SURGICAL-MANAGEMENT OF HIGH-GRADE INTRACRANIAL DURAL ARTERIOVENOUS-FISTULAS - LEPTOMENINGEAL VENOUS DISRUPTION WITHOUT NIDUS EXCISION

OBJECTIVE: Of intracranial dural arteriovenous malformations (AVMs), t hose with cortical venous drainage pose the greatest risk of hemorrhag ing. Given recent advances in endovascular, surgical, and radiosurgica l techniques, the optimal management of these dural AVMs is controvers ial. For surgical candidates, the choice of intraoperative techniques remains unclear. Several authors have suggested that surgical clipping of the draining vein close to the nidus of dural AVMs can provide ade quate treatment for some lesions. However, recent reports have also pr omoted partial or complete surgical resection of these lesions. METHOD S: We present five cases of dural AVMs with cortical venous drainage t hat were surgically treated by the senior author between 1993 and 1996 , and we review their management, Our series includes two frontal, one temporal, and two occipital lesions. Three patients presented with in tracerebral hemorrhages, one with headache and eye pain, and one witho ut symptoms. All five patients demonstrated venous aneurysms associate d with the AVMs. Two patients underwent incomplete endovascular emboli zation before surgery. Operative management in all cases involved clip ping of the draining vein as close as possible to the AVMs, together w ith extensive cautery of the surrounding dura. RESULTS: Postoperative angiography demonstrated complete angiographic obliteration in all cas es. The four symptomatic patients all experienced clinical improvement postoperatively. The asymptomatic patient remained asymptomatic. With a mean follow-up period of 29 months, no patient has developed recurr ent symptoms. CONCLUSION: Surgical clipping of the draining vein close to dural AVMs has proven safe and effective in our experience. Given the highly vascular nature of dural AVMs, often near major dural sinus es, surgical resection of these lesions may not be indicated.