Introduction: Dural arteriovenous fistulas (DAVFs) with cortical venous drainage (CVR) frequently present with symptomatic intracranial hemorrhage necessitating early multimodality treatment.

Methods: From 2011-2017, 11 consecutive patients with posterior fossa DAVFs with CVR were treated. Radiographic characterization of the DAVFs, clinical characteristics of the patients, and effectiveness of treatment modalities were recorded.

Results: There were 8 men and 3 women, mean age 65 years (SD ±14.2). Clinical presentation was symptomatic hemorrhage in 6 (55%) patients, ataxia in 2 (18%) patients, pulsatile bruit in 1 (9%) patient and seizure in 1 (9%) patient. In 1 (9%) patients, the DAVF was an incidental finding. Patients presented with Cognard grades of 3 (9%), 2A+B (9%) or 2B (81.8%). Seven (64%) patients had drainage to the transverse/sigmoid sinus with pial venous reflux, 3 (27%) to the superior petrosal sinus with cortical reflux, 4 (36.4%) to pial veins, 1 (9%) to the vein of Galen and 1 (9%) to the basal vein of Rosenthal. Surgical intervention following embolization was performed in 3 (27.2%) patients, 5 patients (45.5%) had embolization only and 3 (27.2%) patients had staged embolization. There was no residual in the surgery or embolization only intervention groups. One (9%) patient had evidence of a residual fistula following a staged embolization procedure, which required subsequent radiosurgery. Of the 10 initially symptomatic patients, 7 patients (70%) had post-procedural resolution of their symptoms, 1 (10%) patient had persistent dysarthria and 2 (20%) patients had persistent vertigo. There were no permanent procedural complications.

Conclusions: The present series demonstrates the use of combinatory therapeutic options and their combinations for the treatment of posterior fossa DAVFs. The most important factors associated with success in treating this rare entity is an understanding of the vascular anatomy, a selection of the appropriate treatment modality and close patient follow up.

Patient Care: This retrospective series highlights existing evidence for the multi-modality treatment of posterior fossa DAVF’s and will help promote the most effective strategies toward the comprehensive treatment of DAVFs.

Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the etiology and clinical sequelae of DAVF 2) Discuss in small groups the radiographic grading schemes for DAVF 3) Identify appropriate and effect multimodality treatments of DAVF

References: 1. Kortman HG, Bloemsma G, Boukrab I, Peluso JP, Sluzewski M, van der Pol B,Beute GN, Majoie CB, van Rooij WJ. Treatment of cranial dural arteriovenous fistulas with exclusive cortical venous drainage: A single-center cohort of 35 patients. Interv Neuroradiol. 2017 Jan 1:1591019917728399. 2. Pierot L, Chiras J, Meder JF, Rose M, Rivierez M, Marsault C. Dural arteriovenous fistulas of the posterior fossa draining into subarachnoid veins. AJNR Am J Neuroradiol. 1992 Jan-Feb;13(1):315-23.