Intracerebral hemorrhage due to dural arteriovenous malformations and fistulae.

Intracerebral hemorrhage is the most devastating complication of dural AVMs. The lesions most at risk are those located at the tentorial incisura and in the anterior cranial fossa. The more common dural AVMs located at the transverse-sigmoid sinus and cavernous sinus typically do not hemorrhage and more frequently present with insidious symptoms such as a cranial bruit, tinnitus, or headache. Angiographic appearance of pial draining veins or an intervening varix identifies those patients most at risk for bleeding. An aggressive clinical stance must be taken in this group of patients, with the goal being complete extirpation of the lesion, because any residual AVM can enlarge and recruit pial veins, thus increasing the chances of future hemorrhage. Hemorrhage, which frequently is massive, can be spontaneous or occur after endovascular embolization. When hemorrhage does occur, medical and surgical management must be immediately instituted to avoid secondary brain injury. Therapeutic options include surgery and embolization using particulate material or polymerizing glues, alone or in combination. Although surgery remains the most effective and versatile method for treating dural AVMs, endovascular therapy and stereotactic radiosurgery will likely play more significant roles in treating these lesions in the future.