How is dural arteriovenous fistula treated?

Author: Jiang Chuhan, Chief Physician, Beijing Tiantan Hospital, Capital Medical University

Reviewer: Xu Jun, Chief Physician, Beijing Tiantan Hospital, Capital Medical University

There are three treatment methods for dural arteriovenous fistula: conservative treatment, interventional treatment, surgery and gamma knife-assisted treatment.

Among them, conservative treatment is mainly suitable for cases where symptoms are not very serious, such as dural arteriovenous fistula in the cavernous sinus area. Although there is a little exophthalmos and the eyes are a little red, there is no intracranial cortical venous drainage and the symptoms are not very serious. Conservative treatment can be carried out with regular follow-up.

For example, the dural arteriovenous fistula in the transverse sinus-sigmoid sinus area has the same drainage as the normal brain tissue drainage, without reflux and with some mild, tolerable intracranial murmurs, which can also be treated conservatively.

There are also some areas, such as the foramen magnum area, which we also call the dura mater arteriovenous fistula at the head and neck junction. Interventional treatment can easily cause brainstem damage or posterior cranial nerve damage, so if it is not very serious, choose conservative treatment.

For patients who choose conservative treatment and have no changes in symptoms, they can generally have a follow-up examination once a year. The follow-up examination mainly includes MRI, CT scan, and cerebrovascular examinations, such as MRA (magnetic resonance angiography) or CTA (CT angiography).

Figure 1 Original copyright image, no permission to reprint

If the patient is doing conservative treatment by himself, he can lie down, bend his neck slightly, and then use the healthy hand to press the pulsation of the affected carotid artery. Then put the affected hand on the tragus, and touch the superficial temporal artery pulsating in front of the tragus. You can feel the pulsation of this small artery. After pressing the carotid artery with your hand, when you feel the pulsation at the tragus weaken, become lighter, or disappear, it means that the compression is effective.

As long as there are no discomfort symptoms, some patients can be cured by this method by applying pressure more than 3-4 times a day, each time for more than 30 minutes.

In addition to pressing by yourself, you can also ask your family to do it. The method is the same. Someone else helps him press and touch the position in front of the tragus to judge whether the pressure is applied or not. Many patients can be cured through this method.

After compression, the symptoms are relieved, and finally, through imaging examinations, such as cerebral angiography, CTA (CT angiography), or MRA (magnetic resonance angiography), it is found that there is no fistula, and anatomical cure can be achieved.

Another thing is that neck compression is mainly used to treat dural arteriovenous fistula in the cavernous sinus area. There is a phenomenon that must be paid attention to. When pressing the neck, the symptoms will worsen at a certain stage. The exophthalmos will be more severe than before, and the eyes will be redder, so some patients are often afraid and dare not press. In fact, this is the time to use neck compression. You must persist. After persisting for this period of time, the symptoms will be relieved.

If the doctor determines that conservative treatment is not suitable or that conservative treatment is ineffective, interventional treatment will be performed. Interventional treatment is the preferred treatment for dural arteriovenous fistula.

Figure 2 Original copyright image, no permission to reprint

The principle of treatment is to reach the fistula through the blood vessels and eliminate the communication between the artery and vein. Generally, a spring coil or glue is used to eliminate this communication, and it is considered a cure.

The interventional methods include arterial approach, venous approach, and sometimes direct puncture approach.

The arterial approach is generally through cannulation of the femoral artery, insertion of a microcatheter into the blood supply artery, and then injection of glue and filling of spring coils to eliminate the communication between the artery and vein.

Sometimes the arterial pathway is very tortuous and there are many blood supplying arteries, so the treatment cannot be completed through the arteries. In this case, we have to "take a back road" and reach the fistula site through the venous system, fill in spring coils, apply glue, and then eliminate the arteriovenous connection.

In some cases, the arterial route is not accessible, and the venous route is also difficult to reach the site of the fistula. What should we do? Then we can use the direct puncture method to reach the site of the fistula, and then fill the coil and glue to eliminate the arteriovenous connection. The direct puncture method is generally used in the cavernous sinus. We call it transorbital puncture, which is punctured directly from under the eye. This method can also be used to perform arteriovenous fistula surgery.

For arteriovenous fistulas that cannot be cured by various methods, or that have recurred after interventional treatment and it is difficult to do interventional treatment again, the arteriovenous fistula can be clipped by surgery, or gamma knife irradiation can be used, that is, radiation therapy is used to eliminate the communication between the artery and vein and eliminate the fistula.

However, neither surgery nor gamma knife is the main treatment for dural arteriovenous fistula. Interventional treatment is still the preferred treatment.