Evolution of different therapeutic strategies in the treatment of cranial dural arteriovenous fistulas--report of 30 cases.

30 cases of cranial dural arteriovenous fistuals, treated between 1983 and 1992, are reported. Twelve presented with an aggressive clinical course including intracranial haemorrhage, progredient neurological deficit, medically intractable seizures, and cerebellar symptoms. The other 18 patients had a more benign clinical presentation with audible bruit, exophthalmus, chemosis, and cranial nerve dysfunction. One of the latter had symptoms of pseudotumour cerebri due to sinus occlusion with contralateral sinus stenosis. The most common location was at the transverse sinus, followed by the cavemous sinus, the tentorial ring, and the orbita. Four vessel angiography verified the diagnosis and demonstrated all fistulas, mainly supplied by branches of the external carotid artery. 16 of 18 benign lesions were treated by endovascular therapy alone. Two recent patients received adjuvant stereotactic radiosurgery. Among these 18 patients 2 remained untreated, one because of spontaneous fistula thrombosis prior to therapy and one because of poor medical condition. 12 of 16 treated benign dural fistulas were partially occluded. In 6 of them spontaneous fistula thrombosis occurred during the following months. Total endovascular obliteration was achieved in the remaining 4 patients. 7 of 12 aggressive fistulas were embolized only, one of them having additional radiosurgery. Two of them were totally obliterated and five partially. Surgery was performed in the remaining 5 aggressive fistulas. Complete microsurgical excision was achieved in 2 and partial in further two, who presented initially with a life-threatening intracerebral clot. In one early case ligation of the external carotid artery was done, which is now obsolete. Over all 20 of 28 treated patients became asymptomatic or improved clinically. 3 of the remaining 8 patients were unchanged, two deteriorated despite therapy, and 3 worsened after therapy. All of the latter complications occurred early in our series due to thromboembolic events during the procedure. One surgical patient suffered from a new facial nerve palsy postoperatively. Follow up time in all treated patients was between 1 and 139 months with a mean of 48,3 months.