04.11.

2019

• 63 yo
• SHA
• VII cn paresis ,
• Orbital pain
• Dizziness

Natural history and Salvatore Mangiafico

Interventional Nurovascular unit
classification of dAVF Careggi University Hospital
Florence

1 2

3 4

second case: SHA

5 6
 04.11.2019

Third Case: seizure

7 8

a problem is always made of several questions and its solution

is always to anwser to each one of them
• Is it a A‐V malformation ?

• May this A‐V shunt explain the clincal presentation?

the problem is how to treat it ? • Wich is its possible evolution ?

• Where the A‐V shunt is it

• Wich way to follow to occlude it ?

9 10

Dural Arterior Venous Fistulas (DAVF)

are acquaided vascular «malformations» DAVF account for approximately 10–15% of all intracranial
with un unknown aetiology or secondary vascular malformations
due to trhombophilic state, phlogistitic or
traumatic process in wich multiple 0.16 per 100 000 per year approximately 12.5%of all
arteriovenous shunts develop inside dural
intracranial AVMs
vascular stuctures without the interposition
of a malformative nidus.
the mean age of presentation is between 50 and 60 years.
DAVF are almost exclusively supplied by
meningeal arteries arising from esternal , in Japan 0,29 a 100.000 su 1815 casi Acta Neuroch Suppl 2016
internal carotid and vertebral arteries and
rarely from intracranial pial branches

Venous drainage can be formed between

dural sinus, cortical veins or both

11 12
 04.11.2019

Etiopathogenesis : Neo vascularization and venous

3 theories
1 )venous sinus occlusion precedes and is
directly responsible for development of the
fistula. Venous sinus thrombosis results in the
release of angiogenic factors from
theorganizing thrombus, which subsequently
leads to the invasion of small dural arteries
and formation of small dural arterio venous
shunts(Houseretal.,1979).
Menigeal arteries have no connection dilatation are induced by an
with the sinus and cortical veins (BV) inflammatory process
2)DAVFs arise from naturally occurring dormant
channels between dural arteries and sinuses, which
open when the sinus is occluded and venous pressure is
increased (Piton et al., 1984; Mullan, 1994).
3) Venous hypertension may lead to tissue hypoxia
and increased production of angiogenic factors, which
promote endothelial proliferation and neoangiogenesis
(Lawton et al., 1997; Tirakotai et al., 2004; Kojima et al.,
2007).

13 14

sinus‐type DAV Fistulas

no‐sinus type DAV Fistulas the inflammatory processes and
the inflammatory processes throbososis effect a long segment of a
and throbosis effect the dural dural sinus It starts from the wall
segment of a bridging vein inside the sinus

Opening of Dural AV Thrombosis of the EV

shunt and increases the AV flow Sinus occlusion and
penetration of dural Inside the Sinus and EV, reflux in BV
arteries inside the Recruitment of other Recruitment of trans
sinus Dural feeders osseus feeders

15 16

Hystology
• Histologic studies suggests that microscopic thrombosis is always present and plays
an important role in the release of growth factors and theformation o fDAVFs
(Uranishi et al., 1999).
Site od origin of the DAVF
• In immuno‐histochemical studies, expression of basic fibroblast growth factor and
vascular endothelial growth factor has been identified in the wall of the dural sinuses
in patients withD AVFs (Teradaetal., 1996; Uranishi et al., 1999).

17 18
 04.11.2019

• The exact site of the original lesion

( EV , DS , BV) may dictate the arterial
CDAVF feeders of the lesions, their venous
drainage pattern, and as a consequence,
their tendency for a certain clinical
behavior.

• CDAVFs may develop in three distinct

levels of the cranial venous system
3

• the bridging veins, BV ,(1)

• the dural sinuses, DS ( 2) ,
2
• and the emissary veins, EV (3 ).

19 20

dural entrances of the BVs are 1) DAVF of the EV

overlapped by a layer of
numerous small meningeal
veins and venous lacunae
(arrowhead)
( osteodural sinus type DAVF)
Emissary veins pass with cranial nerves through apertures in the cranial wall and
establish communication between the sinuses inside the skull and the veins external to it
• mastoid emissary vein
• veins in the hypoglossal canal • The parietal emissary
• Cavernous sinus • The occipital emissary vein
• emissary veins of the middle fossa • posterior condylar vein
through the foramen ovale, rotundum,
lacerum, • temporal emissary
• inferior petrosal sinus has also the • superficial petrosal vein
position and function of an emissary • meningo‐orbital vein
vein connecting the cavernous sinus
with the jugular vein

21 22

2 ) DAVF of the SINUS wlall

CDAVFs of an Emissary Vein (EV) pure sinus type DAVF
• drain mostly to the sinus and not
directly the cortical venous Periostal – dural sinus DAVF
system Dural –dural sinus DAVF
Sinus at the convexity • Falcine sinus
• recruits additionally osseous • Superior sagittal sinus
arterial feeders • Sinis rectus
Base and posterior fossa sinus • Tentorial sinus
• adds“purely meningeal” • Transverse sinus
branches as the middle
• Sigmoid sinus
meningeal artery, posterior
• Occipital sinus
meningeal, or meningeal
• Torcular
branches of the ICA.

23 24
 04.11.2019

3) DAVF of the BV( non‐sinus DAVF)

(veno‐sinusal Junction)

• The distal segment of a BV embryologically, anatomically, and histologically seems to be part of the dural
system.
• The BVs are closely attached to the inner dural surface and have a shorter or longer intradural course
before they enter the sinus [75]. Therefore,from the embryological point of view, the distal BV segment,
veno‐sinusal junction, appears to belong to the dural system.

Tentorial sinus DAVF

25 26

Hui Han
Neurosurgery 67; 2010
BV DAV shunt ( two subtypes) Comunicating vein

• arteriovenous dural shunt can be primarily

located on a bridging vein , the veno‐sinus
junction is patent ; the A‐V fow is directed
towards the sinus and mainly toward the
pial vein

• thrombosis of the venous –sinus Junction,

the shunt venous drainage is exclusively
cortical.

a BV (arrow) from the occipital lobe (O) drains Disconneted bridging

the BVs (arrows) directly entering the dural
into the meningeal vein (arrowhead) in the vein
cerebral falx (F) before entering the SSS
sinuses (asterisks) in the middle cranial fossa.
Arrowheads indicate the dural entrance sites
(asterisk). vein)

27 28

Comunicanting BV

Is the Sinus filling is syncronous with the BV’s

29 30
 04.11.2019

Disconnected Bridging vein

The Dural AV sunt is on the BV at the conjunction point with Sinus and it
does not communicate with the sinus
unique drainage trhotugh a pial vein that runs along the falx cerebri
Sinus opacifization is delayed

31 32

The natural history of cranial dural arteriovenous

malformations (AVM's) is highly variable

Natural history • In adults the natural history of DAVFs is influenced by

1. the pattern of venous drainage
2. the presenting symptoms
3. localization

33 34

The natural history of cranial dural arteriovenous

malformations (AVM's) is highly variable

• In adults the natural history of DAVFs is influenced by

1. the pattern of venous drainage DAVFs without CVD
2. the presenting symptoms Sinus type DAVF
3. localization

35 36

DAVF without CVD
• a benign clinic course was
observed in 98.5% of the
patients
• Syntomatology : bruit
• Managed conservatively
• if treatment is contemplated it
should not be too aggressive
37
• DAVFs that acquire cortical venin dreinage
(CVD) can present with aggressive clinical
features, including either ICH or
nonhemorrhagic neurologic deficits (NHNDs)
related to focal or regional venous hypertension
• Or progressive clinical features
dementia,seizures,parkinsonism,or ataxia due
to cerebral edema or ischemia related to diffuse
and extensive venous hypertension
(Barrow et al., 1985; Lasjaunias et al.,
1986;Awad etal.,1990).
• DAVFs draining into perimedullary spinal veins
may cause myelopathy and progressive
tetraplegia
(Hurst et al., 1999; Lv et al., 2011).
39
physiopathology
Parenchimal Hem
ICH is believed to occur from rupture
of fragile parenchymal veins as a result
of exposure to increased pressure from
retrograde venous reflux..
41
04.11.2019
DAVF with CVD ( cerebral vein drainage)
• annual rate of conversion to a higher
grade DAVF of 1%‐1.5% angiographic
progression to a more aggressive
fistula
• Follow up of DAVF without VCD
(Borden type I) fistulas is generally
recommended
Bridging vein type DAVF
sinus type DAVF with CVD
38
• The annual ICH, NHND, and
mortality rate was 7.6%, 11%, and
3.8% (Strom and colleagues (2009 in a
series of 28 patients with DAVFs with CVD)
• annual ICH rate o f 8.1%,NHND rate
of 6.9%, and a combined annual
event rate of 15%
(Toronto Brain Vascular Malformation
Group : 20 DAVFs with CVD that were
followed over a 4‐year period )
40
The natural history of cranial dural arteriovenous
malformations (AVM's) is highly variable
Parenchimal ischemia
parenchymal ischemia is thought to occur • In adults the natural history of DAVFs is influenced by
from venous congestion and hypertension, 1. the pattern of venous drainage
Crhronic venous congestion prevents
adequate arterial delivery of oxygen and 2. the presenting symptoms
removal of metabolic byproducts within the 3. localization
surrounding parenchyma
42
 04.11.2019

Difference in natural Hystory

according to the clinical presentation
• asymptmaic patients : Clinical features of CDVF presenting
annual ICH, NHND, and mortality rate was 1.4%, 0%, and 0% with hemorrhage
• symptomatic patients : • The vast majority of patients
the annual ICH, NHND, and mortality rate was 7.6%, 11%, and 3.8% were male (86%), and the most
respectively in common presenting symptom
was sudden onset headache.
• All DAVFs had cortical venous
drainage, and about one‐third
(Strom and colleagues ;2009) were associated with a venous
varix. The most common
location was tentorial (75%).

43 44

1 ) Cotical Dementia from

venous congestive encephalopathy DAVF

• Clinically Progressive
• intracranial venous pressure with signs • Combination of hig flow fistulas
of pseudotumor cerebri with severe with sinus stenosis or thrombosis
headaches and papilledema and • Extensive reflux in cortical and
occasionally progressive cognitive deep veins
decline leading to dementia • Stasis and engorgement in
leptmeningeal and deep venous
• Two Types of Vascular Dementia related circulation
to DAVFs
• Trans medullary vein congestion
withe matter edema and
hydrocepahalus

45 46

47 48
 04.11.2019

of CT or MR imaging revealed abnormalities in each patient,

reflecting the impaired parenchymal venous drainage

pseudophlebitic pattern (PPP) describe Tortuous, engorged veins on the

venous phase of the brain circulation

49 50

2) Thalamic Dementia
Icv hypertenion
Bi‐thalamic edema

6 m decline cognitive
Cognard grade IIb dAVF.

51 52

The natural history of cranial dural arteriovenous

14 pts mean FU 4,5 years
Natural Hystory • an intracranial hemorrhage
Clinical course ovf (35%).
• non hemorrhagic
CDAVF with long term
neurological deficit was
persistent cortical (45%)
venous reflux
• 6 patients expired after a
hemorrhage, and 3 patients
died of progressive
neurological deterioration.
• Two patients a spontaneous
closure of the DAVF (10%).
• annual mortality rate of malformations (AVM's) is highly variable
10.4%.
• annual risk for
hemorrhage8.1%
• In adults the natural history of DAVFs is influenced by
• Annual risk of non
hemorrhagic neurological
deficit 6.9%, 1. the pattern of venous drainage
• resulting in an annual 2. the presenting symptoms
event rate of 15.0%.
3. localization

( J.Marc et al Stroke. 2002;33:1233‐1236.)

53 54
 04.11.2019

• transverse‐sigmoid sinus DAVF (TS DAVF)

Mode of presentation and location of DAVFs
are closely related . A) Group 1. TS DAVF without restriction of
parent sinus.
B) Group 2. TS DAVF with stenosis of parent
sinus.
• Transverse sigmoid junction DAVFs typically suffer from pulsatile tinnitus due to C) Group 3. TS DAVF with one side
the presence of a high‐flow,low‐pressure shunt in close proximity to the auditory occlusion(thrombosis) of parent sinus.
D) Group 4. TS DAVF with proximal and distal
apparatus. ICH in case of leptomenigeal reflux portion occlusion (thrombosis) of parent sinus.
• Middle fossa DAVFs are more likely to present with pulsatile tinnitus due to This group has retrograde leptomeningeal
increased drainage through the sigmoid and transverse sinuses. venous drainage only and was called as TS
DAVF with isolated sinus.
E) Group 5. TS DAVF with pure leptomeningeal
venous drainage. The parent sinus is patent.
Subgroup was the presence of LMVD, the
presence of venous aneurysm and the
presence of spinal venous drainage.

Lalwani’s classification o

55 56

fistulas (DAVF) drains into leptomeningeal vein (LMV) without

the venous sinus interposition

C Est sin pre embol

57 58

Cavernous davf

• Cavernous sinus DAVFs (indirect CCFs) arterialize the ophthalmic veins and
typically present with exophthalmos, chemosis, and visual loss due to increased
intraocular pressure (Suh et al., 2005)

Barrow classification

59 60
 04.11.2019

Clinical symptoms and Imaging

61 62

JVjugular vein, SSsigmoid sinus, 6 cerebellar (spinal) drainage into petrous

1 anterior drainage into superior ophthalmic vein (SOV) STVsuperficial temporal vein vein (PV), leading to ataxia and hemorrhage
and inferior ophthalmic vein (IOV), which can
lead to ocular symptoms (eg, exophthalmos
and chemosis);
2 postero.inferior drainage into inferior petrous sinus
(IPS), basilar plexus and pterygoid plexus, leading to bruit
and cranial
nerve deficits;
3 posterior drainage into superior petrous sinus (SPS),
leading to bruit;
4 cortical reflux into sphenoparietal sinus
and superficial middle cerebral vein (SMV),
leading to venous infarction and hemorrhage;
5 deep drainage into deep middle cerebral
vein and uncal vein, leading to hemorrhage.
.

RadioGraphics 2004; 24:1637–1653

63 64

DAVF Anterior cranial Fossa

• Anterior cranial fossa DAVFs often present with hemorrhage given the frequency 1. Head hache
of retrograde CVD with these fistulas, but they can also present with proptosis 2. seisure
and chemosis if they acquire cavernous sinus drainage.
3. Visual defect
4. ICH (61 **‐68%*)

Awad et al (1990) *
Agid et al (2009) **

65 66
 04.11.2019

• The tentorial middle region (TMR) includes the midline and paramedian
tentorium TMR DAVFs are divided into the following four types:
• Tentorial DAVFs have also been observed to carry a high risk of intracerebral
hemorrhage since they almost always acquire retrograde cortical vein drainage
• incisural DAVF,
• Galenic DAVF,
• straight sinus DAVF
• and torcular DAVF

Acta Neurologica Belgica https://doi.org/10.1007/s13760‐018‐1044‐3

67 68

Superior Petrsal vein DAVF : VII cn peripheral paresis

Tentorial medial region DAVF

• frequently have retrograde drainage through CVs and deep
drainage through the vein of Galen
• hemorrhage,
• bilateral thalamic venous hypertension
• perimedullary venous plexus medullary syndrome.
• The draining vein may become variceal due to the high flow.
• Even more rarely, the draining vein can dilate into a giant
venous ampulla, causing mass effects ( cranial nerve paresis).
• are classified as Borden II‐III and Cognard IIb‐IV

69 70

71 72
 04.11.2019

petrosal vein–
draining DAVFs
• Petrosal vein DAVF : cranial nerve

• were localized to the dural

zone around the
termination of the petrosal
vein as it penetrates the
dura mater into the superior
petrosal sinus
Symptomathology
• SAH
• venous congestion (supratentorial region in and spinal in
• , cerebellar hemorrhage ,
• trigeminal neuralgia
• , and mass effect

73 74

’
Venous dreiange of inferior tentorial and petrosal vein DAVF
Petrosal vein DAVF Vena basale

• 2 type of venous Vena latereo

dreinage mesencefalica

• Ascending or • ipsilateral ascending course Vena ponto

trigeminale

• Descending through the lateral

mesencephalic vein, basal vein,
• According to and the vein of Galen
anatomical dispostion
of the petrosal vein Mmedial type. The
Varice
.Lateral type vena di dandy
The superior petrosal superior petrosal sinus
sinus drains laterally and has no connection
has no connection with the transvers e-
medially with the sigmoid junction and
cavernous sinus drains onl y medially

75 76

56 v o m
Venous dreiange of inferior tentorial and petrosal vein DAVF since 2 years facial neuroalgia ( trigeminal nerve V2)
From few months oral neuralgia induced by
swalallowing ( right glossofaringeal nevralgia )

• to the contralateral side

through the transverse pontine
vein, the vein of the
pontomedullary sulcus, or the
anastomotic vein of the lateral
recess of the fourth ventricle

77 78
 04.11.2019

Petrosal vein DAVF

(BV davf , extrasinusal DAVF

79 80

Superior Petrsal vein DAVF : VII cn peripheral paresis

81 82

Medulla bridging vein

• Brainstem DAVFs are more likely to present with quadriparesis and lower cranial
nerve palsies.

83 84
 04.11.2019

Medulla Bridging Vein–Draining DAVFs

near the foramen magnum
Site of dural shunt • Drainage into the medullary vein • the vein of the pontomedullary sulcus
• occiput– C1 space and/or the spinal vein
• the lateral medullary vein
• level of the foramen magnum • ascending venous drainage into the Pont med
cortical vein of the cerebellum or • antero lateral med vein sulc v
• above the foramen magnum. supratentorially through the lateral are connected with bridging vein to
pontine and lateral mesencephalic vein Antero lat
1. the sigmoid sinus med v
dural branches • Descending drainage through the
anterior and/or posterior spinal vein 2. inferior petrosal sinus near the jugular foramen,
Lat med v
VA and/or branches of the 3. to the marginal sinus near the hypoglossal canal.
neuromeningeal trunk of the ascending
pharyngeal artery

Matsushima T, Rhoton AL Jr, de Oliveira E, Peace D: Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:63–105, 1983

85 86

Extra sinusal type DAVF

CCJ DAVF,

• feeding vessels were C1 and C2

radicular artery and draining vessels
were posterior medullary vein or
anterior medullary vein or intracranial
vein. When draining vessels were
posterior medullary vein or anterior
medullary vein, patients presented
with myelopthy.
• If CCJ DAVF had venous aneurysm,
patients presented with subarachnoid
haemorrhage

87 88

Davf 1. Introducing in the comunication a common A) Classification based on Embriology

Language
classifications 2. better understanding the pathology
are useful for 3. foreseing the clincial evolution

89 90

91
three different dural compartments
related to the embryologic bony structures:
• 1. The ventral group of endochondral bone
from the dura propria and osteal dura (VE
group)
• 2. The dorsal group of membranous bone
from the dura propria and osteal dura (DM
group)
• 3. The falx and tent of the cerebellum
group only from the dura propria (FT
group)
93
95
04.11.2019
Embryology of Dura
• Embryologically, the intracranial dural membrane is derived from bony
structures
• It is formed by two connective tissue layers: an external periosteal layer and
an inner meningeal layer
• the outer dural layer forms the inner periosteum ( perioseal layer) it is
highly vascularizes
• bony structures consist of two types of bony tissue endochondral bone with
cartilaginous ossification and membranous bone based on the
intramembranous ossification
92
VE group: Ventral Epidural group
on the surface of endochondral
bone
• carotid cavernous sinus,
• sigmoid sinus
• Anterior condylar confluence
• Dural arteriovenous shunts in these regions involve
mainly the epidural space and are in direct contact with
the adjacent osseous structures that they may invade or
recruit the blood
• The venous afferents of these regions are closely
related to the bony structures‐ Osteodural DAVF
94
Sigmoid sinus DAVF
96
 04.11.2019

Clinic features
ventral epidural group

• female predominance,
more benign clinical presentations,
lower rate of cortical and spinal venous
reflux,
restriction of the venous outflow.

ACC: anterior condilar confluence SPS

JF : j ugular foramen ACV
SM: sinus marginalis sin
OS : occipital sinus SPI
SCS: sub occipital cavernous sinus
LCV: lateral
Anterior condularDAVF
condylar vein ACC ACV dx
ACV: anterior condilar vein ACV
PCV: posterior condilar vein
HCG : Hypoglossal Canal
SM

97 98

DM group: Dorsal group

On the surface of membranous

bone
• The transverse sinus,
• confluence (torcular Herophili),
• marginal sinus (dorsal portion),
• medial occipital sinus
• accessory epidural sinuses on
the dorsal surface of posterior

Marginal sinus ( dorsal portion )

99 100

3. FT DAVF
dura propria group (two folding internal layers )
Clinic features
ventral dorsal group
The dorsal epidural group had a lower mean age and a higher
rate of multiplicity DURA PROPRIA
Moore aggressive presentation
High rate of cotical reflux due to outflow restrictin
• superior sagittal sinus
• falcine sinus and inferior sagittal sinus
• Tentorial siunus (Falx and tent of the
cerebellum )
• olfactory groove (paramedian surface of crista
galli),

DVAFs are located where the pial emissary bridging vein

pierces the dura BV DAVF

101 102
 04.11.2019

SM1

Tentorial sinus DAVF

103 104

• The lateral epidural group presented

later in life with a male predominance,
more aggressive clinical presentations
• include DAVS draining into emissary‐
bridging vein .cortical venous reflux is
present without evidence of venous
outflow restriction.

105 106

Drainage pattern and clinical difference

• Drainage pattern
• cranial VE and DE type of b) Hemodynamic Classification based on the
DAVSs was primarily through VE
the sinuses, resulting in Types
I, IIa, IIb, and IIab according
FT angiographic findings
to the Cognard classification
and Type 1 and Type 2
secondary changes of the DAVF outflow
according to the Borden
classification depending on
outflow restrictions.
• FT type (Lateral Epidural LE) DM
epiduralspaces ) dreinage was Male/female
primarly through the BV
resulting in BordenType3 and
Cognard 3‐5

107 108
Folie 104

SM1 alongi
Salvatore Mangiafico, 9/13/2008

Secondary Thrombotic phenomena of the venous sinus itself
or its connections with BVs and EVs apparently will modify
this original tendency of the intact anatomic disposition
109
Borden Type I dural AVFMs drain
directly into dural venous sinuses
or meningeal veins.
111
annual hemorrhage rate and angioarchitecture
Borden type 2
• female predilection
• 18% percent of type II dAVF presented
with hemorrhage
• the annual hemorrhage rate was 6%
• the mean age was 60 years and the male‐
to‐female ratio was 0.7, similar to type I
dAVF.
• A notable majority of dAVF were
transverse‐sigmoid (61%), with the
second most frequent location being
cavernous (10%)
Borden 2 and 3
annual rates of 4% for NHNDs.
The annual mortality rate as a result of
NHNDs was 1%
113
04.11.2019
• Djinjian ‐Merland
• Borden
• Cognard
110
Borden type 3
• shunts with exclusive leptomeningeal venous
drainage
• fistula engaging a bridging vein that had lost its
connection to the parent sinus into which it
previously drained; it was characterized by an
arterial network of feeders converging onto the wall
of a bridging vein, with leptomeningeal venous
reflux
Borden type 2 shunts with mixed sinusal‐cortical • sinus was opacified prior to the BVs
venous
Partially or Thrombosed or stenotic Sinus
leptomeningeal venous reflux following the
opacification of the sinus
112
Cognard Classification
Borden type3
• Male predominance , mean age was 59
years.
Patterns of venous drainage allowed classification of dural AVFs into
five types:
• , and only 3% were cavernous.
• type I, located in the main sinus, with antegrade flow;
• 34% rate of hemorrhagic presentation
• annual rate of hemorrhage 10% • type II, in the main sinus, with reflux into the sinus (IIa), cortical veins
(IIb), or both (IIa + b)
• Borden type III dAVF with venous ectasia, rate
of hemorrhagic presentation was similarat26 • type III, with direct cortical venous drainage without venous ectasia
%,but the annual hemorrhage rate 21%
• type IV, with direct cortical venous drainage with venous ectasia;
• The most common location
tentorial(28%),and petrosal (13%). • type V, with spinal venous drainage.
• 9% were transverse‐sigmoid
Radiology. 1995 Mar;194(3):671-80
Bradley A. Gross, dAVF NATURAL HISTORY
Neurosurgery 71:594–603, 2012
114
 04.11.2019

B) Classification
based on the letomenigeal venous dreinage

In both the Bordenand Cognard classification systems, the higher the fistula grade
the worse the natural history (Borden et al., 1995; Cognard et al., 1995).

115 116

Classifications ( Borden and Cognard) focused on the venous drainage,

presence of leptomeningeal venous refllux, and on the direction of flow

“none of the above classifications ( Broden Cognard )

• Differntiates direct from exclusive leptomeningeal venous drainage,
• considers cortical venous congestion
• Consider ectasia in dural sinus‐cortical venous drainage

117 118

Caso seno sospeso “ dural shunts are grouped according to three factors

• Directness (d) of leptomeningeal venous drainage expresses the

exact site of the shunt (bridging vein vs sinus wall)
• Exclusivity (e) Almost all bridging vein shunts and all “isolated” sinus
shunts had an exclusive leptomeningeal
• Venous strain (s), manifested as ectasia and/or congestion, denotes
the decompensation of the cerebral venous system due to the shunt
reflux

119 120
 04.11.2019

• direct LVD was defined by venous drainage that used the bridging and leptomeningeal
vein(s) without interposition of any sinus. In these cases, the exact location of the shunt Dural sinus shunt (DDS) and Brdignig vein shunt(BVS)
was the bridging vein (BV) and not the venous sinus. 8 groups
• non direct LVD was defined by venous drainage that used the BVs but with the
interposition of a sinus, which implies that the shunt was primarily or solely located in green have non exclusive LVD ;therefore ,they drain to both the sinus and the cortical veins; they
the wall of the sinus. correspond to Borden type II

• exclusive LVD was defined as venous drainage by only the leptomeningeal veins either
because the shunt was located in a BV with its exit to the sinus occluded or because the text
text in
only exit of the sinus was through the BV s to the leptomeningeal venous system. white
in
black
• nonexclusive LVD was defined by drainage that occurred both by cortical veins and also have no have
by the venous sinuses, dural veins, or emissary veins (EV). signs of signs
leptomen of
• Presence of ectasias or congestive pseudophlebitic appearance was recorded as cortical ingeal lepto
venous strain. Other associated venous outflow restrictions (VOR) of the venous sinuses, venous meni
as complete or partial thrombosis or stenotic appearance, werealso recorded. strain ngeal
veno
us
red have an exclusive LVD ( leptomeningeal venous dreinage) ; strain
they correspond to Borden type III

121 122

nD‐nE‐nS nD‐nE‐S dural shunt

DAVF with dreinage towards bridging Vein and Dural sinus DAVF with drainage in varicose bridging and Dural sinus

123 124

nD‐E‐nS
nD‐E‐S dural shunt
DAVF with non direct , esclusive in cortical , non ectasic vein
DAVF with non direct , esclusive in cortical , ectasic vein
( isolated sinus )
( isolated sinus with venous ectasia )

125 126
 04.11.2019

D‐nE‐nS D‐nE‐S dural shunt

BV Davf with direct towards a non ectatic cortical vein ; dreinage non exclusive (also into the sinus ) Non Esclsive direct cortical vein drainage with veous ectasia
Non isolated BV ( comunicates with sinus ) Non isolated BV ( in comunication with the sinus)

127 128

D‐E‐nS dural shunt

Esclsive direct cortical vein drainage without veous ectasia
Isolated BV
D‐E‐S dural shunt
Esclsive direct cortical vein drainage with vneous ectasia

129 130

Dss dural sinus shunt
ISS isolated sinus shunt
BVS bridging vein shunt
conclusion
Intracranial dural fistulas differ in
• clinical expression ,and evolution
• bleeding rate
• gender differences
• primary localization (sinus non sinus)
• embryological development (Dorsal basal ventra lateral Epidural
spaces )
• entity of cerebral venous involvement (focal, regional or diffuse)
• typology of venous dreinage

131 132
 04.11.2019

conclusion
Each DAVF has exclusive features

Intracranial dural fistulas are not a homogeneous pathology

The functional anatomical understanding ( beyond the

Calssification ) is essential before any therapeutic action

Natural history and Salvatore Mangiafico

Interventional Neurovascular unit
classification of dAVF Careggi University Hospital
Florence

133 134