Concepts of combined endovascular and surgical treatment for dural arteriovenous fistulae: concepts derived from experience in treating three unusual lesions.

BACKGROUND: We describe a treatment protocol for patients who have a dural arteriovenous fistulae (dAVF) not curable solely by an endovascular approach.

MATERIAL AND METHODS: Three patients suffering from neurological impairment due to a complex dAVM (intracranial haemorrhage 2, intracranial hypertension 1) were treated by a combination of arterial embolization treatment and subsequent surgery.

RESULTS: Marked reduction of flow was achieved by embolization of the main arterial feeders of the fistulae. Surgery eliminated the residual dAVFs completely and without permanent morbidity.

CONCLUSION: It is necessary to eliminate a dural fistula completely, especially in a patient whose fistula had drainage or reflux into cortical veins, which have a high risk of intracranial haemorrhage and venous hypertension. We present an approach to treatment using transarterial embolization and early surgery which may offer a safe and effective way to achieve complete elimination of the lesion, avoiding increased risk to important venous drainage.