SURGICAL-MANAGEMENT OF DEEP-SEATED DURAL ARTERIOVENOUS-MALFORMATIONS

The best treatment for deep-seated dural arteriovenous malformations ( AVMs) remains controversial. Therapeutic options include transarterial and transvenous embolization, surgical excision of the dural nidus, l igation of draining veins, and stereotactically guided radiation treat ment. The authors report on their experience with the application and technique of skull base surgical approaches for deep-seated dural AVMs . Their series includes six patients who were surgically treated for f ive tentorial dural AVMs and one inferior petrosal sinus dural AVM bet ween 1991 and 1995. Three patients presented with progressive brainste m dysfunction, one had progressive myelopathy, and two suffered subara chnoid hemorrhage. Venous hypertension caused progressive neurological deterioration in four patients and ruptured venous aneurysms caused h emorrhage in two patients. Four of the five tentorial dural AVMs recei ved bilateral arterial supply from the internal carotid arteries and e xternal carotid arteries (ECAs). The dural AVM of the inferior petrosa l sinus was fed from both vertebral arteries and ECAs. In this series, all dural AVMs drained into deep cerebral veins. Intra- and postopera tive angiographic studies were used to document complete obliteration in each case. After surgery, three patients developed transient, delay ed (24-72 hours) neurological worsening. One month postsurgery, all si x patients showed improvement from their preoperative neurological fun ction. Surgical resection of these deep-seated dural AVMs was accompli shed by eliminating the arterial supply rather than ligating the drain ing veins to avoid aggravating the underlying venous hypertension. Thi s study demonstrates an important role for skull base surgical approac hes in the management of patients with deep-seated dural AVMs that hav e hemorrhaged, are not obliterated by embolization, and for which ster eotactically guided radiation therapy is an unsuitable option.