A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment

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✓ A classification is proposed that unifies and organizes spinal and cranial dural arteriovenous fistulous malformations (AVFMs) into three types based upon their anatomical similarities. Type I dural AVFMs drain directly into dural venous sinuses or meningeal veins. Type II malformations drain into dural sinuses or meningeal veins but also have retrograde drainage into subarachnoid veins. Type III malformations drain into subarachnoid veins and do not have dural sinus or meningeal venous drainage. The arterial supply in each of these three types is derived from meningeal arteries.

The anatomical basis of the proposed classification is presented with several cases that illustrate the three types of dural AVFMs. A rationale for the treatment of spinal and cranial dural AVFMs according to their anatomical characteristics is discussed.

Article Information

Address reprint requests to: William A. Shucart, M.D., Department of Neurosurgery, New England Medical Center #178, 750 Washington Street, Boston, Massachusetts 02111.

© AANS, except where prohibited by US copyright law.

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Figures

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    Illustration showing a Type I(a) dural arteriovenous fistulous malformation of the superior petrosal sinus (simple fistula) from the right subtemporal approach. The nidus is a simple fistula from the middle meningeal artery draining into superior petrosal sinus. Note the normal anterograde drainage of petrosal vein into superior petrosal sinus. The tentorial artery of Bernasconi and Cassonari arising from meningohypophyseal trunk of right internal carotid artery does not supply the fistula. Number 3 = oculomotor nerve; number 4 = trochlear nerve; number 5 = trigeminal nerve; ATV = anterior temporal vein draining into cavernous sinus; CS = cavernous sinus; ICA = internal carotid artery; ILTV inferolateral temporal vein draining into tentorial venous lake; MMA = middle meningeal artery; PV = petrosal vein; SPS = superior petrosal sinus; T = tentorium; taBC = tentorial artery of Bernasconi and Cassonari (anterior marginal tentorial branch of internal carotid artery).

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    Illustration showing a Type I(b) dural arteriovenous fistulous malformation of the superior petrosal sinus (complex nidus) from the right subtemporal approach. The nidus on wall of superior petrosal sinus drains into arterialized superior petrosal sinus. Note the multiple arterial feeding vessels from branches of middle meningeal artery (MMA), cavernous carotid artery and posterior cerebral artery (PCA) through tentorial branch (taDS). The petrosal vein has normal drainage into superior petrosal sinus (SPS). Number 3 = oculomotor nerve; number 4 = trochlear nerve; number 5 = trigeminal nerve; number 6 = abducens nerve; ICA = internal carotid artery; BA = basilar artery; PV = petrosal vein; BV = basal vein of Rosenthal.

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    Illustration showing a Type II(b) dural arteriovenous fistulous malformation of superior petrosal sinus (complex nidus) from the right subtemporal approach. The nidus on wall of superior petrosal sinus drains in retrograde fashion into petrosal vein. Number 3 = oculomotor nerve; number 4 = trochlear nerve; number 5 = trigeminal nerve; C = cerebellum; ICA = internal carotid artery; SCA = superior cerebellar artery; T = tentorium and tentorial branch of superior cerebellar artery; MMA = middle meningeal artery; PV = arterialized petrosal vein.

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    Illustration showing a Type III(b) dural arteriovenous fistulous malformation of tentorium (complex nidus) from the right subtemporal approach. The nidus on wall of superior petrosal sinus drains into petrosal vein. The malformation is supplied by meningeal branches of cavernous internal carotid artery (taBC), posterior cerebral artery (taDS), and middle meningeal artery (MMA). The malformation does not drain into superior petrosal sinus. The tentorium (T) has been incised and reflected to demonstrate the arterialized petrosal vein (PV) with retrograde drainage into basal vein of Rosenthal (BVR). Number 3 = oculomotor nerve; number 4 = trochlear nerve; number 5 = trigeminal nerve; number 6 = abducens nerve; number 7 = facial-vestibulocochlear nerve complex; BA = basilar artery; CS = cavernous sinus; ICA = internal carotid artery; ITLV = inferomedial temporal lobe vein draining into basal vein; PCA = posterior cerebral artery; SCA = superior cerebellar artery.

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    Illustration showing a Type III(b) dural arteriovenous fistulous malformation of tentorium cerebelli from the right subtemporal approach. The nidus on tentorial venous lake drains in retrograde fashion through inferior temporal lobe vein. The nidus is supplied by middle meningeal artery (MMA) and tentorial artery (taBC). The tentorial dural lake has aneurysmal dilatation and does not drain into superior petrosal sinus; the draining vein has multiple aneurysms. Number 3 = oculomotor nerve; number 4 = trochlear nerve; number 5 = trigeminal nerve; ITLV = inferior temporal lobe vein with multiple aneurysms; SPS = superior petrosal sinus; T = aneurysmal tentorial venous lake.

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    Illustration showing a spinal Type I(b) dural arteriovenous fistulous malformation. The nidus on nerve root sleeve is fed by meningeal branches of radicular artery. The dilated venous plexus causes nerve root and spinal cord compression; however, venous drainage of spinal cord is not affected. ara = anterior branch of radicular artery; dsv = dorsal spinal cord venous plexus draining into radicular vein; dvp = dural venous plexus, arterialized and dilated; md = meningeal (or true) dura; mra = meningeal branch of radicular artery; ra = radicular artery; rv = radicular vein; sp = spinal periosteum (or periosteal dura).

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    Illustration showing a spinal Type III(a) dural arteriovenous fistulous malformation. The arteriovenous fistula on nerve root sleeve is fed by meningeal branch of radicular artery and drains into dorsal spinal venous plexus through subarachnoid anastomotic vein (arterialized). The dural venous plexus between spinal periosteum and meningeal dura does not drain the nidus. ara = anterior branch of radicular artery; df = dural fistula; dsv = dorsal spinal cord venous plexus draining into radicular vein; dvp = dural venous plexus; md = meningeal (or true) dura; mra = meningeal branch of radicular artery; ra = radicular artery; rv = radicular vein; pra = posterior branch of radicular artery; sp = spinal periosteum (or periosteal dura).

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    Lateral arterial-phase angiogram demonstrating two dural arteriovenous malformations (arrows). The first is at the superior petrosal sinus supplied by the tentorial branches of the intracavernous carotid artery and draining through the petrosal vein into the deep venous system. The second nidus located at the base of the superior sagittal sinus is supplied primarily by ethmoidal perforators from the ophthalmic artery and drains into a cortical vein.

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    Arteriograms demonstrating a Type III(b) dural arteriovenous malformation nidus on the superior sagittal sinus. Left: Anteroposterior arteriogram. Arterial supply is from multiple meningeal arteries and selective injection demonstrates supply from left middle meningeal artery. Venous drainage is into dilated right occipital anastomotic vein between the superior sagittal sinus and vein of Galen. No drainage into superior sagittal sinus through nidus is located on sinus. A Type IIIb nidus is not a simple fistula. Center: Lateral arteriogram. Selective injection demonstrates posterior meningeal arterial supply and drainage into occipital vein toward vein of Galen. There is no filling of superior sagittal sinus despite presence of nidus on sinus. Right: Lateral arteriogram. Postoperative venous-phase study after ligation of draining vein. The arteriovenous malformation (AVM) is eliminated and although the superior sagittal sinus is stenotic, it is patent. The site of stenosis is related to the AVM nidus (center).

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    Illustration showing the various types of dural arteriovenous malformations (AVMs) on left transverse sinus (ts) supplied by the middle meningeal artery (MMA). A: Type I(a) dural AVM with anterograde venous drainage. The fistula (f) is between a branch of MMA and the ts. B: Type I dural AVM. Thrombosis of sigmoid sinus causes reversal of flow within the ts. The ts drains normally across the torcular Herophili (tH). The vein of Labbé (VL) drains normally into the ts. C: Type II dural AVM. The proximal ts stenosis redirects outflow into VL which drains in retrograde direction. D: Type III dural AVM. Transverse sinus thrombosis with the patent channel draining f into the dilated, arterialized VL. E: Type III dural AVM. Transverse and sigmoid sinuses have partially recanalized. The f drains through the persistent channel into the VL. F: Type III dural AVM. After further recanalization of transverse and sigmoid sinuses, the sinus lumen is patent and venous blood flows anterograde from the tH to the jugular vein. The dural f is not in communication with lumen of sinus and persistently drains retrograde into the VL.

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