Surgical management of high-grade intracranial dural arteriovenous fistulas: Leptomeningeal venous disruption without nidus excision

OBJECTIVE: Of intracranial dural arteriovenous malformations (AVMs), those with cortical venous drainage pose the greatest risk of hemorrhaging. Given recent advances in endovascular, surgical, and radiosurgical techniques, the optimal management of these dural AVMs is controversial. For surgical candidates, the choice of intraoperative techniques remains unclear. Several authors have suggested that surgical clipping of the draining vein close to the nidus of dural AVMs can provide adequate treatment for some lesions. However, recent reports have also promoted partial or complete surgical resection of these lesions. METHODS: We present five cases of dural AVMs with cortical venous drainage that were surgically treated by the senior author between 1993 and 1996, and we review their management, Our series includes two frontal, one temporal, and two occipital lesions. Three patients presented with intracerebral hemorrhages, one with headache and eye pain, and one without symptoms. All five patients demonstrated venous aneurysms associated with the AVMs. Two patients underwent incomplete endovascular embolization before surgery. Operative management in all cases involved clipping of the draining vein as close as possible to the AVMs, together with extensive cautery of the surrounding dura. RESULTS: Postoperative angiography demonstrated complete angiographic obliteration in all cases. The four symptomatic patients all experienced clinical improvement postoperatively. The asymptomatic patient remained asymptomatic. With a mean follow-up period of 29 months, no patient has developed recurrent symptoms. CONCLUSION: Surgical clipping of the draining vein close to dural AVMs has proven safe and effective in our experience. Given the highly vascular nature of dural AVMs, often near major dural sinuses, surgical resection of these lesions may not be indicated.