D Preciado, MD; J Perendreu, MD; J Branera, MD; B Consola, MD; V P Beltran Salazar,

MD; D Canovas, MD.

Department of Radiology, Section of Vascular and Interventional Radiology
UDIAT.CD. SDI. Corporació Sanitaria Parc Tauli. Sabadell, Barcelona (Spain)
Dural arteriovenous fistulas (DAVFs) are pathologic shunts between dural
arteries and dural venous sinuses, meningeal veins, or cortical veins; they
consist of abnormal arteriovenous communications developed within a venous
space contained between the two layers of the dura mater.

DAVFs are rare, representing 10% to 15% of intracranial vascular malformations.

dural sinus thrombosis

Usually acquired
lesions, may occur venous hypertension
secondary to
trauma
 DAVFs most often involve the following sinuses:
1. Transverse
2. Cavernous
3. Sigmoid

Tentorial DAVF are the most aggressive. Other clincally aggressive DAVFs are
usually associated with leptomeningeal venous drainage or reflux.

The gold angiography for diagnosis

Method: By transarterial and/or transvenous routes or
standards for
DAVFs are direct puncture of affected dural sinus
endovascular
intervention for treatment
Goal: Total fistula occlusion without interfering with
normal dural venous drainage

DAVFs could remain clinically silent or involute spontaneously.

 • Predisposing factor: hypercoagulability
Venous sinus
thrombosis

• Opens up the microvascular connections within the dura; these channels become
hypertrophied, resulting in direct shunting between the arteries and veins. If the DAVF
Venous grows pial supply could be recruited from parenchymal vessels.
hypertension

• The involved dural sinus receives arterialized blood flow that can lead to mechanical
obstruction of the sinus and result in retrograde drainage of the cortical veins.
Cortical
venous
reflux

• The cortical veins may dilate, predisposing to intracranial hemorrhage.

Intracranial
hemorrhage
Venous drainage, in particular reflux into pial veins correlates with DAVF pattern.

DAVFs that present with intracranial hemorrhage or nonhemorrhagic neurologic deficits

have a higher risk of new significant events than asymptomatic fistulas.

Cortical venous drainage and aggressive

symptomatology are clearly linked to unfavorable
natural history.
DAVFs could have a dynamic course.

DAVFs progress to higher grade lesions, in 3 clinical situations:

- spontaneously.
- after an uneventful diagnostic cerebral angiogram.
- after partial treatment.

Factors predisposing to an aggressive course include:

- leptomeningeal (cortical) venous drainage and galenic drainage (deep
veins).
- variceal or aneurysmal venous dilatations.
- location in the tentorium.

Any change in patient’s symptoms can reflect a variation of the venous drainage pattern
and requires further diagnostic examinations.
 CLINICAL MANIFESTATIONS
(Signs/symptoms depend on site, type of the shunt)

Benign course Malignant presentation

(sex, lesion location, and venous
drainage pattern , particularly cortical
venous reflux (CVR))

Incidentally Asymptomatic Non-hemorrhagic Intracranial

discovered lesions neurological hemorrhage
dysfunction

Death
CT:
Often the first imaging test to rule out intracranial bleeding after focal neurologic signs.
Findings are often normal; sometimes an area of low density due to edema of chronic venous congestion.

CT angiography:
Can show details of angioarchitecture.
Can be normal if shunts are small.
In aggressive DAVF, we can see enlarged cortical draining veins with tortuous dural feeders and
enlarged dural sinus.

Angiogram shows a superior longitudinal

Simple cranial CT shows an acute DAVF (Cognard IV) involving branches of both
hematoma in the frontopareital external carotid arteries and retrograde
parenchyma. venous drainage through superficial cortical
veins.
 MRI can show:
Thrombosed or stenosed dural venous sinus; dilated cortical veins without a parenchymal nidus;
thickened dural leaflet; hypertrophied pachymeningeal arteries; dilated, tortuous, and variceal
venous channels.
Focal T2 hyperintensity in adjacent brain due to retrograde leptomeningeal venous drainage
(RLVD) and venous perfusion abnormalities.

MRI: Focal hyperintensity in T2 due to RLVD. MRA shows dilated cortical veins
Angiogram: DAVF in the straight sinus—vein of Galen. without a parenchymal nidus
Angiography:

Gold standard for diagnosis and planning therapy.

Identify feeders, type of venous drainage, retrograde flow, occlusion of sinuses, and
circulation time.

Common findings:
- Multiple arterial feeders (dural branches, most commonly from ECA
followed by from lCA).
- Involved dural sinus often thrombosed.
- Cortical venous reflux.
- Venous ectasia and cortical venous collaterals.
- Variceal or aneurysmal venous dilatations.
 Right Left external
external carotid
carotid

Right branch of
the ophthalmic
artery

Angiography shows parasagittal

DAVF nourished by various
subsidiary arteries of both external
carotids and the right branch of the
ophthalmic artery .
 Left transverse sinus DAVF with multifocal arteriovenous shunts,
and dural sinus disease with network of tiny "crack-like“ vessels
in the wall.

Longitudinal sinus

Left transverse sinus DAFV

Occipital artery

Cerebral angiogram (sagital view) Cognard Type IIA: Located in main sinus,
reflux into sinus but not cortical veins.
Differential diagnosis:

- Mixed pial-dural AVM:

• True pial supply to DAVF is rare.
• Usually occurs with large posterior fossa or superficial
hemispheric AVM.

- Thrombosed dural sinus:

• Collateral/congested venous drainage can mimic DAVF.

• Can be spontaneous, traumatic, infectious (thrombophlebitis).

- Vascular neoplasm:

• Acutely thrombosed DAVF may enhance, have edema/mass

effect, mimic a neoplasm.
• Neoplasms usually do not invade dura, but cause sinus
thrombosis.
The most widely used classification are Cognard and Borden.
Classification is based on the correlation between the angiographic characteristics of the DAVFs and
their clinical presentation.

• Cognard classification is based on:

- direction of dural sinus drainage.
- the presence or absence of CVR (cortical venous reflux).
- the venous outflow architecture (nonectatic cortical veins, ectatic cortical
veins, or spinal perimedullary veins).

• Cognard classification enables accurate comparison of clinical and radiological

parameters:
- Lack of CVR (Cognard types I and IIa) is associated with a benign
natural history with a low risk of intracranial hemorrhage.
- Presence of CVR (Cognard type IIb-V) is an aggressive feature and is
associated with a high risk of hemorrhage.
COGNARD CLASSIFICATION OF DAVF
Anterograde drainage into sinus.

IIA Drainage into main sinus with reflux into secondary sinus.

IIB Drainage into main sinus with reflux into cortical veins.

IIA + IIB Drainage into main sinus with reflux into secondary sinus(es) and
cortical veins.
Direct cortical venous drainage without ectasia

Direct cortical drainage with venous ectasia

Drainage into the spinal perimedullary veins.

DAVF at sigmoid sinus: Cognard type I. Angiography shows arteriovenous fistula at the sigmoid sinus, depending on the dural branches of
the external carotid, specifically the occipital, with only anterograde venous drainage into the left sigmoid sinus.

SAGITTAL VIEW CORONAL VIEW

• Borden classification is based on:
- the site of venous drainage.
- the presence of cortical venous reflux (CVR).
- number of fistulas (single-hole or multiple-hole fistulas).
• Simplicity without loss of predictability.
• Borden type I DAVFs have a benign clinical course and a high rate of spontaneous
remission.

BORDEN CLASSIFICATION OF DAVF

Venous drainage directly into dural venous sinus or meningeal vein.

Venous drainage into dural venous sinus with cortical venous reflux

Venous drainage directly into cortical veins.

o Conservative treatment: In DAVFs with benign course: symptomatic treatment and
supportive measures.

o Endovascular embolization.

o Surgical resection: Indicated only in cases where endovascular approaches have failed
or are not feasible.

o Stereotaxic radiosurgery: Reserved for carefully selected DAVFs for which

endovascular and surgical options have been exhausted.
The risk of hemorrhage remains during the latency period until the vessel thromboses and
the fistula closes, so it is inappropriate as the primary treatment in hemorrhagic DAVFs
due to the high risk of rebleeding.
 o Endovascular embolization using transarterial or transvenous approaches has become
ENDOVASCULAR TREATMENT PROCEDURE
a first-line treatment for DAVFs, especially since the advent of ONYX ® (eV3; Neu-
rovascular Inc., Irvine, CA, USA).

o The goal is complete and definitive angiographic fistula obliteration.

o To obtain complete obliteration of the fistula or satisfactory flow reduction with

suppression of CVR, some lesions need multiple microcatheter embolization or
multiple treatment sessions.

o Transvenous embolization with detachable coils and/or in combination with ONYX ®

is possible when transarterial embolization is unavailable.

o The balloon-assisted flow control technique is an effective method for high-flow

DAVFs.

o Angiographic follow-up 3 to 9 months after treatment.

PROCEDURE DETAILS I:

1- Patients need general anesthesia and anticoagulation during the treatment.

2- Transarterial approach (via femoral artery) using a 6F guiding catheter.

3- Cerebral angiogram required to confirm the diagnosis, determine angiographic

characteristics, and assist treatment planning.

4- Using a roadmapping technique, a microcatheter (in our center Marathon microcatheter

(EV3, Irvine, CA)) is coaxially navigated through the guiding catheter into a selected
feeding artery.

5- A microguidewire helps advance the microcatheter until it reaches or comes as close as

possible to the fistula.
ENDOVASCULAR TREATMENT PROCEDURE
PROCEDURE DETAILS II:

6- Superselective angiography: to reveal the focal angioarchitecture and dynamic

flow characteristics of the fistula.

7- Endovascular material (EVOH (Ethilene Vinyl Alcohol (ONYX ®)) / Nbutyl-2-

cyanoacrylate, NBCA) and concentration of the embolized material to use is based
on the distance from the fistula, flow velocity of the shunt, and risk of venous
migration. Sometimes coil placement is necessary to decrease the flow velocity
at the fistula before injecting the liquid embolic agent.

8- Injection of ONYX ® : it is intermittently injected until the proximal draining

veins are completely filled, thereby completely obliterating the fistula.
DAVF of superior Treament with EVOH (Ethilene Control shows complete
longitudinal sinus Vinyl Alcohol (ONYX ®)) embolization of the DAVF.
 CORONAL SAGITTAL
VIEW VIEW

Angiogram shows DAVF of the left

sigmoid-transverse sinus.
Anterograde drainage from multiple
veins toward the left sigmoid-
transverse sinus and retrograde
drainage into parietal superficial
cortical veins, which are markedly
tortuous and collateralized toward
the superior longitudinal sinus.
Cerebral angiogram (lateral view): Cognard Type IIB DAVF of the left sigmoid-
transverse sinus.
 CORONAL VIEW
Same patient as before, after treatment with ONYX ®

BEFORE ONYX ® AFTER

DAVF in the left sigmoid-transverse sinus was embolized with ONYX ®

through a 6F guide catheter, together with a microcatheter in the left occipital
artery, a branch of the external carotid artery. About 70% of the DAVF was embolized with
ONYX ®; but some cortical reflux remains after
treatment
 Same patient as before, evolving to Cognard IV ( Direct cortical
drainage with venous ectasia)

CORONAL SAGITTAL
VIEW VIEW
 COGNARD TYPE III PREONYX ® : Direct cortical venous drainage without ectasia

SAGITTAL
VIEW

A direct arteriovenous communication through arteriovenous microconnections at

the level of the left anterior parietal cortical vein (near the superior longitudinal
CORONAL sinus), with arterial afferents depending on the right occipital and left medial
VIEW meningeal , drained by multiple veins through parietal cortical veins that drain the
left sigmoid sinus and the superior longitudinal sinus.
 COGNARD TYPE III POST ONYX ®

Superselective embolization of the left medial meningeal artery with ONYX ® delivered by a microcatheter and a
microguide.
 COGNARD TYPE III POSTONYX ®

REMEMBER: COGNARD TYPE III PREONYX ®

: Direct cortical venous drainage without
ectasia

Complete embolization of a DAVF of the left

parietal cortical vein with ONYX ®
DAVFs are uncommon, and their pathophysiology is complex.

We hope this presentation has made them easier to understand and that you have
learned what to account in the general radiologic differential diagnosis.

When the multidisciplinary team decides on treatment, endovascular treatment is

the first choice.

Treatment should be tailored to each patient and his or risk factors.

The liquid embolic agent ONYX ® is the safe and efficacious, making it our first
choice for these lesions.
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