Introduction: The high incidence of intracranial hemorrhage in dural AVF's with leptomeningeal venous drainage is well recognized. However, the venous drainage is often quite bizzare and the hemorrhage often remote from the actual fistula. As the arterial supply often comes from the external carotid, the lesion may not get diagnosed without selective angiography. The extensive nature of these lesions, especially one involving the skull base and tentorium, pose difficulty in their management.
Methods: Retrosceptive review of our AVM data base was done to evaluate the patients with established diagnosis of Intrcranial dural AVFistulas(DAVF's).
Results: Amongst 110 patients with intracranial DAVF's, we found 52 patients withleptomeningeal venous drainage. Twenty five patients (48%)presented with hemorrhage, while another one had a fatal hemorrhage during observation. Majority of patients with hemorrhage were males (84%) and 50-75 age group (76%). They were mainly clustered around the torcula and tentorium. Five patients with their initial bleed were not thoroughly investigated to establish the diagnosis. Four others had repeat hemorrhage while awaitng treatment (two while still inpatient)worsening their neurologic deficits and one with fatal bleed after partial treatment. All except three patients underwent treatment with microsurgery or a combination of embolization and surgery. Out of those three, one had fatal hemorrhage, second died of ventriculitis while recovering from initial bleed, and the third had treatment elsewhere after another bleed with reported poor outcome. The treated patients had good to excellent outcome with no operative mortality and resolution of most of the deficits. One patient(4%)had worsening of deficit from brain stem infarct.
Significant number of other 26 patients also presented with neurologic symptoms. Almost all of them were advised treatment, and majority treated with good outcome and a few minor neurologic deficits.
Conclusions: Despite extensive nature of both arterial supply and leptomeningeal venous drainage, it is feasible to treat these lesions with satisfactory outcome as shown by our experience. Left alone the outlook is poor with persistent risk of bleeding and/ or progressive defecit. As the fistula can be remote from the site of bleed, hemorrhages in unusual location deserve more thorough evaluation with selective external carotid angiography.
Patient Care: If the learning objectives are achieved, all of the benefits directly improve the patient care and their outcomes.
Learning Objectives: 1.Re-emphasis of highly critical nature of this subset of Dural AVF's.
2.Understanding complexity of diagnosis and technical cosideration in the treatment.
3. Appreciating the urgency of treatment.
References: Malik GM,Pearce JE,Ausman JI, et.al. Dural Arteriovenous Malformations and Intracranial Hemorrhage. Neurosurgery 1984; 15:332-339