EVOLUTION OF DIFFERENT THERAPEUTIC STRATEGIES IN THE TREATMENT OF CRANIAL DURAL ARTERIOVENOUS-FISTULAS - REPORT OF 30 CASES

30 cases of cranial dural arteriovenous fistulas, treated between 1983 and 1992, are reported. Twelve presented with an aggressive clinical couse including intracranial haemorrhage, progredient neurological def icit, medically intractable seizures, and cerebellar symptoms. The oth er 18 patients had a more benign clinical presentation with audible br uit, exophthalmus, chemosis, and cranial nerve dysfunction. One of the latter had symptoms of pseudotumour cerebri due to sinus occlusion wi th contralateral sinus stenosis. The most common location was at the t ransverse sinus, followed by the cavernous sinus, the tentorial ring, and the orbita. Four vessel angiography verified the diagnosis and dem onstrated all fistulas, mainly supplied by branches of the external ca rotid artery. 16 of 18 benign lesions were treated by endovascular the rapy alone. Two recent patients received adjuvant stereotactic radiosu rgery. Among these 18 patients 2 remained untreated, one because of sp ontaneous fistula thrombosis prior to therapy and one because of poor medical condition. 12 of 16 treated benign dural fistulas were partial ly occluded. in 6 of them spontaneous fistula thrombosis occurred duri ng the following months. Total endovascular obliteration was achieved in the remaining 4 patients. 7 of 12 aggressive fistulas were embolize d only, one of them having additional radiosurgery. Two of them were t otally obliterated and five partially. Surgery was performed in the re maining 5 aggressive fistulas. Complete microsurgical excision was ach ieved in 2 and partial in further two, who presented initially with a life-threatening intracerebral clot. In one early case ligation of the external carotid artery was done, which is now obsolete. Over all 20 of 28 treated patients became asymptomatic or improved clinically. 3 o f the remaining 8 patients were unchanged, two deteriorated despite th erapy, and 3 worsened after therapy. All of the latter complications o ccurred early in our series due to thomboembolic events during the pro cedure. One surgical patient suffered from a new facial nerve palsy po stoperatively. Follow up time in all treated patients was between 1 an d 139 months with a mean of 48,3 months.