Iatrogenic and traumatic Dural arteriovenous fistulas: Illustrative cases and literature review

Dural arteriovenous fistulas (dAVFs) are a type of vascular malformation that form within the dura mater. Though historically considered rare, their detection is expected to increase with the broader use of advanced cerebral angiography techniques. We describe two 80-year-old men presented for neurovascular procedures. The first, following an emergency craniotomy for subdural hematoma (SDH) evacuation, underwent middle meningeal artery embolization (MMAE). During the procedure, an incidental, asymptomatic middle meningeal artery and superficial temporal artery to superior sagittal sinus (MMA/STA-SSS) dAVF was identified ipsilateral to the original surgical site. Given the fistula's low-risk nature, a conservative, watchful waiting approach was chosen. The second patient, undergoing digital subtraction angiography (DSA) for subarachnoid hemorrhage (SAH), was found to have an MMA-fed dAVF. Due to the unclear causality of this fistula with the concurrent SAH and subdural hematoma (SDH), MMAE was performed to treat the dAVF. With the increasing use of cerebral angiography techniques such as MMAE and DSA for a broader range of indications, the incidence of incidentally and unexpectedly discovered dAVFs is expected to increase. Clinicians should become well-versed in recognizing this condition, treatment indications, and the various management options available, including endovascular embolization, radiosurgery, microsurgery, and serial monitoring.