March-April 2019
from Vollherbst DF, Ulfert C, Neuberger U, et al. Endovascular Treatment of Dural arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus. AJNR Am J Neuroradiol. 2018 July.

Intracranial Dural Arteriovenous Fistulas: Endovascular Treatment Approaches

Philipp Gölitz

Philipp Gölitz

Cerebral dural arteriovenous fistulas (dAVFs) are characterized by pathologic direct shunts between dural arteries and veins or a venous sinus, with the fistula point or zone located at the dural level. Most often they are found at the wall of the transverse sinus (50%), the cavernous sinus (16%), the superior sagittal sinus (8%), or at the tentorium cerebelli (12%).1 dAVFs are an acquired disease, probably based on (transient) venous thrombosis inducing venous hypertension and subsequently progressive arterialization of the venous vessel wall.

Microvascular connections within the dura might be intrinsic2 and become activated and later hypertrophied, or might be a result of neovascularization3 promoted by angiogenic growth factors. Most practically, dAVFs are classified according to Borden et al4 and Cognard et al,5 with higher grades indicating an increased risk for cerebral hemorrhage. Due to technical innovations like the development of compliant, inflatable occlusion balloons and liquid embolic agents, endovascular embolization has been established as the first-line treatment for dAVFs. Basically, sinus-preserving and sinus-occluding embolization techniques can be distinguished.

The occlusion of a dural sinus, however, carries a risk of venous infarction or hemorrhage. The sinus-preserving technique by transarterial embolization with liquid embolics requires superselective catheterization of arterial feeders to deliver the embolic agent. Onyx (Covidien, Irvine, California) has been widely used as a liquid embolic agent for transarterial embolization,6-8 allowing considerable penetration and casting of the fistula site, but also harboring the risk of accidental embolization of the distal venous system, which may result in the exacerbation of venous hypertension, venous infarction, and/or hemorrhage. Sinus-occluding techniques are still effective treatment options, with a high rate of definite fistula occlusion, but at the cost of a relevant, … more »


Endovascular Treatment of Dural Arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus

Markus A. Möhlenbruch, MD

Markus A. Möhlenbruch


Dominik Vollherbst, MD

Dominik Vollherbst

Endovascular therapy has become the treatment of choice for most dural arteriovenous fistulas (dAVFs) and has considerably improved in recent years, which can be attributed to—among other factors—the introduction of new treatment techniques. A variety of endovascular treatment techniques are currently being used, such as a transarterial, transvenous, or combined approach. In special situations, especially in patients with lateral … more »


Endovascular Treatment of dAVF of the Transverse and Sigmoid Sinus Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

Pasquale Mordasini, MD

Pasquale Mordasini

Over the past few decades, endovascular embolization has become the first-line treatment for a wide range of dural arteriovenous fistulas. Treatment of dural arteriovenous fistulas of the transverse and sigmoid sinuses by endovascular means offers a minimally invasive treatment approach; however, it is often challenging due to the anatomic complexity of the lesions. Several transarterial and transvenous endovascular approaches have been advocated, including sacrificing the recipient sinus by occlusion.

Transvenous balloon protection of the recipient venous sinus using large, compliant, dedicated dimethyl sulfoxide-resistant balloons has … more »


Toward a Better Understanding of Dural Arteriovenous Fistula Angioarchitecture: Superselective Transvenous Embolization of a Sigmoid Common Arterial Collector

Maksim Shapiro MD

Maksim Shapiro


Eytan Raz MD PhD

Eytan Raz

How well do we understand the anatomy of dural arteriovenous fistulas (dAVFs)? Where among the myriad vessels we see increasingly well on ever-advancing MR, CT, and volumetric angiographic images is the “seat of disease”?

Our paper reviews existing literature and our experience, suggesting that many transverse/sigmoid dAVFs consist of 1, or at most a limited number of, direct arteriovenous connection(s). The seemingly complex angioarchitecture of these lesions is proposed to represent myriad artery-to-artery … more »