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Dural Arteriovenous Fistula

Summary

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  • Abnormal connection between dural arteries and venous sinuses or cortical veins
  • Presents with pulsatile tinnitus, headache, or intracranial haemorrhage
  • Diagnosed by catheter angiography; treated with endovascular embolisation or surgery1

Pathophysiology

  • Acquired lesions resulting from:
    • Venous sinus thrombosis
    • Trauma
    • Surgery
    • Hypercoagulable states
  • Classified by Cognard or Borden systems based on venous drainage pattern
  • Increased risk of intracranial haemorrhage with cortical venous drainage

Demographics

  • Incidence: 0.15-0.29 per 100,000 person-years
  • Peak age: 50-60 years
  • Slight female predominance
  • Higher incidence in postmenopausal women and pregnancy

Diagnosis

  • Clinical presentation:
    • Pulsatile tinnitus
    • Headache
    • Intracranial haemorrhage
    • Seizures
    • Neurological deficits
  • Bruit on auscultation over mastoid or orbit
  • Catheter angiography: gold standard for diagnosis and classification

Imaging

  • CT:
    • Nonspecific findings
    • May show dilated vessels, venous sinus thrombosis, or haemorrhage
  • CT angiography:
    • Demonstrates abnormal arterial feeders and early venous filling
    • Limited in detecting small fistulas
  • MRI:
    • Flow voids representing enlarged vessels
    • T2 hyperintensity in white matter (venous congestion)
    • Susceptibility-weighted imaging: prominent cortical veins
  • MR angiography:
    • Time-of-flight and contrast-enhanced techniques
    • Shows abnormal arterial feeders and early venous filling
  • Catheter angiography:
    • Definitive diagnosis and classification
    • Identifies arterial feeders, fistula location, and venous drainage pattern

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  • A 60-year-old patient presented with headache.
  • An MRI on admission showed a dilated vessel in the posterior fossa with a rim of oedema within the cerebellum.
  • Immediately after the MRI, the patient's headache worsened and a CTA showed haemorrhage around the dural arteriovenous fistula that was supplied by the PICA.

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  • A 60-year-old patient presented with headache and ataxia.
  • The arterial phase of the DSA showed an abnormal vessel arising from the PICA draining into a dilated vein.

Treatment

  • Cortical venous drainage (Cognard IIb+) is the key indication for treatment, usually by endovascular (often transvenous) embolisation
  • Low-grade fistulas without cortical reflux may be observed

Differential diagnosis

Imaging differential Differentiating feature
Arteriovenous malformation Parenchymal nidus supplied by pial arteries, rather than a direct dural shunt
Pial arteriovenous fistula Direct artery-to-vein shunt within the parenchyma, pial rather than dural supply
Carotid-cavernous fistula Shunt into the cavernous sinus with a dilated superior ophthalmic vein and proptosis
Dural venous sinus thrombosis Sinus filling defect without arterial feeders (though it can cause a fistula)
Vascular tumour (e.g. haemangiopericytoma) Enhancing dural mass rather than a network of shunting vessels

  1. Alkhaibary et al. Intracranial dural arteriovenous fistula: a comprehensive review of the history, management, and future prospective. 2023. Acta neurologica Belgica - Open in new tab. ↩