Three-dimensional computed tomography angiography in presurgical planning for treatment of infratentorial dural arteriovenous fistulas

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Dural arteriovenous fistulas (DAVFs) with pure leptomeningeal drainage may be cured by simple interruption of their venous side. This report illustrates the cases of 3 patients undergoing surgery for fistulas classified as Borden Type III, involving the posterior cranial fossa. Preoperatively, the surgical anatomy of these lesions was investigated with 3D reformatting of multislice CT angiography, in addition to conventional angiography. Reformatted images clarified the surgical anatomy of the malformation. Reconstructing both the osseous and the vascular structures and simulating the surgical orientation allowed localization of the dural takeoff point of the DAVF's drainage, showing its relationship with osseous landmarks. Precise localization of the DAVF's drainage may help in choosing the most direct and effective approach to treat the malformation. The reported cases could be treated with a standard retrosigmoid exposure, avoiding the need for more complex cranial base approaches.

Abbreviations used in this paper: CPA = cerebellopontine angle; DAVF = dural arteriovenous fistula; ECA = external carotid artery; IAM = internal auditory meatus.

Abstract

Dural arteriovenous fistulas (DAVFs) with pure leptomeningeal drainage may be cured by simple interruption of their venous side. This report illustrates the cases of 3 patients undergoing surgery for fistulas classified as Borden Type III, involving the posterior cranial fossa. Preoperatively, the surgical anatomy of these lesions was investigated with 3D reformatting of multislice CT angiography, in addition to conventional angiography. Reformatted images clarified the surgical anatomy of the malformation. Reconstructing both the osseous and the vascular structures and simulating the surgical orientation allowed localization of the dural takeoff point of the DAVF's drainage, showing its relationship with osseous landmarks. Precise localization of the DAVF's drainage may help in choosing the most direct and effective approach to treat the malformation. The reported cases could be treated with a standard retrosigmoid exposure, avoiding the need for more complex cranial base approaches.

Dural arteriovenous fistulas draining into subarachnoid veins are associated with an aggressive clinical history.1–4,7,15 Depending on clinical data and the location and pattern of venous drainage of the malformation, either surgery or endovascular embolization is currently used to obliterate the shunt.10,21 Surgical interruption of the venous side of the malformation is a simple and effective therapy for most intracranial DAVFs without involvement of major dural sinuses.3,5,19 Understanding the exact location of the fistulous tract is a key factor in selecting the proper surgical approach. Location of the fistulous tract in relation to the dura mater and bone structures can be difficult to pinpoint using catheter angiography alone. The presence of tortuous, dilated veins superimposed on the fistula, combined with the high flow rate, can obscure the exact point of communication. Precise presurgical localization of the fistula is particularly useful in treating lesions of the cranial base, an anatomical area in which minor modifications of a working perspective often correspond to different surgical approaches. We describe 3 patients who were treated with disconnection of DAVFs involving the posterior cranial fossa. In these 3 patients, 3D CT angiography allowed presurgical visualization of the fistula in relation to the osseous anatomy, thus facilitating our choice of the proper surgical approach.

Illustrative Cases

Case 1

History and Examination

This 48-year-old man was admitted after subacute onset of severe tetraparesis, dyspnea, dysphagia, and sphincter paralysis. On MR imaging, T2-weighted sequences showed hyperintensity within the medulla oblongata, with flow voids surrounding the bulbomedullary surface (Fig. 1A). Conventional angiography disclosed an early shunt between a tentorial branch of the ECA and an intracranial vein crossing the posterior fossa, down to the level of the foramen magnum, eventually bifurcating into a posterior and an anterior longitudinal spinal vein (Fig. 1B). Dural sinuses were not recruited by the shunt. A CT angiography study with 3D images (reconstructed without subtracting the bone and rotated to simulate a posterior perspective) showed the DAVF's draining vein arising from the petrous surface between the IAM and the superior petrosal sinus and running inferiorly through the CPA (Fig. 1C).

Fig. 1.
Fig. 1.

Case 1. A: Preoperative T2-weighted sagittal MR image showing diffuse hyperintensity of the bulbomedullary junction with flow-void images surrounding the surface of the cervical spinal cord. B: Cerebral angiogram obtained after injection of the left ECA. Tentorial branches (single arrow) of the middle meningeal artery supply a dural shunt in the region of the tentorial hiatus. A single efferent vessel runs inferiorly with a straight course in the region of the foramen magnum (double arrow). C: Three-dimensional CT angiogram, arterial phase, showing the malformation as seen from a left retrosigmoid perspective. The draining vein (DV) arises from the petrous surface immediately above the IAM, and runs inferiorly through the foramen magnum (FM). The superior lip of the IAM is hyperostotic. D: Intraoperative photograph (left retrosigmoid craniotomy) showing the arterialized vein emerging, as expected, between the tentorium and the IAM. The hyperostosis shown on CT angiography is also evident. E: Postoperative angiogram obtained after injection of the left ECA, showing disappearance of the shunt. AICA = anterior inferior cerebellar artery; M = mastoid tip; V cn = fifth cranial nerve.

Operation

A standard retrosigmoid approach was used. As anticipated based on the CT angiogram, the arterialized vein was seen emerging from the posterior surface of the petrous bone just above the IAM (Fig. 1D). The vessel was secured with an aneurysm clip as it entered the subarachnoid space. Within 1 minute, the vein turned blue.

Postoperative Course

On postoperative angiography, the fistula was no longer visible (Fig. 1E). Two months after surgery, the patient experienced significant motor recovery of the upper limb strength but only minimal improvement of the paraparesis.

Case 2

History and Examination

This 46-year-old man presented with a 10-day history of burning dysesthesia in the left hemiface and with peripheral left facial palsy. An admission CT scan disclosed a complex vascular lesion in the left CPA, with an ectatic structure compressing the brainstem (Fig. 2A). An MR imaging study confirmed this finding. Conventional angiography showed a DAVF fed by external and internal carotid artery branches. The lesion drained intradurally through a single vein, which dilated into a large varix before emptying into the galenic venous system (Fig. 2B). Three-dimensional CT angiography reconstructions confirmed a single draining vein and localized its intradural takeoff point along the inferior surface of the tentorium. A postdilation stenosis was also evident (Fig. 2C).

Fig. 2.
Fig. 2.

Case 2. A: Preoperative CT scan obtained after contrast administration, showing a large vascular lesion effacing the left CPA and compressing the brainstem. B: Cerebral angiogram obtained after injection of the left ECA. Branches from the middle meningeal artery give rise to a thick dural network in the region of the tentorium (single arrow). There is early filling of a large varix, which empties into the sinus rectus through a tortuous vein (double arrow). C: Three-dimensional CT angiogram, arterial phase, showing the surgical anatomy of the malformation as seen from a left retrosigmoid perspective. The superior rim of the petrous ridge indicates the position of the tentorium. The large varix (V) is filled by a draining vein (takeoff point indicated by arrow) emerging from the tentorium superior and slightly anterior to the IAM. The varix empties into a tortuous vein with a focal stenosis (S). D: Intraoperative photograph (left retrosigmoid craniotomy) showing that after emerging from the tentorium, as anticipated based on CT angiography, a single draining vein dilates into a varix, which obliterates the left posterior cranial fossa. The fifth cranial nerve (V cn) is stretched over the wall of the venous ectasia. E: Intraoperative photograph showing that after clipping of the venous pedicle, the venous ectasia becomes pale and softer. F: Postoperative angiogram obtained after injection of the left ECA, showing disappearance of the malformation.

Operation and Postoperative Course

Via a standard retrosigmoid approach, the proximal portion of the draining vein was readily identified beneath the tentorium (Fig. 2D). After closing the vessel with 2 aneurysm clips, the remaining part of the venous compartment collapsed and became pale (Fig. 2E). After surgery, the facial nerve function improved. Postoperative angiography showed resolution of the malformation (Fig. 2F).

Case 3

History and Examination

This 58-year-old man was evaluated because of a long-standing history of rightsided, continuous facial pain, which had become more intense in the few months preceding evaluation. Results of MR angiography suggested the presence of an arteriovenous malformation. A conventional cerebral angiogram revealed the lesion to be a DAVF fed by tentorial branches of the meningohypophyseal trunk and dural branches of the occipital artery (Fig. 3A). The venous drainage was through the petrosal vein into the lateral mesencephalic vein, basal vein, and into the vein of Galen (Fig. 3A). Three-dimensional CT angiography clearly visualized the point of fistulization right along the superior petrosal sinus posterior and superior to the IAM (Fig. 3B).

Fig. 3.
Fig. 3.

Case 3. A: Cerebral angiogram, right ECA injection. Feeders from the occipital artery converge at a dural nidus (single arrow). A single efferent vessel (double arrow) reaches the galenic venous system, finally emptying into the sinus rectus (arrowhead). B: Three-dimensional CT angiogram of the cranial base as seen from above. The takeoff point (arrow) of the draining vein is above and behind the IAM. The sinus rectus (SR), draining the malformation, is visible in the arterial phase. C: Intraoperative photograph showing, as expected, that the drainage is found immediately beneath the tentorium (T). D: Postoperative angiogram obtained after injection of the right ECA, showing disappearance of the malformation. MCF = middle cranial fossa.

Operation and Postoperative Course

The lesion was approached via a standard retrosigmoid approach. The large draining vein was identified as it emerged from the dura mater (Fig. 3C), and it was closed with 2 permanent aneurysm clips. Postoperative cerebral angiograms confirmed obliteration of the fistula (Fig. 3D). The patient noted immediate resolution of his facial pain and made an uneventful recovery.

Discussion

Borden Type III fistulas2 can be permanently cured by simple interruption of their leptomeningeal drainage.3,5,8,9,17,20 Surgical disconnection can usually be achieved without difficulties once the proper site of fistulization is identified. Therefore, correct exposure of the vein itself represents the key step of the procedure. This issue is even more relevant for lesions involving the posterior cranial fossa, an area in which minor modifications of a working perspective often correspond to different surgical approaches. Accordingly, different types of cranial base approaches have been used to treat posterior fossa DAVFs.6,11,23 Nevertheless, the presurgical criteria leading to the choice of a specific approach have not always been detailed. Conventional neuroimages as well as the surgeon's personal experience were probably the main factors affecting the decision-making process.

Catheter angiography is essential to understanding the flow dynamics of the malformation and to ascertain its fistulous nature and the number of draining veins. However, precise topographical localization of the DAVF's drainage and its relationship with the skull base is not always immediately apparent on conventional angiograms alone. Noninvasive techniques like MR imaging and CTbased angiography are used with increasing frequency to improve diagnosis of intracranial DAVFs.12–14 Renner and colleagues18 reported the use of MR angiography to localize a tentorial DAVF. This technique might suffer 2 limitations that could potentially compromise the accuracy of surgical planning: 1) the bidimensional nature of MR angiography images and 2) the suboptimal visualization of bone landmarks adjacent to the draining vein. Intraoperative neuronavigation is an appealing adjunct to preoperative imaging planning. A recent report, however, found it to be beneficial only for small, superficial DAVFs. Localization of deep-seated lesions was less accurate due to brain shift and brain retraction.22 Three-dimensional rotational angiography has also been described as a localizing tool in the surgery of spinal DAVFs,16 but its use in intracranial fistulas has not been investigated.

In our 3 patients, reformatted CT angiography proved to be a straightforward procedure. Because it is entirely based on data post-processing, it may easily integrate a standard spiral CT study. To highlight the surgical anatomy of the malformation, the key step of the procedure is including both the vascular and the bone anatomy in the reconstruction. In this way, a properly rotated reconstruction may effectively simulate a surgical perspective. In the cases we describe here, this method localized the surgical target infratentorially, immediately above the IAM, which is an area normally exposed by a standard retrosigmoid approach. This was valuable information because it ruled out the need for more complex cranial base approaches. Based on this experience, we believe that 3D CT angiography should be used in addition to conventional angiography as part of the routine presurgical workup of these lesions.

Disclaimer

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Acknowledgments

The authors thank Mrs. Francesca Cotugno for her precious support in the management of 2 reported cases.

References

  • 1

    Awad IALittle JRAkarawi WPAhl J: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:8398501990

  • 2

    Borden JAWu JKShucart WA: A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82:1661791995

  • 3

    Brown RD JrWiebers DONichols DA: Intracranial dural arteriovenous fistulae: angiographic predictors of intracranial hemorrhage and clinical outcome in nonsurgical patients. J Neurosurg 81:5315381994

  • 4

    Collice MD'Aliberti GArena OSolaini CFontana RATalamonti G: Surgical treatment of intracranial dural arteriovenous fistulae: role of venous drainage. Neurosurgery 47:56 672000

  • 5

    Collice MD'Aliberti GTalamonti GBranca VBoccardi EScialfa G: Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage. J Neurosurg 84:8108171996

  • 6

    De Jesus ORosado JE: Tentorial dural arteriovenous fistula obliterated using the petrosal approach. Surg Neurol 51:1641671999

  • 7

    Duffau HLopes MJanosevic VSichez JPFaillot TCapelle L: Early rebleeding from intracranial dural arteriovenous fistulas: report of 20 cases and review of the literature. J Neurosurg 90:78841999

  • 8

    Fujita ATamaki NNakamura MYasuo KMorikawa M: A tentorial dural arteriovenous fistula successfully treated with interruption of leptomeningeal venous drainage using microvascular Doppler sonography: case report. Surg Neurol 56:56612001

  • 9

    Hoh BLChoudhri TFConnolly ES JrSolomon RA: Surgical management of high-grade intracranial dural arteriovenous fistulas: leptomeningeal venous disruption without nidus excision. Neurosurgery 42:7968051998

  • 10

    Kakarla UKDeshmukh VRZabramski JMAlbuquerque FCMcDougall CGSpetzler RF: Surgical treatment of highrisk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications. Neurosurgery 61:4474592007

  • 11

    Kattner KARoth TCGiannotta SL: Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases. Neurosurgery 50:115611612002

  • 12

    Kwon BJHan MHKang HSChang KH: MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns. AJNR Am J Neuroradiol 26:250025072005

  • 13

    Meckel SMaier MRuiz DSYilmaz HScheffler KRadue EW: MR angiography of dural arteriovenous fistulas: diagnosis and follow-up after treatment using a time-resolved 3D contrast-enhanced technique. AJNR Am J Neuroradiol 28:8778842007

  • 14

    Noguchi KMelhem ERKanazawa TKubo MKuwayama NSeto H: Intracranial dural arteriovenous fistulas: evaluation with combined 3D time-of-flight MR angiography and MR digital subtraction angiography. AJR Am J Roentgenol 182:1831902004

  • 15

    Pierot LChiras JMeder JFRose MRivierez MMarsault C: Dural arteriovenous fistulas of the posterior fossa draining into subarachnoid veins. AJNR Am J Neuroradiol 13:3153231992

  • 16

    Prestigiacomo CJNiimi YSetton ABerenstein A: Threedimensional rotational spinal angiography in the evaluation and treatment of vascular malformations. AJNR Am J Neuroradiol 24:142914352003

  • 17

    Reinges MHThron AMull MHuffmann BCGilsbach JM: Dural arteriovenous fistulae at the foramen magnum. J Neurol 248:1972032001

  • 18

    Renner CHelm JRoth HMeixensberger J: Intracranial dural arteriovenous fistula associated with progressive cervical myelopathy and normal venous drainage of the thoracolumbar cord: case report and review of the literature. Surg Neurol 65:5065102006

  • 19

    Thompson BGDoppman JLOldfield EH: Treatment of cranial dural arteriovenous fistulae by interruption of leptomeningeal venous drainage. J Neurosurg 80:6176231994

  • 20

    Ushikoshi SHoukin KKuroda SAsano TIwasaki YMiyasaka K: Surgical treatment of intracranial dural arteriovenous fistulas. Surg Neurol 57:2532612002

  • 21

    van Rooij WJSluzewski MBeute GN: Dural arteriovenous fistulas with cortical venous drainage: incidence, clinical presentation, and treatment. AJNR Am J Neuroradiol 28:6516552007

  • 22

    Vougioukas VICoulin CJShah MBerlis AHubbe UVan Velthoven V: Benefits and limitations of image guidance in the surgical treatment of intracranial dural arteriovenous fistulas. Acta Neurochir (Wien) 148:1451532006

  • 23

    Zhou LFChen LSong DLGu YXLeng B: Tentorial dural arteriovenous fistulas. Surg Neurol 67:4724822007

Article Information

Address correspondence to: Sergio Paolini, M.D., Department of Neurosurgery, Via G. A. Sartorio, 44–00147 Rome, Italy. email: spao2@yahoo.com.

Please include this information when citing this paper: published online October 3, 2008; DOI: 10.3171/2008.4.17515.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. A: Preoperative T2-weighted sagittal MR image showing diffuse hyperintensity of the bulbomedullary junction with flow-void images surrounding the surface of the cervical spinal cord. B: Cerebral angiogram obtained after injection of the left ECA. Tentorial branches (single arrow) of the middle meningeal artery supply a dural shunt in the region of the tentorial hiatus. A single efferent vessel runs inferiorly with a straight course in the region of the foramen magnum (double arrow). C: Three-dimensional CT angiogram, arterial phase, showing the malformation as seen from a left retrosigmoid perspective. The draining vein (DV) arises from the petrous surface immediately above the IAM, and runs inferiorly through the foramen magnum (FM). The superior lip of the IAM is hyperostotic. D: Intraoperative photograph (left retrosigmoid craniotomy) showing the arterialized vein emerging, as expected, between the tentorium and the IAM. The hyperostosis shown on CT angiography is also evident. E: Postoperative angiogram obtained after injection of the left ECA, showing disappearance of the shunt. AICA = anterior inferior cerebellar artery; M = mastoid tip; V cn = fifth cranial nerve.

  • View in gallery

    Case 2. A: Preoperative CT scan obtained after contrast administration, showing a large vascular lesion effacing the left CPA and compressing the brainstem. B: Cerebral angiogram obtained after injection of the left ECA. Branches from the middle meningeal artery give rise to a thick dural network in the region of the tentorium (single arrow). There is early filling of a large varix, which empties into the sinus rectus through a tortuous vein (double arrow). C: Three-dimensional CT angiogram, arterial phase, showing the surgical anatomy of the malformation as seen from a left retrosigmoid perspective. The superior rim of the petrous ridge indicates the position of the tentorium. The large varix (V) is filled by a draining vein (takeoff point indicated by arrow) emerging from the tentorium superior and slightly anterior to the IAM. The varix empties into a tortuous vein with a focal stenosis (S). D: Intraoperative photograph (left retrosigmoid craniotomy) showing that after emerging from the tentorium, as anticipated based on CT angiography, a single draining vein dilates into a varix, which obliterates the left posterior cranial fossa. The fifth cranial nerve (V cn) is stretched over the wall of the venous ectasia. E: Intraoperative photograph showing that after clipping of the venous pedicle, the venous ectasia becomes pale and softer. F: Postoperative angiogram obtained after injection of the left ECA, showing disappearance of the malformation.

  • View in gallery

    Case 3. A: Cerebral angiogram, right ECA injection. Feeders from the occipital artery converge at a dural nidus (single arrow). A single efferent vessel (double arrow) reaches the galenic venous system, finally emptying into the sinus rectus (arrowhead). B: Three-dimensional CT angiogram of the cranial base as seen from above. The takeoff point (arrow) of the draining vein is above and behind the IAM. The sinus rectus (SR), draining the malformation, is visible in the arterial phase. C: Intraoperative photograph showing, as expected, that the drainage is found immediately beneath the tentorium (T). D: Postoperative angiogram obtained after injection of the right ECA, showing disappearance of the malformation. MCF = middle cranial fossa.

References

1

Awad IALittle JRAkarawi WPAhl J: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:8398501990

2

Borden JAWu JKShucart WA: A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82:1661791995

3

Brown RD JrWiebers DONichols DA: Intracranial dural arteriovenous fistulae: angiographic predictors of intracranial hemorrhage and clinical outcome in nonsurgical patients. J Neurosurg 81:5315381994

4

Collice MD'Aliberti GArena OSolaini CFontana RATalamonti G: Surgical treatment of intracranial dural arteriovenous fistulae: role of venous drainage. Neurosurgery 47:56 672000

5

Collice MD'Aliberti GTalamonti GBranca VBoccardi EScialfa G: Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage. J Neurosurg 84:8108171996

6

De Jesus ORosado JE: Tentorial dural arteriovenous fistula obliterated using the petrosal approach. Surg Neurol 51:1641671999

7

Duffau HLopes MJanosevic VSichez JPFaillot TCapelle L: Early rebleeding from intracranial dural arteriovenous fistulas: report of 20 cases and review of the literature. J Neurosurg 90:78841999

8

Fujita ATamaki NNakamura MYasuo KMorikawa M: A tentorial dural arteriovenous fistula successfully treated with interruption of leptomeningeal venous drainage using microvascular Doppler sonography: case report. Surg Neurol 56:56612001

9

Hoh BLChoudhri TFConnolly ES JrSolomon RA: Surgical management of high-grade intracranial dural arteriovenous fistulas: leptomeningeal venous disruption without nidus excision. Neurosurgery 42:7968051998

10

Kakarla UKDeshmukh VRZabramski JMAlbuquerque FCMcDougall CGSpetzler RF: Surgical treatment of highrisk intracranial dural arteriovenous fistulae: clinical outcomes and avoidance of complications. Neurosurgery 61:4474592007

11

Kattner KARoth TCGiannotta SL: Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases. Neurosurgery 50:115611612002

12

Kwon BJHan MHKang HSChang KH: MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns. AJNR Am J Neuroradiol 26:250025072005

13

Meckel SMaier MRuiz DSYilmaz HScheffler KRadue EW: MR angiography of dural arteriovenous fistulas: diagnosis and follow-up after treatment using a time-resolved 3D contrast-enhanced technique. AJNR Am J Neuroradiol 28:8778842007

14

Noguchi KMelhem ERKanazawa TKubo MKuwayama NSeto H: Intracranial dural arteriovenous fistulas: evaluation with combined 3D time-of-flight MR angiography and MR digital subtraction angiography. AJR Am J Roentgenol 182:1831902004

15

Pierot LChiras JMeder JFRose MRivierez MMarsault C: Dural arteriovenous fistulas of the posterior fossa draining into subarachnoid veins. AJNR Am J Neuroradiol 13:3153231992

16

Prestigiacomo CJNiimi YSetton ABerenstein A: Threedimensional rotational spinal angiography in the evaluation and treatment of vascular malformations. AJNR Am J Neuroradiol 24:142914352003

17

Reinges MHThron AMull MHuffmann BCGilsbach JM: Dural arteriovenous fistulae at the foramen magnum. J Neurol 248:1972032001

18

Renner CHelm JRoth HMeixensberger J: Intracranial dural arteriovenous fistula associated with progressive cervical myelopathy and normal venous drainage of the thoracolumbar cord: case report and review of the literature. Surg Neurol 65:5065102006

19

Thompson BGDoppman JLOldfield EH: Treatment of cranial dural arteriovenous fistulae by interruption of leptomeningeal venous drainage. J Neurosurg 80:6176231994

20

Ushikoshi SHoukin KKuroda SAsano TIwasaki YMiyasaka K: Surgical treatment of intracranial dural arteriovenous fistulas. Surg Neurol 57:2532612002

21

van Rooij WJSluzewski MBeute GN: Dural arteriovenous fistulas with cortical venous drainage: incidence, clinical presentation, and treatment. AJNR Am J Neuroradiol 28:6516552007

22

Vougioukas VICoulin CJShah MBerlis AHubbe UVan Velthoven V: Benefits and limitations of image guidance in the surgical treatment of intracranial dural arteriovenous fistulas. Acta Neurochir (Wien) 148:1451532006

23

Zhou LFChen LSong DLGu YXLeng B: Tentorial dural arteriovenous fistulas. Surg Neurol 67:4724822007

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