DURAL ARTERIOVENOUS-FISTULAS INCLUDING THE TRANSVERSE AND SIGMOID SINUSES - RESULTS OF TREATMENT IN 30 CASES

We report about the treatment and outcome of 30 patients with dural ar teriovenous fistulas including the transverse and sigmoid sinuses trea ted between 1986 and 1995. All patients underwent panangiography for d efinitive diagnosis. The dAVF were supplied by the external carotid ar tery system alone (14 patients), both external and internal carotid sy stems (10 patients) or both anterior and posterior circulation (6 pati ents). Depending on the venous drainage the fistulas were classified f ollowing a modification of Djindjian's description with 18 patients re vealing Type I (main sinus with antegrade flow), 5 Type II a (main sin us with reflux into the contralateral sinus), 5 Type II b (cortical ve ins), 1 Type II a + b (both) and 1 of Type III (diner cortical drainag e). Fruit, pulsatile tinnitus and headaches were the most common sympt oms. 6 patients presented with intracranial haemorrhage, 4 with progre ssive neurological deficit or seizures and 3 with dementia. Arterial e mbolization was performed in all cases except one, where a transvenous approach for balloon occlusion of the transverse sinus was performed. 21 patients were treated by single or repeated embolization alone. On ly in 9/21 cases did arterial embolization result in complete occlusio n of the fistula. In 12/21 patients incomplete occlusion was achieved. Following embolization 8 patients underwent additional surgery includ ing coagulation of the feeding arteries and arterialized veins, sinus resection and reconstruction of the sinus. Overall, 18 patients were c ured, 11 improved and 1 patient was unchanged. There was a total numbe r of 5 complications including transient stroke, transient facial nerv e palsy, and a small necrotic skin area following embolization. Venous infarction of the occipital lobe was induced by transvenous occlusion and surgical resection of the transverse sinus in one patient each, r espectively. From our results we conclude that the endovascular therap y alone is the treatment of choice in case of Type I fistulas. In dAVF of Type II and III repeated endovascular treatment seems not to be su fficient and additional surgery is necessary.