Grading venous restrictive disease in patients with dural arteriovenous fistulas of the transverse/sigmoid sinus

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✓ Dural arteriovenous fistulas of the transverse/sigmoid sinus usually cause pulse-synchronous bruit but may present catastrophically. Current systems for classifying these vascular malformations do not consider obstruction of venous outflow, which increases the risk of intracranial hemorrhage due to retrograde flow via cortical veins. The authors have developed a grading system based on the severity of venous restrictive disease determined by superselective angiography. In a retrospective analysis of 25 patients with dural arteriovenous fistulas of the transverse/sigmoid sinus treated between 1988 and 1990, the grade of venous restrictive disease reflected the clinical presentation. Visual symptoms and central nervous system hemorrhage were more common in patients with cortical venous drainage and more severe distal venous occlusion (Grade 3: 31% and 31%, respectively; Grade 4: 67% and 100%, respectively) than in patients with cortical venous drainage and mild-to-moderate venous restrictive disease (Grade 2: 13% and 0%, respectively) or those without venous outflow (Grade 1: 0% and 0%, respectively). These preliminary results suggest that this grading system may be useful for predicting the risk of catastrophic clinical presentation and for guiding therapeutic decision-making in patients with dural arteriovenous fistulas of the transverse/sigmoid sinus. A prospective study of a larger number of patients is needed to validate the predictive value of this new grading system.

Article Information

Present address for Dr. Lalwani: Laboratory of Molecular Biology, National Institute on Deafness and Other Communication Disorders, Bethesda, Maryland.Address reprint requests to: Anil K. Lalwani, M.D., Department of Neurological Surgery, c/o The Editorial Office, 1360 Ninth Avenue, Suite 210, San Francisco, California 94122.

© AANS, except where prohibited by US copyright law.

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    Diagrammatic representations of the grading system for venous restrictive disease in patients with dural arteriovenous fistulas of the transverse/sigmoid sinus. Upper Left: Grade 1. This lesion is supplied by the ipsilateral middle meningeal artery and the occipital artery (lateral projection). There is normal antegrade venous outflow, and cortical venous drainage is absent. Upper Right: Grade 2. Antegrade venous flow is diminished by mild-to-moderate venous restrictive disease; retrograde venous flow through the transverse sinus and cortical venous flow are present. Lower Left: Grade 3. Normal antegrade venous drainage is totally absent. Arterialized venous blood drains via the cortical veins, and retrograde venous flow through the transverse sinus to the torcular herophili is present. Lower Right: Grade 4. Venous drainage is through enlarged cortical veins only.

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    Algorithm for the treatment of dural arteriovenous fistula (DAVF) of the transverse/sigmoid sinus based on the grade of venous restrictive disease. F/U = follow-up monitoring; TV = transvenous; STV = surgical transvenous. * = STV or TV coil embolization is inappropriate for Grade 2 lesions without cortical venous drainage.

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