Surgical strategies of cerebral arteriovenous malformations and dural arteriovenous fistulas

Abstract

Despite the recent advances in endovascular technique and stereotactic radiosurgery, microsurgery still remains an important treatment option for complex brain arteriovenous malformations (bAVMs) and dural arteriovenous fistulas (dAVFs).This article describes the surgical strategy and tactics for shunt point extirpation used for each entity. In bAVM surgery, the shunt point (nidus) is approached from the arterial side and staged shunt reduction followed by total extirpation is achieved by feeder disconnection and nidus removal. Conversely, a venous approach is used and targeted shunt extirpation is proposed simultaneously in dAVF surgery, using selective cortical drainer disconnection. This strategy can achieve total elimination of the arteriovenous shunt in patients with Borden type HI dAVF; and deaden critical cortical venous reflux in patients with Borden type II dAVF. The importance of understanding the difference in surgical strategies used between bAVM and dAVF surgery is discussed.