頭蓋内硬膜動静脈瘻に対する低侵襲外科治療  [in Japanese] Less Invasive Surgery for Intracranial Dural Arteriovenous Fistulae  [in Japanese]

Endovascular therapy, including transarterial or tranvenous embolization, has been standard treatment for intracranial dural arteriovenous fistulae (DAVFs). However, it is not always possible when the dural sinus is isolated from the internal jugular vein, such as type III or IV DAVFs of Cognard's classification. In 23 cases, we performed less invasive surgery or surgery associated with endovascular therapy. We present our surgical procedures and clinical results in this paper. The location of the DAVF was the cavernous sinus (CS) in 2 patients, transverse-sigmoid sinus (TS-SS) in 12, superior sagittal sinus (SSS) in 2, craniocervical junction (CCJ) in 3, anterior cranial base (ACB) in 2, and tentorium in 2. Twelve patients with DAVFs in TS-SS, 2 in SSS, and 1 in CS were treated with craniotomy/craniectomy and embolization. Surgical exposure of the superior ophthalmic vein and coil embolization were performed for the CS DAVF in 1 case. Three CCJ, 2 ACB, and 2 tentorial DAVFs were treated with surgical coagulation of the draining vein under fluoroscopic guidance. In our series, 22 of 23 patients were cured completely without any new neurological deficit. Transient speech disturbance was recognized in 1 patient, due to subcortical hemorrhage related to manipulation of a guide wire. Less invasive surgery, including surgery combined with embolization or surgical coagulation of the draining vein, was effective and safe for DAVFs that could not be cured with endovascular treatment alone.