Multiple synchronous intracranial dural arteriovenous fistulas.

BACKGROUND

Intracranial multiple dural arteriovenous fistulas (DAVFs) are rare, with most reports limited to small case series and basic descriptive analyses. To better understand this condition-often linked to lower cure rates and higher progression risk-we conducted a comparative analysis of their angiographic characteristics, clinical presentations, and outcomes.

METHODS

Data were retrospectively collected from the Dural Arteriovenous Fistula Research and Management in China (DREAM-INI) database. Lesions were classified as multifocal or diffuse based on angiographic features, and as progressive or non-progressive based on follow-up angiographic findings. We compared these subtypes as well as multiple versus single DAVFs, and further investigated the predictors of disease progression in patients with multiple DAVFs.

RESULTS

A total of 90 cases of multiple synchronous DAVFs were included. Compared to the multifocal type, diffuse-type patients were younger (P = 0.002), and more frequently exhibited sinus occlusion/stenosis (P = 0.019), sinus-type DAVF (P < 0.001), pial artery supply (P = 0.009), venous congestion (P = 0.030), and lower complete obliteration rates (P = 0.001). Progressive DAVFs were associated with younger age (P = 0.001), sinus-type DAVF (P = 0.020), higher rates of diffuse-type lesions (P < 0.001), pial artery supply (P = 0.037), deep venous drainage (P = 0.032), and venous congestion (P = 0.005). Among the 14 treatment-related complications, 8 (57.1%) were associated with pial artery embolization. Compared to single DAVFs, patients with multiple DAVFs had a significantly lower rate of good outcomes (P < 0.001) and a higher incidence of fistula-related death (P = 0.001). On multivariate analysis, only younger age remained a significant predictor of progression (OR 2.86; 95% CI 1.02-7.99; P = 0.045).

CONCLUSIONS

Diffuse and progressive types often occur in younger patients and are associated with sinus-type fistulas and venous hypertension-related angioarchitectural features. Disease progression may involve enhanced neoangiogenesis. Treatment of refractory DAVFs should prioritize reducing venous hypertension and improving cerebral hemodynamics, rather than solely pursuing complete obliteration.