomas AJ. Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series. Oper Neurosurg (Hagerstown). 2021 Mar 15;20(4):364-372. doi: 10.1093/ons/opaa423. PMID: 33378448. Link to article on publisher's site

Journal/Book/Conference Title

Operative neurosurgery (Hagerstown, Md.)

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