Combined Endovascular and Microsurgical Treatment for Cerebral Dural Arteriovenous Fistulas in the Hybrid Operating Room

Aims: Dural arteriovenous fistulas (dAVF) are vascular pathologies in which branches of the carotid or vertebrobasilar arteries shunt through the meninges. Treatment is indicated to control symptoms and to prevent devastating intracranial hemorrhage. It includes endovascular, microsurgical and stereotactic radiosurgical interventions and combinations thereof. In this study, we present our experience with a series of dAVF cases treated in a hybrid operation room (hOR) with a combined microsurgical and endovascular approach.

Methods: We consecutively registered all patients treated in our institution for cerebral dAVF in a hybrid setting between 2010 and 2016. We retrospectively reviewed these cases and recorded the following characteristics: age; gender; clinical presentation on admission, symptoms related to the fistula, AVF initial presentation including Borden, Cognard and D E S score, presurgical therapies, microsurgical and endovascular interventions in the hybrid OR including intraoperative control DSA (iDSA), post-operative imaging, GCS and symptoms on discharge as well as clinical and radiological examinations on follow-up.

Results: A total of 10 consecutive patients with cerebral dAVF (8/10 Borden Type 2 or higher) treated in our hOR were included in this study. Seven out of ten cases underwent multiple embolizations (up to 3) and hybrid procedures. In 2/10 cases iDSA after microsurgical resection revealed remnants of the fistula which could be re-resected in the same procedure. At the end of operations, all but one case had intraoperatively confirmed radical treatment of the dAVF with no remnant in the final iDSA. In 7/10 patients, a cure of the dAVF could be documented in the late follow-up (median FU 10 months). Two cases showed recurrence after 2 and 5 months, respectively. In all interventions and operations no relevant complications occurred.

Conclusions: Radical treatment of complex cerebral dAVFs (Borden >2) remains a challenge for neurosurgeons and interventional neuroradiologists. Combined endovascular and microsurgical approaches within the hOR might offer much higher rates of radical treatment and long-term cure of dAVF.